students health plan

7/31/2019 Students Health Plan

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STUHLTHPLNMG2011

MONTANA UNIVERSITYSYSTEM STUDENTINSURANCE PLAN

PPO

MEMBER GUIDE

Effective September 1, 2011


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CUSTOMER SERVICE, BENEFIT MANAGEMENT,AND PRIOR AUTHORIZATION

1-800-447-7828

Website:

Customer Service

Montana Provider Directory

Other Featureswww.bcbsmt.com

BlueCard Nationwide/Worldwide Coverage Program

1-800-810-BLUE(2583)http://www.bcbs.com/healthtravel/finder.html

Appeals, Complaints, and Grievances

Fax Number

1-406-437-7875

Prescription Drug Pharmacy Integrated Benefit

Ridgeway Pharmacy Mail Service

1-800-630-3214

Blue Cross and Blue Shield of Montana560 North Park Avenue

P.O. Box 4309Helena, MT 59604-4309

1-800-447-7828

Claims:Blue Cross and Blue Shield of MontanaP.O. Box 5004

Great Falls, MT 59403


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Certain terms in this Member Guide are defined in the Definitions section of this Member Guide. Defined terms are

capitalized.

MEMBER GUIDE

This Member Guide is a summary of the Benefits available under the Group Plan. Nothing in this Member

Guide will alter any of the terms, conditions, limitations, or Exclusions of the Group Plan. If questions should

arise, the provisions of the Group Plan will prevail. Please refer to the Group Plan on file with your employerif you have any questions which arent answered in the Member Guide or call your Blue Cross and Blue

Shield of Montana representative.

PRIVACY OF INSURANCE AND HEALTH CARE INFORMATION

It is the policy of Blue Cross and Blue Shield of Montana to protect the privacy of Members through

appropriate use and handling of private information. Further, appropriate handling and security of private

information may be mandated by state and/or federal law.

The Group and Beneficiary Member may receive a copy of Blue Cross and Blue Shield of Montanas "Notice

of Privacy Practices," or other information about privacy practices, by calling the telephone number or writing

to the address shown on the inside cover of this Member Guide.

MEMBERS RIGHTS

When requested by the insured or the insureds agent, Montana law requires Blue Cross and Blue Shield of

Montana to provide a summary of a Members coverage for a specific health care service or course of

treatment when an actual charge or estimate of charges by a health care provider, surgical center, clinic or

Hospital exceeds $500.


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TABLE OF CONTENTS

- i -

OUTLINE OF COVERAGE

Schedule of Benefits 1..............................................................................................................................................

PROVIDERS OF CARE FOR MEMBERS

Professional Providers and Facility Providers 6........................................................................................................

How Providers are Paid by the Plan and Member Responsibility 6..........................................................................

SPECIAL PROVISIONS

Out of State Services 7.............................................................................................................................................

Out of PPO Network Referrals 7...............................................................................................................................

Benefit Reduction for Services Provided by a Non-PPO Network Provider 7...........................................................

OUT-OF-STATE SERVICES---THE BLUECARD PROGRAM 8.....................................................................................

COMPLAINTS, GRIEVANCES AND APPEALS

Complaints and Grievances 8...................................................................................................................................

Appeal of Denied Claims or Requested Services 9..................................................................................................

BENEFIT MANAGEMENT

Plan Notification and Prior Authorization 10..............................................................................................................

Care Management 11...............................................................................................................................................

ELIGIBILITY AND ENROLLMENT

Who is Eligible 11.....................................................................................................................................................

Special Enrollment in the Case of Marriage, Birth, Adoption or Placement for Adoption 14.....................................

When Benefits Begin 14...........................................................................................................................................

Change of Status 14.................................................................................................................................................

Refunds 14...............................................................................................................................................................

QUALIFIED MEDICAL CHILD SUPPORT ORDER (QMCSO) 15..................................................................................

PREEXISTING CONDITIONS 15....................................................................................................................................

TERMINATION OF COVERAGE

Termination When No Longer Eligible for Coverage or Family Member Status Changes 16...................................

Benefits after Termination of Coverage 16...............................................................................................................

Conversions Policies 16............................................................................................................................................

BENEFITS

Advanced Practice Registered Nurses and Physician AssistantsCertified 17.......................................................

Ambulance 17...........................................................................................................................................................Anesthesia Services 18............................................................................................................................................

Autism Spectrum Disorders 18.................................................................................................................................

Blood Transfusions 18..............................................................................................................................................

Chemical Dependency 18.........................................................................................................................................

Chemotherapy 19.....................................................................................................................................................

Chiropractic Services 19...........................................................................................................................................

Contraceptives 19.....................................................................................................................................................

Convalescent Home Services 19..............................................................................................................................

Dental Accident Services 20.....................................................................................................................................


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TABLE OF CONTENTS

- ii -

Dental Extractions 20................................................................................................................................................

Diabetic Education 20...............................................................................................................................................

Diabetes Treatment (Office Visit) 20.........................................................................................................................

Diagnostic Services 20.............................................................................................................................................

Durable Medical Equipment 21.................................................................................................................................

Emergency Room Care 21.......................................................................................................................................

Foot Orthotics 21......................................................................................................................................................Home Health Care 22...............................................................................................................................................

Home Infusion Therapy Services 22.........................................................................................................................

Hospice Services 23.................................................................................................................................................

Hospital Services - Facility and Professional 23.......................................................................................................

Inborn Errors of Metabolism 24.................................................................................................................................

Mammograms 25......................................................................................................................................................

Maternity Services Professional and Facility Covered Providers 25......................................................................

Medical Supplies 25..................................................................................................................................................

Mental Illness 26.......................................................................................................................................................

Midwives 27..............................................................................................................................................................Naturopathy 27.........................................................................................................................................................

Newborn Initial Care 27............................................................................................................................................

Nurse Specialist 27...................................................................................................................................................

Office Visits 27..........................................................................................................................................................

Orthopedic Devices 27..............................................................................................................................................

Physician Medical Services 27.................................................................................................................................

Postmastectomy Care and Reconstructive Breast Surgery 28.................................................................................

Preadmission Testing 28..........................................................................................................................................

Prescription Drug Pharmacy Integrated Benefit 28...................................................................................................

Private Duty Nursing 29............................................................................................................................................Prostheses 29...........................................................................................................................................................

Radiation Therapy Service 30...................................................................................................................................

Rehabilitation Facility and Professional 30............................................................................................................

Severe Mental Illness 32...........................................................................................................................................

Surgical Services 32.................................................................................................................................................

Therapies - Outpatient 33.........................................................................................................................................

Transplants 33..........................................................................................................................................................

Well-Child Care 34....................................................................................................................................................

COORDINATION OF BENEFITS WITH OTHER INSURANCE

Definitions 34............................................................................................................................................................Order of Benefit Determination Rules 36..................................................................................................................

Effect on the Benefits of This Plan 37.......................................................................................................................

Right to Receive and Release Needed Information 38.............................................................................................

Facility of Payment 38...............................................................................................................................................

Right of Recovery 38................................................................................................................................................

EXCLUSIONS AND LIMITATIONS 38............................................................................................................................

ADDITIONAL BENEFIT

Repatriation/Evacuation Benefit 41...........................................................................................................................


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TABLE OF CONTENTS

- iii -

CLAIMS

How to Obtain Payment for Covered Expenses for Benefits 41...............................................................................

GENERAL PROVISIONS

Modification of Group Plan 42...................................................................................................................................

Clerical Errors 42......................................................................................................................................................

Notices Under Contract 42........................................................................................................................................

Contract Not Transferable by the Member 43...........................................................................................................

