2013-200118-1 flyer-v6_benefit summary

Student Injury and Sickness Insurance Plan
for the Undergrad, Graduate & International
Students of the Kansas Board of Regents
State Universities
2013-2014
The Kansas Board of Regents (KBOR) is pleased to offer an Injury and Sickness Insurance Plan underwritten by UnitedHealthcare InsuranceCompany. Domestic undergraduate degree seeking students who are enrolled during fall and/or Spring Semester who are undergraduates taking6 or more credit hours (3 or more credit hours during the summer semester) or on a school approved/sponsored internship, or International studentson Optional Practical Training are eligible to enroll in this insurance plan. Health Science Students are required to have health insurance and musteither enroll in this plan or show proof of health insurance coverage in an alternative plan. Masters Students taking 3hrs/semester, participants ina school approved/sponsored internship, Doctoral Student, and Post Doctoral Fellows are eligible to enroll in this insurance plan. F-1 Internationalstudents and J-1 Exchange Visitors are required to have health insurance and must either enroll in this plan or show proof of health insurancecoverage in an alternative plan that meets their university's requirements. Students must attend classes for at least the first 31 days after the startdate of the policy. Semester based online courses, home study and correspondence classes do not count. Highlights of the Coverage and Services
offered by UnitedHealthcare StudentResources are:
UnitedHealthcare InsuranceCompany and is based on policy Up to $500,000 Per Policy Year Maximum Benefit for Covered Medical Expenses.
$300 Deductible for Preferred Providers Per Insured Person Per Policy Year, $600 Deductible for Outof Network Providers Per Insured Person Per Policy Year .
Covered Medical Expenses for Preferred Providers are payable at 80% of Preferred Allowance and Out of Network benefits are payable at 60% of Usual and Customary charges (all benefits are subject to satisfaction of the Deductible, specific benefit limitations, maximums and Copays as described in Preferred Provider Out-of-Pocket Maximum of $10,000 Per Insured Person, Per Policy Year. Out-of- Network Out-of-Pocket maximum of $20,000 Per Insured Person, Per Policy Year. After the Out-of-Pocket Maximum has been satisfied, Covered Medical Expenses will be paid at 100% up to the policy Maximum Benefit subject to any applicable benefit maximums. Refer to the plan certificate for details about how the Prescription Drug Benefits: $5 Copay per prescription for generic prescriptions / 30% Copay for brand name prescriptions filled at the Student Health Center. $15 Copay for Tier 1 / 30% Copay for Tier 2 up to a 31-day supply per prescription filled at a UnitedHealthcare Pharmacy (UHCP). $20Copay for generic drugs / 40% Copay for brand name up to a 31-day supply per Prescription at an Preventive Care Services which include, but are not limited to, annual physicals, GYN exams, routine screenings and immunizations are covered at 100% with no Copay or deductible only when the services are received from a Preferred Provider. Please see www.healthcare.gov for complete detailsof the services provided for specific age and risk groups.
Coverage available for eligible Dependents.
The deductible will be waived and benefits paid at 100% for treatment rendered for Covered MedicalExpenses at the Student Health Center.
The Preferred Provider Network for this plan is UnitedHealthcare Choice Plus. Additionally, forPittsburg State University students, Mount Carmel Regional Medical Center is a Preferred Provider.
Preferred Providers can be found using the following link,http://www.uhcsr.com/lookupredirect.aspx?delsys=52 FrontierMEDEX – Domestic Students are eligible for FrontierMEDEX services when 100 miles ormore away from your campus address and 100 miles or more away from your permanent homeaddress . International Students are covered worldwide except in their home country.
Your student health insurance coverage, offered by UnitedHealthcare Insurance Company
may not meet the minimum standards required by the healthcare reform law for
restrictions on annual dollar limits. The annual dollar limits ensure that consumers have
sufficient access to medical benefits throughout the annual term of the policy. Restrictions
for annual dollar limits for group and individual health insurance coverage are $1.25 million
for policy years before September 23, 2012; and $2 million for policy years beginning on or
after September 23, 2012 but before January 1, 2014. Restrictions on annual dollar limits for
student health insurance coverage are $100,000 for policy years before September 23, 2012
and $500,000 for policy years beginning on or after September 23, 2012, but before January
1, 2014. Your student health insurance coverage puts a policy year limit of $500,000 for
each Injury or Sickness that applies to the essential benefits provided in the Schedule of
Benefits unless otherwise specified. If you have any questions or concerns about this
notice, contact Customer Service at 1-888-344-6104. Be advised that you may be eligible
for coverage under a group health plan of a parent's employer or under a parent’s individual
health insurance policy if you are under the age of 26. Contact the plan administrator of
the parent’s employer plan or the parent’s individual health insurance issuer for more
information.
