school of visual arts - student insurance · pdf file3 administered by: consolidated health...

School of Visual Arts
("the Policyholder")
2017-2018 Student Health Plan
("the Plan")
Student Hel Insurance Plan
Designed Exclusively for the Students of:
School of Visual Arts New York, NY
2017 - 2018 Underwritten by: Atlanta International Insurance Company (AIIC) Flushing, NY Policy Number: AIIC1718NYSHIP08
Group Number: ST0654SH
Effective: 8/25/2017 8/25/2018

2 Administered by: Consolidated Health Plans 2077 Roosevelt Ave. Springfield, MA 01104
School of Visual Arts 2017-2018 Student Insurance Plan
Table of Contents Where to Find Help........................................................................................................................................................ 3
Am I Eligible? ................................................................................................................................................................. 3
Coverage for Dependents .............................................................................................................................................. 3
How Do I Waive? ........................................................................................................................................................... 3
Effective Dates & Costs .................................................................................................................................................. 4
Preferred Provider Organization (PPO) Network .......................................................................................................... 4
Preauthorization Procedure .......................................................................................................................................... 4
Exclusions and Limitations ............................................................................................................................................. 5
Schedule of Benefits ...................................................................................................................................................... 7
Claim Procedures ......................................................................................................................................................... 19
Grievances, Utilization Review, and Appeals ............................................................................................................... 19
Value Added Services .................................................................................................................................................. 19

Where to Find Help
For Questions About: Please Contact:
Insurance Benefits Enrollment Waiver
University Health Plans, a Risk Strategies Company 15 Pacella Park Drive Randolph, MA 02368 Phone: (800) 437-6448 Fax: (617) 472-6419 www.universityhealthplans.com or email us at [email protected]
Claims Processing ID Cards Preferred Provider Listings ID card Requests
Consolidated Health Plans 2077 Roosevelt Avenue Springfield, Massachusetts 01104 (877) 657-5030 www.chpstudent.com
Preferred PPO Provider Listings Consolidated Health Plans or www.cigna.com
Prescription Drug Providers Cigna PBM www.cigna.com
Am I Eligible? If You are a full-time or part-time student, School of Visual Arts (SVA) requires You to have health insurance that is comparable to the SVA Student Health Plan. To make sure You have sufficient coverage, You will be automatically enrolled in the Plan and billed by Student Accounts for the Health Insurance Plan Cost unless You waive coverage under the Plan, by the Waiver Deadline (below) by providing proof that You have other health insurance coverage that meets this requirement. If You are a full-time or part-time student, enrolling in the Fall, You will be enrolled for the Annual Coverage Term. If You are a full-time or part-time student enrolling in the Fall but are not registered for Spring classes, You will be enrolled for the Fall Coverage Term only.
Coverage for Dependents You, the Student, to whom the Certificate is issued, are covered under the Certificate. Members of Your family may also be covered depending on the type of coverage You selected. In Section V of the Certificate, see the provision entitled Who is Covered.
How Do I Waive? If You have other health insurance coverage that is comparable to the SVA Student Health Plan and, therefore, You do not wish to be enrolled in the Plan, You must complete the online waiver form and provide proof of comparable health insurance coverage at www.sva.edu/uhp by the applicable waiver deadline date. If You do not complete a waiver form by the applicable waiver deadline date, 10/2/17, You will be enrolled in the Plan and will be responsible for the Health Insurance Plan Cost.
If You have other comparable health insurance coverage but miss the Annual / Fall waiver deadline date, You may complete and submit an appeal form along with proof of Your comparable health insurance coverage by contacting University Health Plans at 1-800-437-6448 or [email protected]. The deadline to submit a waiver appeal for Fall is 12/6/17, and for Spring, it is 4/6/18. If approved, the appeal form is for the Fall Coverage Term only. If You wish to waive coverage for the Spring Coverage Term, You must complete an online waiver form and provide proof of comparable health insurance coverage by the Spring waiver deadline date which is 2/4/18 for Spring. Waiver submissions may be audited by SVA, University Health Plans, and/or their contractors or representatives. You may
http://www.universityhealthplans.com/mailto:[email protected]://www.consolidatedhealthplan.com/http://www.sva.edu/uhptel:(800)%20437-6448mailto:[email protected]

be required to provide, upon request, any coverage documents and/or other records demonstrating that You meet the Policyholder's requirements for waiving coverage under the Plan. By submitting the waiver form, You agree that Your current health insurance plan may be contacted for confirmation that Your coverage is in force for the applicable Plan Year and that it meets the Policyholder's waiver requirements.
Effective Dates & Costs All time periods begin and end at 12:01 A.M., local time, at the Policyholder's address.
Coverage Period Coverage Start Date Coverage End Date Enrollment/Waiver Deadline
Annual 8/25/17 8/25/18 10/2/17 ----------------------------------------------------------------------------------------------------------------------------- --------------------------- Fall 8/25/17 2/24/18 10/2/17 ----------------------------------------------------------------------------------------------------------------------------- --------------------------- Spring (for new students to the School in the Spring semester only) 1/3/18 8/25/18 2/4/18 ----------------------------------------------------------------------------------------------------------------------------- ---------------------------
Rates for Undergraduate and International Students Dependent rates are in addition to the student rate.
Annual Fall Spring
Student* $2,140 $1,070 $1,346 ----------------------------------------------------------------------------------------------------------------------------- --------------------------- Spouse* $2,140 $1,070 $1,346 ----------------------------------------------------------------------------------------------------------------------------- --------------------------- Each Child* $2,140 $1,070 $1,346 -------------------------------------------------------------------------------------------------------------------------------------------------------- 3 or more Children* $6,420 $3,210 $4,038 --------------------------------------------------------------------------------------------------------------------------------------------------------
*The above rates include an administrative service fee
Preferred Provider Organization (PPO) Network By enrolling in this Insurance Program, you have the Cigna PPO Network of participating Providers with access to quality health care at discounted fees. To find a complete listing of the Networks participating Providers, go to www.cigna.com, or contact Consolidated Health Plans toll-free at (877) 657-5030, or www.chpstudent.com for assistance.
Preauthorization Procedure Services Subject to Preauthorization. Our Preauthorization is required before You receive certain Covered Services. You are responsible for requesting Preauthorization for in-network and out-of-network services listed in the Schedule of Benefits section of the Certificate.
Preauthorization Procedure. If You seek coverage for services that require Preauthorization, You must call Us at the number on Your ID card.
You must contact Us to request Preauthorization as follows:
At least two (2) weeks prior to a planned admission or surgery when Your Provider recommends inpatient Hospitalization. If that is not possible, then as soon as reasonably possible during regular business hours prior to the admission.

After receiving a request for approval, We

school of visual arts - student insurance · pdf file3 administered by: consolidated health...

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