Validity of Contract 43...............................................................................................................................................

Waiver 43..................................................................................................................................................................

Payment by the Plan 43............................................................................................................................................

Conformity With State Statutes 43............................................................................................................................

Forms for Proof of Loss 43.......................................................................................................................................

Members Rights 43...................................................................................................................................................

Alternate Care 43......................................................................................................................................................

Benefit Maximums 43...............................................................................................................................................

Pilot Programs 44.....................................................................................................................................................

Fees 44.....................................................................................................................................................................

Subrogation 44.........................................................................................................................................................

Statements are Representations 44.........................................................................................................................

When the Member Moves Out of State 44................................................................................................................

Right to Audit 45.......................................................................................................................................................

Independent Relationship 45....................................................................................................................................

Blue Cross and Blue Shield of Montana as an Independent Plan 45.......................................................................

DEFINITIONS 45.............................................................................................................................................................


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1

OUTLINE OF COVERAGE

Schedule of Benefits PPO

Group Name: MONTANA UNIVERSITY SYSTEM STUDENT

INSURANCE PLAN

Group Number: X58188-100

Effective Date: September 1, 2011

Maximum Benefit per Benefit Period: $200,000

Maximum Benefits for specific Benefits are listed in this

Schedule of Benefits.

Benefit Period: September 1, 2011 to August 31, 2012

Additional days of coverage may be available for newly enrolled students, depending on the semester registration

dates at each specific campus.

The Benefits are subject to the Benefit Period unless otherwise specified.

Preexisting Condition Exclusion Period: 12 Months for Preexisting Conditions

Nonparticipating Provider Differential: Professional

Provider 20%

Facility

Provider 20%

Participating Providers accept the Allowable Fee plus any Deductible and Coinsurance from the Member as payment

in full for Covered Medical Expenses. Nonparticipating providers can bill the difference between the Allowable Fee

and their total charge, including the differential, plus any Deductible and Coinsurance and the Member is responsible

for these amounts.

Deductible: Individual: $300

Deductible does not apply to the following Benefits:

Diabetic Education

Hospice

Mammograms

Newborn Initial Care and Lifesaving Procedures

Well-Child Care

Some Benefits may have payment limitations, refer to the specific Benefit in this Schedule of Benefits for additional

information.

Coinsurance: 30% unless otherwise specified

Coinsurance is listed by Benefit in this Schedule of Benefits. The Coinsurance a Member pays does not accumulate

to the Deductible.

Note: Services/supplies obtained outside of the PPO Network may have a 25% benefit reduction.

Coinsurance does not apply to the following Benefits:

Diabetic Education

Generic Prescription Drugs

Hospice

Mammograms

Well-Child Care

Some Benefits may have payment limitations, refer to the specific Benefit in this Schedule of Benefits for

additional information.


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OUTLINE OF COVERAGE, continued

2

Out of Pocket Amount: Individual: $5,000

The Deductible and Coinsurance apply to the Out of Pocket Amount. Some Benefits have specific Benefit Period or

lifetime maximums. Even if the Out of Pocket Amount is met, Benefits will not be paid for services after the maximum

Benefit is paid. These specific Benefit maximums are listed in this Schedule of Benefits.

The Out of Pocket Amount does not apply to the following:

25% benefit reduction for non-PPO services Charges in excess of the Allowable Fee

Nonparticipating Provider Differential amount

This means that charges in excess of the Allowable Fee, the Nonparticipating Provider Differential amount and the

25% benefit reduction for non-PPO services do not accumulate to help meet the Out of Pocket Amount.

Term of Member Guide: Monthly

GENERAL PAYMENT PROVISIONS

The following Schedule of Benefits outlines the Deductible, Coinsurance, maximums and limitations for specificBenefits available under the health Plan.

Payment by The Plan for Covered Medical Expenses is based on the Allowable Fee. Please refer to the definition ofAllowable Fee.

The Coinsurance is the percentage the Member pays to providers. Providers may require that the MembersCoinsurance be paid at the time of service.

The Deductible is the amount the Member must pay for covered services each Benefit year before payment is madeby The Plan. Deductible does not apply to some services. These are listed in this Schedule of Benefits.

All services described in the Benefits section are subject to the following provisions unless specifically statedotherwise in this Schedule of Benefits:

Deductible Coinsurance

Out of Pocket Amount

Nonparticipating Provider Differential


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BENEFIT INFORMATION MAXIMUM DEDUCTIBLE COINSURANCE

3

Autism Spectrum DisordersFor Members through 18 years of age Applies 30%

Maximum Per Benefit Period for Physical Therapy, SpeechTherapy, Occupational Therapy, Cardiac RehabilitationTherapy, habilitative and rehabilitative care and AppliedBehavior Analysis (ABA) services:

Members 0 through 8 years of age $50,000Members 9 through 18 years of age $20,000

All other services, except medications/prescription drugs, thatare described in the Benefit section entitled Autism SpectrumDisorders are covered under medical Benefits.

Medications/prescription drugs are covered under the PrescriptionDrug Pharmacy Integrated Benefit.

For Members 19 years of age and older with Autism, referto the following Benefits:

Severe Mental Illness Therapies - Outpatient

For Members 19 years of age and older with Pervasive DevelopmentDisorder or Aspergers Disorder, refer to the following Benefits:

Mental Illness Therapies - Outpatient

Chemical Dependency Treatment

Outpatient (Professional Provider and Facility) Applies 30%

Inpatient Applies 30%

Chiropractic Services Applies 30%

Maximum Benefit Per Benefit Period

Maximum Number of Treatments 5

Convalescent Home Services Applies 30%

Dental Extractions $1,000 Applies 30%

Diabetic Education Benefit

The Deductible and Coinsurance do not apply to thepayment of the first $250. After the payment of $250,Deductible and Coinsurance will apply.

First $250 Does Not Apply Does Not Apply

After the first $250 in Payment Applies 30%

Diagnostic Services Applies 30%

Durable Medical Equipment Applies 30%

Emergency Room Care Applies 30%

Home Health Care Applies 30%Maximum Number of Visits Covered Per Benefit Period 180 Visits

Hospice Care Does Not Apply Does Not Apply

Hospital Facility Services Inpatient and Outpatient

PPO Network Provider Services Applies 30%

Non-PPO Network Provider Services Applies 47.5%*

*This includes the 25% benefit reduction for services provided by a non-PPONetwork Provider. The Nonparticipating Provider Differential does not apply.


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BENEFIT INFORMATION MAXIMUM DEDUCTIBLE COINSURANCE

4

Mammograms

The Deductible and Coinsurance do not apply to the paymentof $70 or the actual charge, whichever is less. After the paymentof $70 or the actual charge, Deductible and Coinsurance apply.

First $70 Does Not Apply Does Not Apply

After the first $70 in payment Applies 30%Maternity Services-Professional and Facility Services Applies 30%

Medical Supplies Applies 30%

Mental Illness

Not including Severe Mental Illnesssee Definitions

Outpatient Treatment Applies 30%

Inpatient Treatment Applies 30%

Partial Hospitalization is covered under the Inpatient Treatment Benefit.

Newborn Initial Care Does Not Apply 30%

Orthopedic Devices Applies 30%

Other Facility Services Inpatient and Outpatient

Participating Provider Services Applies 30%

Nonparticipating Provider Services Applies 30%

Preadmission Testing Applies* Does Not Apply

*The Deductible does not apply if services areobtained with 10 days of admission.

Prescription Drug Pharmacy Integrated Benefit

Retail Pharmacy Prescriptions 34-day supply Applies 30%*

Mail Service Maintenance Prescriptions 90-day supply Applies 30%*

*The Coinsurance will not apply to Generic drugs.

