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Quality health plans & benefitsHealthier livingFinancial well-beingIntelligent solutionsAetna Student HealthPlan Design and Benefits SummaryPreferred Provider Organization (PPO)Towson UniversityPolicy Year: 2021–2022Policy Number: 890420www.aetnastudenthealth.com(877) 437‐6535
This is a brief description of the Student Health Plan. The Plan is available for Towson University students and theireligible dependents. The Plan is underwritten by Aetna Health and Life Insurance Company (Aetna). The exactprovisions, including definitions, governing this insurance are contained in the Certificate issued to you and may beviewed online at www.aetnastudenthealth.com. If there is a difference between this Plan Summary and theCertificate, the Certificate will control.Towson University Health CenterThe Towson University Health Center is the University’s on-campus health facility. Staffed by physicians, nursepractitioners and physician assistants, it is open weekdays from 8:00 a.m. to 5:00 p.m., and is closed on weekendsand holidays. The Nurse Advice line is available after hours and when the health center is closed. The Nurse Line isavailable 24/7 and can be accessed by calling (410) 704-2466. A Registered Nurse will speak to patients and advisethem on the appropriate care needed.For more information, call the Towson University Health Center at (410) 704-2466. In the event of an emergency,call 911 or University Police at (410) 704-2133.Towson University Health Center BenefitsThe following benefits are paid when services are rendered at the Towson University Health Center and subject tothe following Copays and/or yearly maximums: Annual well-woman GYN exam (includes breast exam; pelvic exam and Pap smear (if medically indicated orpatient is 21 or over); and STD screening: Limit one per year, paid at 100%. Routine Physical Exam, including any screening lab and other tests, and any immunizations given inconnection with the exam. Limited to one per year, covered at 100%. TB screening test paid at 100% Allergy shots (Allergy testing/serum not included) paid at 100% after an 8 per visit Copay. All Required and recommended vaccines covered at 100% (Please Note: Meningitis vaccine or waiver is required for students living in on-campus housing.) Treatment of certain skin conditions (non-cystic acne, common warts, and non-malignant moles) paid at100% after a 15 per visit Copay. Smoking Cessation Treatment: 15 per visit Copay.Prescription Drugs* 100% after a 10 Copay for each Tier 1 Generic Prescription Drug 100% after a 40 Copay for each Tier 2 Formulary Brand-Name Prescription Drug 100% after a 60 Copay for each Tier 3 Non-Formulary Brand-Name Prescription DrugReferral RequirementPlease note: To obtain the highest level of benefits, students and their insured dependents may first use theresources of Towson University Health Center for primary care. When care is rendered at Towson University HealthCenter, the 550 Deductible is reduced to 350 (when using a preferred provider) and Covered Medical Expenses arepaid at 100%, following applicable Co-pays. If a student or insured dependent needs a referral to an outsideprovider or facility, the Aetna network of Preferred Providers will be used unless the patient requests otherwise. Byusing Preferred Providers, students and insured dependents receive the highest level of reimbursement: theDeductible will be reduced from 550 to 350 and Covered Medical Expenses paid at 80%. Covered MedicalExpenses incurred for medical treatment outside of the health center for which no referral is obtained or nonPreferred Providers are utilized will result in no reduction of the Deductible.Towson University 2021-2022Page 2
Please Note: Referrals, once issued, are valid per condition, per Policy Year. A new referral is required for eachcondition and for each Policy Year.The Towson University Health Center referral for outside care is not necessary under the followingconditions:1. Medical Emergency. The student should return to the health for necessary follow-up care.2. When UHC is closed.3. When service is rendered at another facility when the health center is closed.4. Medical care received when more than 50 miles away from campus.5. Medical care that is obtained when a student is no longer eligible to use the TUHC due to a change instudent status.6. Gynecological and obstetrical services (including maternity).7. Preventive/Routine Services (services considered preventive according to Health Care Reform and/or servicesrendered not to diagnose or treat an Accident or Sickness).8. Dependents under age 16. (Pediatric Care)Coverage PeriodsStudents: Coverage for all insured students enrolled for the Annual Period will become effective at 12:01 a.m. onAugust 15, 2021 and will terminate at 11:59 p.m. on August 14, 2022. Open enrollment begins August 4, 2021and ends October 1, 2021. Students whose Enrollment Forms and premium payments are received after thePlan’s effective date and prior to the enrollment deadline October 1, 2021, will be made effective August 15, 2021.For Spring-Summer plan, premium payments received prior to enrollment deadline of March 1, 2022 will be madeeffective as of January 15, 2022.Insured dependents: Coverage will become effective on the same date the insured student’s coverage becomeseffective, or the day after the postmarked date when the completed application and premium