UnitedHealthcare StudentResources
8/1/13 - 7/31/14 8/1/13 - 12/31/13 1/1/14 - 5/31/14 Student and Spouse
Student and All Children
Student, Spouse & All Children $10,888.00
PRE-EXISTING CONDITION means: 1) the existence of symptoms within
“Creditable Prior Coverage” means any individual or group policy, the 6 months immediately prior to the Insured's Effective Date under the policy; contract or program provided by an HMO, Insurer, self-insured employer or, 2) any condition which originates, is diagnosed, treated or recommended plan or any other entity that arranges or provides medical, hospital or for treatment within the 6 months immediately prior to the Insured's Effective surgical coverage, not designed to supplement other private or governmental plans. It should include prior coverage under a group or EXCLUSIONS AND LIMITATIONS
individual sickness and accident policy, provided by a government plan(such as Medicaid and Medicare) COBRA, CHAMPUS, the Federal No benefits will be paid for: a) loss or expense caused by, contributed to, or Employee Health Benefits Plan, Peace Corps Plans, the Indian Health resulting from; or b) treatment, services or supplies for, at, or related to any of Service, coverage provided through state high risk pools and other 1. Automobile Excess- No payment will be made for Hospital, medical or Insured Persons who have been insured under a coverage as defined in other health services resulting from accidental bodily Injury arising out of Creditable Prior Coverage and have no gap in such coverage that a motor vehicle accident to the extent that benefits are payable under exceeds 63 days immediately prior to enrollment in this plan will receive any medical expense payment provision of any automobile insurance the applicable amount of credit for prior coverage. If an Insured Person policy, including such benefits mandated by law; has 9 months prior creditable coverage with no gap in coverage 2. Congenital conditions, except as specifically provided for Newborn or exceeding 63 days immediately prior to enrollment in this plan the pre- 3. Cosmetic procedures, except cosmetic surgery required to correct an 16. Prescription Drugs, services or supplies as follows: Injury for which benefits are otherwise payable under this policy or for Therapeutic devices or appliances, including: hypodermic needles, syringes, support garments and other non-medical substances, 4. Custodial Care services and supplies related to custodial care such as regardless of intended use, except as specifically provided in the care provided in rest homes, health resorts, homes for the aged, halfway houses, college infirmaries or places mainly for domiciliary or Custodial Immunization agents, except as specifically provided in the policy, Care. Extended care in treatment or substance abuse facilities also are biological sera, blood or blood products administered on an not covered for domiciliary or Custodial Care; 5. Acne; acupuncture; alopecia; biofeedback-type services; corns, Drugs labeled, “Caution - limited by federal law to investigational calluses and bunions; deviated nasal septum; hirsutism; learning use” or experimental drugs, except for drugs for the treatment of disabilities; nasal and sinus surgery, except for treatment of a Covered cancer that are recognized treatment in one of the standard Injury; nicotine addiction, except as specifically provided in the policy; reference compendia or in substantially accepted peer reviewed obesity and any condition resulting therefrom; patient controlled analgesia (PCA); skeletal irregularities of one or both jaws, including orthognathia and mandibular retrognathia; sleep disorders, including Drugs used to treat or cure baldness; anabolic steroids used for testing thereof; temporomandibular joint dysfunction; Elective and Anorectics - drugs used for the purpose of weight control; Fertility agents or sexual enhancement drugs, such as Parlodel, 7. Eye examinations, eye refractions, eyeglasses, contact lenses, Pergonal, Clomid, Profasi, Metrodin, Serophene, or Viagra; prescriptions or fitting of eyeglasses or contact lenses, vision correctionsurgery, or other treatment for visual defects and problems; except when due to a covered Injury or disease process; Refills in excess of the number specified or dispensed after one (1) 8. Hearing examinations; hearing aids; or other treatment for hearing defects and problems, except as a result of an infection or trauma.
17. Reproductive/Infertility services including but not limited to: family "Hearing defects" means any physical defect of the ear which does or planning; fertility tests; infertility (male or female), including any services can impair normal hearing, apart from the disease process; or supplies rendered for the purpose or with the intent of inducing 9. Immunizations services and supplies related to immunizations, except as conception. Examples of fertilization procedures are: ovulation specifically provided in the policy; preventive medicines or vaccines, induction procedures, in vitro fertilization, embryo transfer or similar except where required for treatment of a covered Injury or as specifically procedures that augment or enhance your reproductive ability; premarital examinations; impotence, organic or otherwise; femalesterilization procedures, except as specifically provided in the policy; 10. Injury caused by, contributed to, or resulting from the addiction to or use of alcohol, intoxicants, hallucinogenics, illegal drugs, or any drugs ormedicines that are not taken in the recommended dosage or for the 18. Routine Newborn Infant care, well-baby nursery and related Physician purpose prescribed by the Insured Person's Physician; charges; except as specifically provided in the policy; 11. Injury or Sickness for which benefits are paid or payable under any 19. Preventive care services; routine physical examinations and routine Workers' Compensation or Occupational Disease Law or Act, or similar testing; preventive testing or treatment; screening exams or testing in the absence of Injury or Sickness; except as specifically provided in thepolicy; 12. Injury sustained while (a) participating in any interscholastic, intercollegiate, or professional sport, contest or competition; (b) traveling 20. Skydiving, parachuting, hang gliding, glider flying, parasailing, sail to or from such sport, contest or competition as a participant; or (c) while planing, bungee jumping, or flight in any kind of aircraft, except while participating in any practice or conditioning program for such sport, riding as a passenger on a regularly scheduled flight of a commercial 13. Organ transplants, including organ donation; 21. Suicide or attempted suicide while sane or insane (including drug overdose); or intentionally self-inflicted Injury; 14. Participation in a riot or civil disorder; commission of or attempt to 22. Surgical breast reduction, breast augmentation, breast implants or breast prosthetic devices, or gynecomastia, except as specifically 15. Pre-existing Conditions except for: 1) individuals who have been continuously insured for at least 9 months under any plan as definedunder Creditable Prior Coverage if the previous coverage was 23. Treatment in a Government hospital, unless there is a legal obligation for continuous to a date not more than 63 days prior to the Insured’s the Insured Person to pay for such treatment; and Effective Date under the Policy; or 2) individuals who have been 24. War or any act of war, declared or undeclared; or while in the armed continuously insured for at least 9 months under the school’s student forces of any country (a pro-rata premium will be refunded upon request insurance policy; or 3) an Insured Person who is under age 19.

Source: http://iss.ku.edu/pdf/insurance/insurance-brochure.pdf