Private Duty Nursing (Inpatient and Outpatient) Applies 30%

Maximum per Benefit Period $10,000

Professional Provider Services Inpatient and Outpatient

Participating Provider Services Applies 30%

Nonparticipating Provider Services Applies 30%

Prostheses Benefit Applies 30%

Rehabilitation Therapy Applies 30%

Lifetime Maximum $100,000

Severe Mental Illness Applies 30%Severe Mental Illness pays as any other medical condition.

Surgery Center Services Outpatient

PPO Network Provider Services Applies 30%

Non-PPO Network Provider Services Applies 47.5%*

*This includes the 25% benefit reduction for services provided by a non-PPONetwork Provider. The Nonparticipating Provider Differential does not apply.

Therapies Outpatient

Physical Therapy, Occupational Therapy, Speech Therapy, Cardiac Therapy Applies 30%


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MONTANA UNIVERSITY SYSTEM STUDENT INSURANCE PLAN

6

PROVIDERS OF CARE FOR MEMBERS

The participation or nonparticipation of providers from whom a Member receives services, supplies, and

medication impacts the amount The Plan will pay and the Members responsibility for payment.

Professional Providers and Facility Providers

Professional providers and facility providers are either Participating Providers or nonparticipating providers.As noted in the Special Provisions section, facilities may also belong to the HealthLink network.

Participating professional providers include, but are not limited to, Physicians, doctors of osteopathy,

dentists, optometrists, podiatrists, nurse specialists, Advanced Practice Registered Nurses, physician

assistants, naturopathic physicians and physical therapists.

Participating facility providers include, but are not limited to, Hospitals, home health agencies,

Convalescent Homes, skilled nursing facilities, freestanding facilities for the treatment of Chemical

Dependency or Mental Illness, and freestanding surgical facilities (surgery center).

The Member may obtain a list of Participating Providers from Blue Cross and Blue Shield of Montana free of

charge by contacting The Plan at the number listed on the inside cover of this Member Guide.

How Providers are Paid by the Plan and Member Responsibility

Payment by The Plan for Benefits is based on the Allowable Fee and is impacted by the participation or

nonparticipation of the provider in the Blue Cross and Blue Shield of Montana provider network.

A Participating Provider agrees to accept payment of the Allowable Fee from Blue Cross and Blue Shield of

Montana for Covered Medical Expenses, together with any Deductible and Coinsurance from the Member, as

payment in full. Generally, The Plan will pay the Allowable Fee for a Covered Medical Expense directly to

Participating Provider. In any event, The Plan may, in its discretion, make payment to the Member, the

provider, the Member and provider jointly, or any person, firm, or corporation who paid for the services on the

Members behalf.

Nonparticipating providers do not have to accept Blue Cross and Blue Shield of Montana payment aspayment in full. Blue Cross and Blue Shield of Montana reimburses a nonparticipating provider for Covered

Medical Expenses according to the Allowable Fee less the Nonparticipating Provider Differential shown in

the Schedule of Benefits. The nonparticipating provider can bill the Member for the difference between

payment by Blue Cross and Blue Shield of Montana and provider charges plus Deductible and Coinsurance.

The Member will be responsible for the balance of the nonparticipating providers charges after payment by

Blue Cross and Blue Shield of Montana and payment of any Deductible and Coinsurance.

For example if the nonparticipating provider charge is $100, the Blue Cross and Blue Shield of Montana

Allowable Fee is $80 and the Nonparticipating Provider Differential is 20%, the Members responsibility would

be calculated as follows:

Nonparticipating

provider charge Allowable Fee

Allowable Fee less

20% nonparticipating

differential for

payment by BCBSMT

Member

responsibility

$100 $80 $80 - 20% = $64

$100 - $64 = $36

plus any Deductible

and Coinsurance

Note: The above example illustrates the impact to a Member if services are obtained from a nonparticipating

provider. Refer to the Special Provisions section for an example of the non-PPO Network Benefit reduction.

Generally, The Plan will pay the Allowable Fee for a Covered Medical Expense directly to the Member. In any

event, The Plan may, in its discretion, make payment to the Member, the provider, the Member and provider


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BENEFITS

7

jointly, or any person, firm, or corporation who paid for the services on the Members behalf.

The Plan will not pay for any services, supplies or medications which are not a Covered Medical Expense, or

for which a Benefit maximum has been met, regardless of whether provided by a Participating Provider or a

nonparticipating provider. The Member will be responsible for all charges for such services, supplies, or

medications.

SPECIAL PROVISIONS

HealthLink is the PPO Network that is utilized under this benefit plan. HealthLink is a network of Hospitals

and surgery centers that are participating within this network. HealthLink facilities are available throughout

Montana and the Member receives a richer Benefit by utilizing this network. If the Member obtains services

or supplies from a non-PPO Network provider, payment will be reduced by 25 percent from that which would

be paid to a PPO Network provider.

The exceptions to the Benefit reduction are:

Emergency Services provided when a Member cannot reasonably reach a PPO Network provider;

Services that are unavailable within the PPO Network.

Out of State Services

If a Member receives services from an out of state provider, then services must be provided by:

Blue Cross and/or Blue Shield PPO facility providers; and/or

Blue Cross and/or Blue Shield participating professional providers* or PPO professional providers.

*Some Blue Cross and/or Blue Shield Plans require services to be provided by a PPO professional provider

for the member to receive the highest level of benefit. Contact the Plan for additional information on out of

state services.

Out of PPO Network Referrals

There may be circumstances under which the most appropriate treatment for the Members condition is not

available through the PPO Network. When this occurs, it is recommended the Members attending Physician

contact The Plan for an out of PPO Network referral. If the referral is not approved, and the Member

chooses to obtain services from a non-PPO Network provider, the non-PPO Network provider Benefit

reduction applies. If The Plan approves the referral, those services will not be subject to the non - PPO

Network provider benefit reduction.

Benefit Reduction for Services Provided by a Non-PPO Network Provider

After Deductible is satisfied, services provided by an out of PPO Network provider will take a 25 percent

Benefit reduction off of the 70% payment by Blue Cross and Blue Shield of Montana. However, if the

Member feels there are circumstances that justify the services by a non-PPO Network provider, the Membermay appeal the reduction. Please read the section entitled Complaints, Grievances and Appeals for

information regarding the procedure to be followed.

If Then

Services are provided by a HealthLink Hospital

or surgery center

The Plan pays 70% of the Allowable Fee


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8

If Then

Services are provided by any Hospital or

surgery center other than a HealthLink network

provider

The Plan calculates what the Members Benefit

would have been had the services been received

at a HealthLink facility (70% of the allowable), and

pays 75% of that amount

For example:

Hospital or

Surgery Center

Total

Allowed HealthLink Pays Member Pays

HealthLink provider $5,000 $3,500 $1,500

Non-HealthLink

provider

$5,000 $2,625

This amount is 75% of the

$3,500 HealthLink would

have paid a HealthLink

facility

$2,375

This amount is the total of:

$1,500 (which is 30% of the

$5,000 allowed) plus the benefit

reduction of $875 (which is 25%

of $3,500)

Note: The above example illustrates the impact of the benefit reduction to a Member if services are

obtained from a non-PPO Network provider. Refer to the Provider of Care for Members section for an

example of nonparticipating provider billing.

OUT-OF-STATE SERVICES---THE BLUECARD PROGRAM

When the Member obtains health care services that are Covered Medical Expenses through BlueCard

outside the geographic area Blue Cross and Blue Shield of Montana serves, the amount the Member pays is

calculated on the lower of:

The billed charges for the Members Covered Medical Expenses, or

The negotiated price that the on-site Blue Cross and/or Blue Shield Plan ("Host Blue") passes on to Blue

Cross and Blue Shield of Montana.

