Special Provisions of the Policy

Newborn Children At the birth of a child to a covered student or covered spouse while the student's insurance is in force, that child will automatically become a covered person from the moment of birth, including:

  1. injury
  2. sickness
  3. medically necessary care and treatment of congenital
  4. defects and birth abnormalities
  5. necessary care and treatment of cleft lip and cleft palate
  6. other care specifically indicated in the Policy.

Coverage will continue without cost for 31 days. If the student has no other covered children, payment for the child's coverage must be remitted within that 31-day period, or the coverage will terminate for that child at the end of the 31-day period.

IMPORTANT NOTE: Hospital charges and associated ancillary charges in conjunction with newborn well baby care following birth are eligible expenses subject to deductible and coinsurance.

Pregnancy Benefits Pregnancy Benefits are provided as any other sickness. Routine pre-natal charges will be paid after delivery. Maternity coverage will include coverage for inpatient care for a mother and her newborn child for a minimum of forty-eight (48) hours after vaginal delivery and a minimum of ninety six (96) hours after delivery by cesarean section.

Mental Health/Substance Abuse Care (except for biologically-based Mental Illnesses)

  • In-Patient: In-Network Maximum: 80% Maximum Allowable payable up to a maximum of 45 days per plan year. Out-of-Network Maximum: 50% Usual and Customary payable up to a maximum of 45 days per plan year. Each 1 day of inpatient care will reduce 2 days of the Partial Care Benefit.
  • Out-Patient: 80% In-Network Maximum Allowable up to a maximum of $1,000 per plan year. 50% Usual and Customary up to a maximum of $1,000 per plan year. There is a $15 co-pay for each out-patient visit.

Biologically-Based Mental Illness Means Schizophrenia, Schizoaffective Disorder, Bipolar Affective Disorder, major depressive disorder, specific obsessive disorder, and panic disorder. Payable as any other illness.

  • In-Network 80% In-Network Maximum Allowable
  • Out-of-Network Maximum: 50% Usual and Customary

State Mandated Benefits

Mammography - Plan pays 80% of maximum allowable not subject to deductible for In Network or 50% Usual and Customary for Out-of-Network, not subject to deductible, according to the following schedule: A baseline mammography for participants between the ages of 35 and 40; once every two years from age 40 to age 49; and yearly for ages 50-65 (unless high risk factors).

Pap Smear - Plan pays 80% (in Network) of maximum allowable for one annual pap smear per plan year or more frequently if recommended by a doctor, not subject to deductible. Or 50% Usual and Customary for Out-of-Network, not subject to deductible.

Prostate Screening Antigen Test (PSA) - Plan pays 80% of maximum allowable for a PSA In Network and 50% Usual and Customary Out-of-Network. Limited to one PSA per plan year for eligible participants age 40 and over.

Child Health Supervision Services - Preventive services and immunizations for dependent children up to age 13. 80% maximum allowable, 50% Out-of-Network U&C. The above wellness benefits are not subject to the deductible.

Home Health Care - Charges by a Home Health Care Agency are limited to 60 visits per year and shall only be covered when such care is ordered by a physician and the patient is confined to his or her home. 80% Maximum Allowable In-Network, 50% U&C Out-of-Network. Limited to 60 visits per plan year.

Outpatient Physical Therapy - Benefits are limited to one visit per day. 80% In-Network allowable, 50% U&C Out-of-Network. Limited to $500 per injury or sickness per plan year. The $500 plan year maximum does not apply if performed immediately after a surgical procedure. Chiropractic charges are covered under outpatient physical therapy and are limited to a $500 lifetime maximum. Accupuncture is excluded from Coverage.

Other Benefits

Hospice Care - Hospice care expenses shall only be covered when provided by a licensed agency for the care of terminally ill patients. Care must be ordered by a physician and reviewed monthly. 80% In-Network allowable, 50% U&C Out-of-Network.

Dental Care - Expenses for dental care are limited to expenses resulting from accidental injury to sound natural teeth. This benefit is payable up to $500 per accidental injury. 80% In-Network allowable, 50% U&C Out-of-Network.

Right of Subrogation and Recovery - The company shall be fully and completely subrogated, unless otherwise prohibited by law, to the rights of the Covered Person against parties who maybe liable to provide indemnity or make a contribution in respect to any matter that is the subject of a claim under this Policy. The Covered Person further agrees to Cooperate fully with Insurers in seeking such indemnity or contribution including, where appropriate, when the Company is instituting proceedings at its own expense against such parties in the name of the Covered Person. Payments made by the Company, which exceed the Covered Medical Expenses (after allowance fo9r Deductible and Coinsurance clauses, if any) payable hereunder shall be recoverable by the Company from or among any persons, firms, or Corporations to or for whom such payments were made or from any insurance organizations who are obligated in respect of any covered Injury or Sickness as their liability may appear.

Coordination of Benefits- If a covered person is also covered under one or more other Plans, the benefits payable under the Policy will be coordinated with the benefits payable under all other Plans under which an individual is covered so that the total benefits paid will not exceed 100% of the eligible expenses incurred.

Extension of Benefits - Should an insured person be totally disabled when his or her insurance terminates under this policy, Covered Expenses for the disabling condition will be payable up the Plan's maximum amount during the continuance of total disability; however, all such payments shall cease on the earliest of the following events: (1) when the insured person is no longer totally disabled; (2) when the insured person becomes eligible for coverage under any other group insurance policy; (3) at the end of the three (3) months following termination of insurance.