are sent, if later.Coverage: for insured dependents terminates in accordance with the Termination Provisions described in theMaster Policy. For more information on Termination of Covered Dependents see page 5 of this Summary ofBenefits.Examples include, but are not limited to: the date the student’s coverage terminates, the date the dependent nolonger meets the definition of a dependent.RatesThe rates below include both premiums for the Plan underwritten by Aetna Health and Life Insurance Company(Aetna), as well as a Towson University administrative fee.STUDENTS and DEPENDENTSAnnual8/15/2021 - 8/14/2022Fall8/15/2021 - 1/14/2022Spring/Summer1/15/2022 - 8/14/2022Summer5/15/2022 - 8/14/2022Student 2,999 1,269 1,730 756Spouse 2,856 1,198 1,658 720Child 2,856 1,198 1,658 720Children 5,712 2,396 3,316 1,440Towson University 2021-2022Page 3
Student CoverageEligibilityInternational StudentsAll International Students on F-1, J-1, or other non-employment related Visas are required to enroll in thisInsurance Plan unless an exception is made by the Towson University Health Center. Exceptions are onlymade if the student is insured through a health insurance plan that the Towson University Health Centercurrently participates with and meets the University’s minimum health insurance standards. If theexception is granted, students may apply for a waiver to ensure the plan meets all of the University’sinsurance standards and requirements.All Other StudentsDomestic undergraduate students at Towson University must be enrolled in nine or more credit hours in thesemester in which they wish to enroll or be in one of the following groups: Graduate students in a degree-seeking program taking 6 or more credits, dissertation/thesis credit, andinternship credit or in a joint program taking part of their credits at Towson. Students in special programs such as English Language Center Students and Visiting Scholars. Students who withdraw from Towson on or before the 31st day of the academic term will be removed from theplan and their premium refunded, provided that the plan was not utilized. International students will be automatically billed for the insurance premium on their bursar account.Charges will only be removed if the waiver application is received and the exception is approved by theTowson University Health Center by the published deadlines.Note: You can be covered under this plan as a part-time student if you are: Enrolled as a part-time student due to a documented disability that prevents you from maintaining a full-timecourse load, and Maintaining a course load of at least 7 credit hours per semesterNote: Students who enroll for the annual plan (August 15, 2021 through August 14, 2022) in the fall semester mayremain in the plan for the full year even if taking less than the required credits in the spring semester. However,students who enroll in the plan for the fall semester only (August 15, 2021 through January 14, 2022) and thendrop below the required credits in the spring semester may not renew.EnrollmentInternational students will be automatically enrolled in this plan, unless an exception is made by the TowsonUniversity Health Center by the specified enrollment deadline dates listed in the next section of thisSummary of Benefits. International students will be automatically billed for the insurance premium by theirdepartments. Charges will only be removed if the exception and waiver application are received andapproved by the published deadlines. All other Eligible Towson University students can enroll voluntarilyOnline at www.aetnastudenthealth.com.Exception: A Covered Person entering the armed forces of any country will not be covered under the Policy as ofthe date of such entry. A pro rata refund of premium will be made for such person, and any covered dependents,upon written request received by Aetna within 90 days of withdrawal from school.Towson University 2021-2022Page 4
Dependent CoverageEligibilityCovered students may also enroll their lawful spouse, including legally recognized same sex marriages, same and/oropposite sex domestic partner, and dependent children under age 26.EnrollmentTo enroll the dependent(s) of a covered student, please complete the online Enrollment Application onwww.aetnastudenthealth.com. If the Enrollment Application is received before August 15, 2021, then there willbe no break in coverage. If the Enrollment Application is received after August 15, 2021, and before the Annual/Fallenrollment deadline coverage will be effective August 15, 2021. The Annual/Fall enrollment deadline is October 1,2021. Dependent enrollment applications will not be accepted after October 1, 2021, unless there is a significantlife change that directly affects their insurance coverage.