Often this "negotiated price" will consist of a simple discount which reflects the actual price paid by the HostBlue. But sometimes it is an estimated price that factors into the actual price expected settlements, withholds,

any other contingent payment arrangements and non-claims transactions with the Members health care

provider or with a specified group of providers. The negotiated price may also be billed charges reduced to

reflect average expected savings with the Members health care provider or with a specified group of

providers. The price that reflects average savings may result in greater variation (more or less) from the

actual price paid than will the estimated price. The negotiated price will also be adjusted in the future to

correct for over- or underestimation of past prices. However, the amount the Member pays is considered a

final price.

Statutes in a small number of states may require a Host Blue to use a basis for calculating Member liability

for Covered Medical Expenses that does not reflect the entire savings realized on a particular claim or to add

a surcharge. Should any state statutes mandate liability calculation methods that differ from the usual

BlueCard method noted in the above paragraph of this section or require a surcharge, Blue Cross and Blue

Shield of Montana would then calculate Member liability for any covered health care services in accordance

with the applicable state statute in effect at the time the Member received those services.

COMPLAINTS, GRIEVANCES AND APPEALS

Complaints and Grievances

If a Member is dissatisfied with any aspect of The Plans service or the care received and would like to notify

The Plan of a Complaint or Grievance, the Member or the Members designated representative may notify

The Plan by telephone, in person, in writing, by fax, or electronic mail. Written Complaints and/or Grievances


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BENEFITS

9

will be acknowledged within 10 days of receipt. The Member will be notified within 60 days of the disposition

of the Complaint or Grievance. The telephone number, fax number and mailing address of The Plan appear

on the inside cover of this Member Guide.

Appeal of Denied Claims or Requested Services

If a Member does not agree with The Plans decision on a denied claim, or a service for which Prior

Authorization was requested or denied, the Member has the right to Appeal that decision utilizing the "first

level" Appeal process.

The Member also has the right to request an independent peer review which is a "second level" Appeal if a

claim or request for services was denied because The Plan determined the services to be not Medically

Necessary (an Adverse Determination) and the Member received a denial on the "first level" Appeal.

1. Expedited Reviews.

If a claim or Prior Authorization request is denied as an Adverse Determination and involves a condition

that seriously threatens the Members life or health, the Member has the right to bypass the first level

Appeal and seek an independent review on an expedited basis. The Members health care provider must

certify in writing, fax or by electronic mail (to the numbers or address listed on the inside cover of this

Member Guide) that the life or health of the Member would be seriously threatened by the delay of an

internal Appeals process. An expedited review will be handled as a "second level" Appeal and theMember will be notified of the disposition of the expedited independent or peer review within 72 hours of

receipt by the peer or independent review organization.

2. Procedures for Appeal Process.

a. First Level Appeal - Plan Review of Denied Claims or a Requested Service.

The Member has 180 days from the date of receipt of notice of The Plans action on a claim or a Prior

Authorization request to request a "first level" Appeal. To request an Appeal, the Member must write

or telephone The Plan at the address and telephone number listed on the inside cover of this

Member Guide. Written requests will be acknowledged within 10 days of receipt. The Member must

state the issue to be reviewed and provide all pertinent information (i.e., medical records, letters,

etc.). The Member may also request a description of any records that The Plan used to make itsoriginal decision. The decision on the review will be made in writing within 60 days of receipt of all

relevant medical records. Once the review has been completed, the Member will be notified of the

outcome.

b. Second Level Appeal - Independent Review of Adverse Determination

The Member has 60 days from the date the internal decision is made of The Plans denial of the "first

level" Appeal of an Adverse Determination to request, in writing, an independent review. The

independent review and the case file will be provided to the peer or independent review organization

within 3 business days from The Plans receipt of the written request for independent review. The

peer or independent review organization has 30 days, from receipt of the request for review and the

case files, to complete the review and notify the Member of the outcome of the independent review.

The Plan will:

accept and comply with the findings made by a peer conducting the independent reviewconcerning an Adverse Determination, a determination as to whether the services wereappropriate and Medically Necessary, or a health care treatment decision; and

pay for the reasonable costs of the independent review. notify the Member of their independent review rights concerning an Adverse Determination by

notifying the Member and the health care provider of any Adverse Determination of an Appeal: within 10 calendar days from the date the decision is made if the decision involves routine

medical care; or within 48 hours from the date the decision is made, excluding Sundays and holidays, if the

decision involves a medical care determination which qualifies for expedited review.


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10

BENEFIT MANAGEMENT

Blue Cross and Blue Shield of Montana or its designee provides Benefit Management services to its

Members. Benefit Management using plan notification, Prior Authorization and Care Management is

designed to:

Provide information regarding Benefits before the Member receives treatment, services, medicines, or

supplies;

Inform the Member of Benefits regarding proposed procedures or alternate treatment plans;

Inform the Member of Participating Providers, including participating out-of-state providers;

Assist the Member in determining out-of-pocket expenses and identify possible ways to reduce suchexpenses;

Help the Member avoid reductions in payment by The Plan which may occur if the services are notMedically Necessary or the setting is not appropriate;

If appropriate, assign a care manager to work with the Member and the providers to design a treatmentplan.

Although Benefit Management is available, notifying The Plan, obtaining Prior Authorization, or participatingin Care Management is not a guarantee of payment by The Plan.

Plan Notification and Prior Authorization

Plan Notification

The Member should notify The Plan of an Inpatient admission, including admissions to a Hospital, Chemical

Dependency Treatment Center, Mental Illness Treatment Center, Chemical Dependency or psychiatric

residential treatment facility, intensive outpatient programs, Outpatient surgery, or other medical procedure or

service as soon as the provider recommends or schedules services to allow The Plan to begin working with

the Member on Benefit Management. Notifying The Plan does not guarantee payment by The Plan.

Contact The Plan at the number listed on the inside cover of this Member Guide for Plan Notification.

Note: It is NOT necessary to notify The Plan of standard x-ray and lab services or Routine office visits.

Prior Authorization

Prior Authorization is recommended for some services, supplies, treatment and drugs to help the Member

identify potential expenses, payment reductions or claim denials the Member may have if the proposed

services, supplies, medications, or on-going treatment are not Medically Necessary or not a Covered Medical

Expense. Prior Authorization is not a guarantee of payment by The Plan.

Examples of services for which Prior Authorization is recommended include, but are not limited to:

Hospice

Home health

Cosmetic/reconstructive surgery

TMJ surgery

Positron Emission Tomography (PET Scans)

Transplants

Sleep studies

Private duty nursing

Chronic pain programs


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BENEFITS

11

Original purchase, repair, or replacement of durable medical equipment and prosthetics over $500

Therapy services and rehabilitation services to ensure that the services or treatment continue to promoteimprovement and demonstrate measurable progress

Applied Behavior Analysis (ABA) services for Autism, Pervasive Developmental Disorder and AspergersDisorder

Outpatient Prescription Drugs, intended for self-administration, included on the Prescription Drug PriorAuthorization list that may be accessed at www.bcbsmt.com

Prescription drugs administered in or purchased and administered in the providers office (Refer to theProvider Policies/Medical Policy section in the Provider tab on www.bcbsmt.com.)

The Prior Authorization process may require additional documentation from the Members health care

provider or pharmacist. In these cases, a written request for Prior Authorization must be submitted to The

Plan by the health care provider and should include pertinent documentation explaining the proposed

services, the functional aspects of the treatment, the projected outcome, treatment plan and any other

supporting documentation, study models, prescription, itemized repair and replacement cost statements,

photographs, x-rays, etc.

If a Member does not obtain Prior Authorization, a retrospective review will be performed after the claims

have been submitted to determine whether or not the services, supplies, or treatment were MedicallyNecessary and/or performed in the appropriate setting. The Member will be responsible for charges for any

services, supplies, treatment or drugs which were not performed in the appropriate setting or which were not

Medically Necessary as determined by Blue Cross and Blue Shield of Montana Medical Policy or the

Pharmacy Benefit Manager medical policy.

Contact The Plan at the number listed on the inside cover of this Member Guide for Prior Authorization.

Care Management

The goal of Care Management is to help the Member receive the most appropriate care that is also cost

effective. If the Member has an ongoing medical condition or a catastrophic illness, the Member should

contact The Plan. If appropriate, a care manager will be assigned to work with the Member and the Members

providers to design a treatment plan. Care Management includes Member education, referral coordination,utilization review and individual care planning. Involvement in Care Management does not guarantee

payment by The Plan.

ELIGIBILITY AND ENROLLMENT

Who is Eligible

1. All students are eligible if they are:

a. A fee-paying student attending credit courses at a participating campus.

b. A student enrolled for four credit hours or more at all campuses. A student enrolled for less thanfour credit hours is not eligible to enroll in the Student Health Plan.

2. Participation Requirements

a. All students enrolled in school for four credit hours or more are automatically enrolled in the Student

Health Plan for the entire semester unless proof of other coverage is submitted. Coverage for

dependents is optional.

The Student Health Plan fee will be assessed each Fall and Spring/Summer semester at registration.

b. Enrollment in the Student Health Plan is required for all International Students and dependents

(residing within the United States), at all campuses regardless of the number of credit hours.


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The Student Health Plan fee will be assessed each Fall and Spring/Summer semester at registration.

c. Summer only students may enroll in The Plan on an optional basis. Enrollment and payment must

be made within the first 5 class days of the summer semester

d. Waiver of coverage must be made within the first 15 class days of the semester. Only students with

proof of other coverage will be allowed to waive coverage.

Enrollment/Waiver Process

The Effective Date of coverage (for those who apply within the periods of eligibility) will be the date assigned

by the Group.

A specific period of time is allowed at the beginning of each semester for enrolling in The Plan or waiving

coverage. For the Fall and Spring/Summer semesters, the enrollment/waiver period begins on the first day

of scheduled classes each semester and ends 15 class days later. New summer students must visit the

Insurance Office on their campus within 15 class days to enroll.

Effective Date of Coverage

1. For the Student.

a. The effective date of coverage for eligible students shall be the first day of the applicable coverage

period.

b. If a student becomes eligible after the beginning of the applicable coverage period, the students

effective date will be the first day of the applicable coverage period after the required premium is

paid.

2. For Dependents.

a. The effective date of coverage for eligible dependents enrolled at the same time as the student is the

same as the students effective date.

b. If a dependent becomes eligible after the students effective date, the dependents effective date of

coverage will be:

1. The date of marriage (if application is received prior to the date of marriage); or2. The date the application is received (if the application is received after the date of marriage); or

3. After the required dues are paid.

After that time described above, you must wait until the new enrollment period.

c. For Newborn Children.

1. For a newborn born to a Member, the date of birth. Coverage will continue for 31 days.

Coverage for the newborn will be provided only if the Beneficiary Member remains covered on

the health plan during the 31 day period. If the Beneficiary Member does not remain covered for

31 days, the newborn will only be covered for the amount of time (during the 31 days) that the

Beneficiary Member is covered.

2. Within 31 days from the date of birth, The Plan must be notified and any dues must be paid to

The Plan to continue coverage under The Plan. However, after 31 days, coverage will not

continue for any newborn child of a covered Dependent child unless the Beneficiary Member

adopts the newborn child or is the legal guardian of the newborn child.

Late Enrollment

Eligible students will not be allowed to enroll in The Plan after the applicable enrollment/waiver period unless

proof is furnished that the student became ineligible for coverage under another group insurance plan during

the 30 days immediately preceding the date of the request for late enrollment. The coverage will be for the

entire semester.


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BENEFITS

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Special Enrollment for Loss of Coverage

Eligible Individuals

A special enrollment period may be available for the following student students and/or Dependents:

1. Eligible Student.

An eligible student who is not currently enrolled and when enrollment was previously offered to the

student and declined, the student was covered under another group health plan or had other healthinsurance coverage.

2. Dependent of Student.

The Dependent of a student who is not enrolled and when enrollment was previously offered and

declined, the Dependent was covered under another group health plan or had other health insurance

coverage.

3. Eligible Student and Dependent.

An eligible student and Dependent who are not enrolled and when enrollment was previously offered to

the student or Dependent and declined, the student or Dependent was covered under another group

health plan or had other health insurance coverage.

Conditions for Special Enrollment for Loss of Coverage

1. When the student declined enrollment for the student or the Dependent, the student stated in writing that

coverage under another group health plan or other health insurance coverage was the reason for

declining enrollment; and

a. The student or Dependent had COBRA continuation coverage and the COBRA continuation

coverage has expired; or

b. The student or Dependent had other coverage that was not under a COBRA continuation provision

and the other coverage has been terminated because of:

1. A loss of eligibility for the coverage. Loss of eligibility for coverage includes a loss coverage as

a result of legal separation, divorce, death, termination of employment, reduction in the numberof hours of employment, and any loss of eligibility after a period that is measured by reference to

any of the forgoing. However, loss of eligibility does not include a loss of coverage due to failure

of the individual or the Beneficiary Member to pay premiums on a timely basis or termination of

coverage for cause; or

2. Employer contributions towards the other coverage have been terminated; or

3. A situation in which the student or Dependent incurs a claim that would meet or exceed a lifetime

limit on all Benefits.

4. A situation in which The Plan no longer offers any benefits to the class of similarly situated

individuals that includes the individual.

c. The student or Dependent loses eligibility under either the Childrens Health Insurance Program or

the Medicaid Program, or the student or Dependent becomes eligible for financial assistance for

group health coverage, under either the Childrens Health Insurance Program or the Medicaid

Program.

2. The student must request enrollment (for the student or the students Dependents) not later than 31 days

after the exhaustion of the COBRA continuation coverage or termination of the other coverage because

of loss of eligibility or termination of employer contributions.

3. The student must request enrollment for the student and or Dependent not later than 60 days after the

date of termination of coverage under either the Childrens Health Insurance Program or the Medicaid

Program.


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4. The student must request enrollment for the student or Dependent not later than 60 days after the date

the student or Dependent is terminated to be eligible for financial assistance under the Childrens Health

Insurance Program or the Medicaid Program.

5. Enrollment during a special enrollment period is subject to all other applicable enrollment requirements of

The Plan and the provisions of this Member Guide.

Effective Date of Enrollment

Enrollment due to loss of coverage will be effective not later than the first day of the first calendar month

beginning after the date the completed request for enrollment is received.

Special Enrollment in the Case of Marriage, Birth, Adoption or Placement for

Adoption

Enrollment will be effective as follows:

1. In the case of marriage, not later than the first day of the first calendar month beginning after the date the

completed request for enrollment is received by The Plan.

2. For a newborn born to a Member, the date of birth. Coverage will continue for 31 days. Coverage for

the newborn will be provided only if the Beneficiary Member remains covered on the health plan during

the 31 day period. If the Beneficiary Member does not remain covered for 31 days, the newborn will onlybe covered for the amount of time (during the 31 days) that the Beneficiary Member is covered.

Within 31 days from the date of birth, The Plan must be notified and any dues must be paid to The Plan

to continue coverage under The Plan. However, after 31 days, coverage will not continue for any

newborn child of a covered Dependent child unless the Beneficiary Member adopts the newborn child or

is the legal guardian of the newborn child.

3. In the case of a dependents adoption or placement for adoption, the date of such adoption or placement

for adoption. In the event the placement is disrupted prior to legal adoption and the child is removed

from placement, coverage shall cease upon the date the placement is disrupted.

4. Enrollment for loss of coverage will be effective not later than the first day of the first calendar month

beginning after the date the completed request for enrollment is received.Individuals enrolling during a special enrollment period are NOT late enrollees.

When Benefits Begin

The Member is entitled to the Benefits of this Member Guide beginning on the Members Effective Date.

Change of Status

Change of Status cards should be completed and returned to The Plan:

1. Addition of dependents;

2. Deletion of dependents;

3. Name changes; or

4. Address changes.

Payment of additional dues must be made within 31 days.

Refunds

Request for refund of membership dues will be made for the following reasons:

1. Entry into the armed forces of any country; or

2. Withdrawal for nonmedical reasons within the first 15 class days of a semester; or


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BENEFITS

15

3. Death of a student.

Refunds for nonmedical withdrawals after the first 15 class days are not allowed. Coverage will continue to

the end of the semester.

QUALIFIED MEDICAL CHILD SUPPORT ORDER (QMCSO)

Beneficiary Members and Family Members can obtain, without charge, a copy of the procedures governing

Qualified Medical Child Support Order (QMCSO) determinations from Blue Cross and Blue Shield of

Montana.

PREEXISTING CONDITIONS

1. Preexisting Condition

A preexisting condition is a condition for which medical advice, diagnosis, care, or treatment was

recommended or received within the 6-Month period ending on the Members Enrollment Date.

2. Preexisting Condition Exclusion PeriodThere is a 12-Month preexisting condition exclusion period.

3. Benefits During the Preexisting Condition Exclusion Period

The Plan will allow up to $500 per lifetime for Covered Medical Expenses related to all preexisting

conditions combined. Once one or more claims accumulate to the $500, then all claims will be reviewed

for preexisting conditions and the preexisting condition exclusion period will apply. This coverage is

subject to the Deductible and Coinsurance provisions of this Plan.

4. Satisfying the Preexisting Condition Exclusion Period

a. If the Member had Creditable Coverage, which ended no more than 63 days from the date that the

Certificate of Creditable Coverage was issued, the preexisting condition exclusion period will be

reduced by the aggregate of the periods of Creditable Coverage applicable to the Member as of theEnrollment Date.

The Plan will assist the Member, if necessary, in obtaining certification of Creditable Coverage from

previous health insurance carriers. For information on how to request Certificates of Creditable

Coverage, please contact customer service at the telephone number or website listed on the inside

cover of this document.

b. The preexisting condition exclusion period is shown on the Schedule of Benefits and will be reduced

by any Creditable Coverage as described above.

5. Exceptions

The preexisting condition exclusion period does not apply to:

a. Newborn children of any Beneficiary Member or Family Member; or

b. Adopted children or children placed for adoption; or

c. Pregnancy; or

d. Genetic information in the absence of diagnosis of the condition related to the genetic information.


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TERMINATION OF COVERAGE

Termination When No Longer Eligible for Coverage or Family Member Status

Changes

1. When No Longer Eligible for Coverage

Your membership, including any Family Members, will terminate on the earlier of:

a. The last day of the period for which payment has been made; and

b. The date the university is no longer participating in the Student Health Plan; and

c. The date of entry into military service, except for temporary duty of thirty (30) days or less.

In the event the covered student withdraws from the university within the 100 percent refund period, the

following action may take place:

If an unexpected illness or accident forces the student to drop classes, and there was intent by the

individual to finish the course of study during the coverage period, he/she may be covered for the

remainder of the coverage period. (In this case, the Director of the Student Health Center would

make the decision on whether a medical release is in order.) Students who intend to pursue this

option should contact the Health Center within the 100 percent refund period.

2. Change of status

Coverage for a Family Member will terminate automatically at midnight, Mountain Standard Time, on

the last day of the semester in which a child reaches age 26 years or marries. Coverage for a spouse

will terminate at midnight, Mountain Standard Time, on the last day of the Month in which the spouses

marriage to the Beneficiary Member is terminated.

Benefits after Termination of Coverage

When the membership of a Beneficiary Member and/or Family Members is terminated for any reason listed in

this section or any other section, Benefits will no longer be provided and The Plan will not make payment for

services provided to them after the date on which cancellation becomes effective, except in the following

instances:

If the Member is receiving Inpatient Care at a health care facility on the day coverage terminates, the Benefits

of this Member Guide shall be provided:

1. Until the maximum amount of Benefits has been paid.

2. Until the inpatient stay ends.

3. Until the end of a 90-day period from the day coverage terminates.

4. Until the Member becomes covered without limitation as to the condition for which the Member is

receiving Inpatient Care under any other group coverage.

5. Or whichever occurs first.

Conversions Policies

Covered persons who have an ongoing medical condition that has been covered under this Member Guide

may wish to consider obtaining a conversion policy from Blue Cross and Blue Shield of Montana.

Conversion policies are typically more expensive than student health insurance policies or individual policies

because preexisting conditions are covered subject to established rules. A conversion policys Benefits may

differ from those of the Student Health Insurance Plan. Benefits and costs will vary depending upon where

the covered person resides.

Conversion Eligibility Students who have terminated from the Montana University System Student

Insurance Plan are eligible, subject to established rules to purchase an individual conversion policy.


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BENEFITS

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Conversion policies are also available for covered Dependents of a student who dies and for a covered child

who ceases to be an eligible Dependent under the Montana University System Student Insurance Plan. In

addition, a spouse or Domestic Partner who ceases to be eligible due to a divorce, or annulment, or

termination of domestic partnership while the student remains insured will have an option to purchase a

conversion policy.

Conversion Enrollment Application for the individual conversion policy must be made and the first

premium paid within 31 days after the notification of termination of the student or Dependent coverage. The

conversion policy is subject to the student having been insured under the Montana University System

Student Insurance Plan for at least three months.

Health Conversion Application Conversion policies must be purchased from a Blue Cross and Blue

Shield Plan in the state or area in which the covered person intends to reside. Application for a conversion is

initiated by contacting Blue Cross and Blue Shield of Montana.

Montana Comprehensive Health Association (MCHA) If the Member and Dependents meet the eligibility

requirements for MCHA, they may enroll in an MCHA Plan with no proof of insurability. Call Blue Cross and

Blue Shield of Montana for more information.

Changing to Individual (Nonconversion) Policies Students who are in relatively good health may also

apply to purchase an individual insurance policy upon termination of coverage. Individual policies are

available from Blue Cross and Blue Shield of Montana. Another type of individual policy is a short-termpolicy. Short-term policies have designated beginning and ending dates and are renewable for up to six

months in one year; for this reason, they are generally less expensive than renewable individual policies. A

short-term policy can provide temporary coverage for a student who anticipates enrolling in an

employer-sponsored group insurance plan later.

BENEFITS

The Plan will pay for the following Benefits provided by a Covered Provider based on the Allowable Fee and

subject to the Nonparticipating Provider Differential, Deductible, Coinsurance and other provisions, as

applicable.Benefits outlined in this section are subject to any specific exclusions identified for that specific Benefit and to

the exclusions and limitations outlined in the Exclusions and Limitations section.

Each campus has a Health Center and Members are encouraged to use the Health Center. This

facility provides primary care to the campus community. Help is available not only for medical

problems and concerns, but also for maintaining and improving health. Health Center personnel

strive to involve students in their health care through teaching and self-help.

If medical care is required, outside of the Health Center either because the Health Center is closed or

the Health Center refers the Member to another provider, regular Benefits will apply.

Advanced Practice Registered Nurses and Physician AssistantsCertified

Services provided by an Advanced Practice Registered Nurse or a physician assistant certified who is

licensed to practice medicine in the state where the services are provided and when payment would

otherwise be made if the same services were provided by a Physician.

Ambulance

Licensed ambulance travel required for an Emergency Medical Condition to the nearest Hospital with

appropriate facilities. In no event will benefits.


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Anesthesia Services

Anesthesia services provided by a Physician (other than the attending Physician) or nurse anesthetist

including the administration of spinal anesthesia and the injection or inhalation of a drug or other anesthetic

agent.

The Plan will not pay for:

a. Hypnosis;

b. Local anesthesia or intravenous (IV) sedation that is considered to be an Inclusive Service/Procedure;

c. Anesthesia consultations before surgery that are considered to be Inclusive Services/Procedures

because the Allowable Fee for the anesthesia performed during the surgery includes this anesthesia

consultation; or

d. Anesthesia for dental services or extraction of teeth, except as included in the Dental Accident Services

section.

Autism Spectrum Disorders

Diagnosis and treatment of autistic disorder, Aspergers Disorder or Pervasive Developmental Disorder, for

covered Members 18 years of age or younger.Covered services include:

Habilitative or rehabilitative care, including, but not limited to, professional, counseling and guidance

services and treatment programs; Applied Behavior Analysis (ABA), also known as Lovaas Therapy;

discrete trial training, pivotal response training, intensive intervention programs, and early intensive

behavioral intervention

Medications

Psychiatric or psychological care; and

Therapeutic care provided by a speech-language pathologist, audiologist, occupational therapist or

physical therapist

For Members 19 years of age and older, the diagnosis and treatment for autism are covered under Severe

Mental Illness. The diagnosis and treatment of Aspergers Disorder or Pervasive Developmental Disorder

are covered under the Mental Illness Benefit. However, medications/prescription drugs and Applied

Behavior Analysis (ABA) services will not be covered under this Member Guide for Members 19 years of age

or older.

The Schedule of Benefits describes payment limitations for these services.

Blood Transfusions

Blood transfusions, including the cost of blood, blood plasma, blood plasma expanders and packed cells.

Storage charges for blood are paid when a Member has blood drawn and stored for the Members own use

for a planned surgery.

Chemical Dependency

Benefits for Chemical Dependency will be paid as any other Illness.

Outpatient Services

Care and treatment for Chemical Dependency when the Member is not an Inpatient Member and provided

by:

a Hospital;

a Mental Health Treatment Center;

a Chemical Dependency Treatment Center;


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BENEFITS

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a Physician or prescribed by a Physician;

a psychologist;

a licensed social worker;

a licensed professional counselor;

an addiction counselor licensed by the state; or

a licensed psychiatrist.

Outpatient services are subject to the following conditions:

the services must be provided to diagnose and treat recognized Chemical Dependency;

the treatment must be reasonably expected to improve or restore the level of functioning that has beenaffected by the Chemical Dependency; and

no Benefits will be provided for marriage counseling, hypnotherapy, or for services given by a staffmember of a school or halfway house.

Inpatient Care Services

Care and treatment of Chemical Dependency, while the Member is an Inpatient Member, and which are

provided in or by:

a Hospital;

a Freestanding Inpatient Facility; or

a Physician.

Medically managed intensive Inpatient Care services and clinically managed high-intensity residential

services are Benefits of this Group Plan.

Inpatient Care services are subject to plan notification. Please refer to the section entitled Benefit

Management.

Chemotherapy

The use of drugs approved for use in humans by the U.S. Food and Drug Administration and ordered by the

physician for the treatment of disease.

Chiropractic Services

Services of a licensed chiropractor.


Contraceptives

Services and supplies related to contraception, including but not limited to, oral contraceptives, contraceptive

devices and injections, subject to the terms and limitations of the Member Guide.

Routine office calls for contraceptive purposes will be covered.

Convalescent Home Services

Services of a Convalescent Home as an alternative to Hospital Inpatient Care. The Plan will not pay for

custodial care.

NOTE: The Plan will not pay for the services of a Convalescent Home if the Member remains inpatient at the

Convalescent Home when a skilled level of care is not Medically Necessary.



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Dental Accident Services

Dental services provided by physicians, dentists, oral surgeons and/or any other provider are not covered

under this Member Guide except that, Medically Necessary services for the initial repair or replacement of

sound natural teeth which are damaged as a result of an Accident, are covered, except that orthodontics,

dentofacial orthopedics, or related appliances are not covered, even if related to the Accident.

Services and supplies provided by a Hospital in conjunction with dental treatment will be covered only when a

nondental physical Illness or Injury exists which makes Hospital care Medically Necessary to safeguard theMembers health. Dental treatment provided in a Hospital unrelated to a nondental physical Illness or Injury

are not paid by The Plan regardless of the complexity of dental treatment and length of anesthesia.

The Plan will not pay for services for the repair of teeth which are damaged as the result of biting and

chewing.

Dental Extractions

Dental extractions and related sedations.


Diabetic Education

Outpatient self-management training and education services for the treatment of diabetes provided by a

Covered Provider with expertise in diabetes.


Diabetes Treatment (Office Visit)

Services and supplies for the treatment of diabetes provided during an office visit. For additional Benefits

related to the treatment of diabetes, e.g., surgical services and medical supplies, refer to that specific Benefit.

Diagnostic Services

Diagnostic x-ray examinations, laboratory and tissue diagnostic examinations and medical diagnosticprocedures (machine tests such as EKG, EEG) are covered. Covered services include, but are not limited to,

the following:

1. X-rays and Other Radiology. Some examples of other radiology include:

Computerized tomography scan (CT Scan)

MRIs

Nuclear medicine

Ultrasound

2. Laboratory Tests. Some examples of laboratory tests include:

Urinalysis

Blood tests

Throat cultures

3. Diagnostic Testing. Tests to diagnose an Illness or Injury. Some examples of diagnostic testing

include:

Electroencephalograms (EEG)

Electrocardiograms (EKG or ECG)


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BENEFITS

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This Benefit does not include diagnostic services such as biopsies which are covered under the surgery

Benefit.

Durable Medical Equipment

The appropriate type of equipment used for therapeutic purposes where the Member resides. Durable

medical equipment must be:

able to withstand repeated use (consumables are not covered); primarily used to serve a medical purpose rather than for comfort or convenience;

generally not useful to a person who is not ill or injured; and

prescribed by a Physician.

The Plan will not pay for the following items:

exercise equipment;

car lifts or stair lifts;

biofeedback equipment;

self - help devices which are not medical in nature, regardless of the relief they may provide for a medicalcondition;

air conditioners and air purifiers;

whirlpool baths, hot tubs, or saunas;

waterbeds;

other equipment which is not always used for healing or curing;

computerized and "deluxe" equipment like motor - driven wheelchairs or beds when standard equipment isadequate. The Plan will have the right to decide when standard equipment is adequate;

durable medical equipment required primarily for use in athletic activities;

replacement of lost or stolen durable medical equipment;

repair to rental equipment;

duplicate equipment purchased primarily for Member convenience when the need for duplicateequipment is not medical in nature.

Prior Authorization from The Plan is recommended for the original purchase or replacement of durable

medical equipment over $500. Please refer to the section entitled Benefit Management.


Emergency Room Care

1. Emergency room care for an accidental Injury.

2. Emergency room care for Emergency Services.

Foot Orthotics

Foot orthotics provided by a Covered Provider.


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Home Health Care

The following services, when prescribed and supervised by the Members attending Physician provided in the

Members home by a licensed Home Health Agency and which are part of the Members treatment plan:

Nursing services.

Home Health Aide services.

Hospice services. Physical Therapy.

Occupational Therapy.

Speech Therapy.

Medical social worker.

Medical supplies and equipment suitable for use in the home.

Medically Necessary personal hygiene, grooming and dietary assistance.

The Plan will not pay for:

Maintenance or custodial care visits. Domestic or housekeeping services.

"Meals-on-Wheels" or similar food arrangements.

Visits, services, medical equipment, or supplies not approved or included as part of the Memberstreatment plan.

Services for mental or nervous conditions.

Services provided in a nursing home or skilled nursing facility.


Home Infusion Therapy Services

The preparation, administration, or furnishing of parenteral medications, or parenteral or enteral nutritional

services to a Member by a Home Infusion Therapy Agency, including:

Education for the Member, the Members caregiver, or a Family Member.

Pharmacy.

Supplies.

Equipment.

Skilled nursing services when billed by a Home Infusion Therapy Agency.

Note: Skilled nursing services billed by a Licensed Home Health Agency will be covered under the homehealth care Benefit.

Home infusion therapy services must be ordered by a Physician and provided by a licensed Home Infusion

Therapy Agency. A licensed Hospital, which provides home infusion therapy services, must have a Home

Infusion Therapy Agency license or an endorsement to its Hospital facility license for home infusion therapy

services.


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BENEFITS

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Hospice Services

A coordinated program of home care and Inpatient Care that provides or coordinates palliative and supportive

care to meet the needs of a terminally ill Member and the Members Immediate Family. Benefits include:

1. Inpatient and Outpatient care;

2. Home care;

3. Skilled nursing;

4. Counseling and other support services provided to meet the physical, psychological, spiritual and social

needs of the terminally ill Member;

5. Instructions for care of the Member, counseling and other support services for the Members Immediate

Family.

The Plan will not pay for services that do not require skilled nursing care, including custodial care or care for

the convenience of the patient or Family Member.

Hospital Services - Facility and Professional

Inpatient Care Services Billed by a Facility Provider

1. Room and Board Accommodations

a. Room and board, which includes special diets and nursing services.

b. Intensive care and cardiac care units which include special equipment and concentrated nursing

services provided by nurses who are Hospital employees.

2. Miscellaneous Hospital Services

a. Laboratory procedures.

b. Operating room, delivery room, recovery room.

c. Anesthetic supplies.

d. Surgical supplies.

e. Oxygen and use of equipment for its administration.

f. X-ray.

g. Intravenous injections and setups for intravenous solutions.

h. Special diets when Medically Necessary.

i. Respiratory therapy, chemotherapy, radiation therapy, dialysis therapy.

j. Physical Therapy, Speech Therapy and Occupational Therapy.

k. Drugs and medicines which:

1. Are approved for use in humans by the U.S. Food and Drug Administration for the specificdiagnosis for which they are prescribed;

2. Are listed in the American Medical Association Drug Evaluation, Physicians Desk Reference, or

Drug Facts and Comparisons; and

3. Require a Physicians written prescription.

Inpatient Care is subject to plan notification and Prior Authorization. Please refer to the section entitled

Benefit Management.


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Inpatient Care services are subject to the following conditions:

1. Days of care

a. The number of days of Inpatient Care provided is 365 days.

b. In computing the number of Inpatient Care days available, days will be counted according to the

standard midnight census procedure used in most Hospitals. The day a Member is admitted to a

Hospital is counted, but the day a Member is discharged is not. If a Member is discharged on the day

of admission, one day is counted.

c. The day a Member enters a Hospital is the day of admission. The day a Member leaves a Hospital is

the day of discharge.

2. The Member will be responsible to the Hospital for payment of its charges if the Member remains as an

Inpatient Member when Inpatient Care is not Medically Necessary. No Benefits will be provided for a bed

"reserved" for a Member. No Benefits will be paid for Inpatient Care provided primarily for diagnostic or

therapy services.

3. The term "Hospital" does not include the following even if such facilities are associated with a Hospital:

a. a nursing home;

b. a rest home;c. hospice;

d. a rehabilitation facility;

e. a skilled nursing facility;

f. a Convalescent Home;

g. a long - term, chronic - care institution or facility providing the type of care listed above.

Inpatient Care Medical Services Billed by a Professional Provider

Nonsurgical services by a Covered Provider, Concurrent Care and Consultation Services.

Medical services do not include surgical or maternity services. Inpatient Care medical services are coveredonly if the Member is eligible for Benefits under the Hospital Services, Inpatient Care Services section for the

admission.

Medical care visits are limited to one visit per day per Covered Provider unless a Members condition requires

a Physicians constant attendance and treatment for a prolonged period of time.

Observation Beds/Rooms

Payment will be made for observation beds when Medically Necessary, and in accordance with Medical

Policy guidelines, subject to the following limitations:

1. When provided for less than 24 hours;

2. Benefits for observation beds will not exceed the semiprivate room rate that would be billed for anInpatient Care stay.

Outpatient Hospital Services

Use of the Hospitals facilities and equipment for surgery, respiratory therapy, chemotherapy, radiation

therapy and dialysis therapy.

Inborn Errors of Metabolism

Treatment under the supervision of a Physician of inborn errors of metabolism that involve amino acid,

carbohydrate and fat metabolism and for which medically standard methods of diagnosis, treatment and

monitoring exist. Benefits include expenses of diagnosing, monitoring, and controlling the disorders by


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BENEFITS

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nutritional and medical assessment, including but not limited to clinical services, biochemical analysis,

medical supplies, prescription drugs, corrective lenses for conditions related to the inborn error of

metabolism, nutritional management, and Medical Foods used in treatment to compensate for the metabolic

abnormality and to maintain adequate nutritional status.

Mammograms

Mammography examinations.

The minimum mammography examination recommendations are:

1. One baseline mammogram for women ages 35 through 39.

2. One mammogram every two years for women ages 40 through 49, or more frequently as recommended

by a Physician.

3. One mammogram every year for women age 50 or older.

Maternity Services Professional and Facility Covered Providers

1. Prenatal and postpartum care.

2. Delivery of one or more newborns.

3. Hospital Inpatient Care for conditions related directly to pregnancy. Inpatient Care following delivery will

be covered for whatever length of time is necessary and will be at least 48 hours following a vaginal

delivery and at least 96 hours following a delivery by cesarean section. The decision to shorten the length

of stay of Inpatient Care to less than that stated in the preceding sentence must be made by the

attending health care provider and the mother.

Under Federal law, Benefits may not be restricted for any hospital length of stay in connection with

childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than

96 hours following a cesarean section. However, Federal law generally does not prohibit the mothers or

newborns attending provider, after consulting with the mother, from discharging the mother or her

newborn earlier than 48 hours (or 96 hours as applicable). In any case, under Federal law, Covered

Providers may not be required to obtain Prior Authorization from The Plan for prescribing a length of staynot in excess of 48 hours (or 96 hours).

4. Payment for any maternity services by the professional provider is limited to the Allowable Fee for total

maternity care, which includes delivery, prenatal and postpartum care.

Please refer also to the Newborn I

students health plan

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