(An example of a significant life change would be loss of health coverage, under another health plan.) The Springenrollment deadline is March 1, 2022. The completed Enrollment Application, and premium, must be submittedonline to Aetna Student Health.For information or general questions on dependent enrollment, contact Aetna Student Health at (877) 437-6535.Important note regarding coverage for a newborn infant or newly adopted child:Your newborn child (including your grandchild) is automatically covered on your health plan from the moment ofbirth. If coverage requires the payment of an additional premium for a dependent, to keep your newborn coveredunder your plan you must enroll the newborn by notifying us (or our agent) of the birth and pay the requiredpremium contribution If you miss this deadline, your newborn will not have health benefits after the first 31 days. If your coverage ends during this 31-day period, then your newborn‘s coverage will end on the same date as yourcoverage. This applies even if the 31-day period has not ended.Upon the death of a spouse or civil union partner, a dependent child previously covered by the spouse or civil unionpartner’s plan.A child that you, or that you and your spouse or civil union partner or domestic partner adopts or is placed with youfor adoption, is automatically covered on your plan for the first 31 days starting on the date of the adoption or thedate the placement is complete, whichever is earlier. To keep your child covered, we must receive your completed enrollment information within 31 days after theadoption or placement for adoption. If coverage requires the payment of an additional premium for a dependent, to keep your adopted child or childlegally placed with you for adoption covered under your plan we must receive your completed enrollmentinformation within the 31 day period. If you miss this deadline, your adopted child or child placed with you for adoption will not have health benefitsafter the first 31 days. If your coverage ends during this 31-day period, then coverage for your adopted child or child placed with you foradoption will end on the same date as your coverage. This applies even if the 31-day period has not ended.A foster child or child under your guardianship – A foster child or a child under your guardianship is automaticallycovered on your plan for 31 days starting on the date you obtain legal responsibility as a foster parent or guardian.A foster child or child under your guardianship is a child whose care, comfort, education and upbringing is left topersons other than the natural parents.Towson University 2021-2022Page 5
If coverage requires the payment of an additional premium for a dependent, to keep your foster child or childunder your guardianship covered under your plan, we must receive your completed enrollment informationwithin that 31-day period. If you miss this deadline, your foster child or child under guardianship will not have health benefits after the first31 days. If your coverage ends during this 31-day period, then coverage for your foster child or child under guardianshipwill end on the same date as your coverage. This applies even if the 31-day period has not ended.A stepchild - You may put a child of your spouse or civil union partner or domestic partner on your plan. You must complete your enrollment information and send it to us within 31 days after the date of your marriageor civil union partnership or your Declaration of Domestic Partnership with your stepchild’s parent. Ask the policyholder when benefits for your stepchild will begin. It is either on the date of your marriage or civilunion partnership or the date your Declaration of Domestic Partnership is filed or the first day of the monthfollowing the date we receive your completed enrollment information. To keep your stepchild covered, we must receive your completed enrollment information within 31 days after thedate of your marriage or civil union partnership or your Declaration of Domestic Partnership. You must still enroll the stepchild within 31 days after the date of your marriage or civil union partnership or yourDeclaration of Domestic Partnership even when coverage does not require payment of an additional premiumcontribution for the stepchild. If you miss this deadline, your stepchild will not have health benefits after the first 31 days. If your coverage ends during this 31-day period, then your stepchild‘s coverage will end on the same date as yourcoverage. This applies even if the 31-day period has not ended.Dependent coverage due to a court order: If you must provide coverage to a dependent because of a court order,your dependent is covered on your health plan for the first 31 days from the court order. To keep your dependent covered, we must receive your completed enrollment information within 31 days of thecourt order. You must still enroll the dependent within 31 days of the court order even when coverage does not requirepayment of an additional premium contribution for the dependent. If you miss this deadline, your dependent will not have health benefits after the first 31 days. f your coverage ends during this 31-day period, then your dependent’s coverage will end on the same date asyour coverage. This applies even if the 31-day period has not ended.If you need information or have general questions on dependent enrollment, call Member Services at (877) 437 6535.Medicare Eligibility NoticeYou are not eligible to enroll in the student health plan if you have Medicare at the time of enrollment in thisstudent plan. The plan does not provide coverage for people who have Medicare.Towson University 2021-2022Page 6
Termination and RefundsWithdrawal from Classes – Leave of Absence: If you withdraw from classes under a school-approved leave ofabsence, your coverage will remain in force through the end of the period for which payment has been receivedand no premiums will be refunded.Withdrawal from Classes – Other than Leave of Absence: If you withdraw from classes other than under a schoolapproved leave of absence within 31 days* after the policy effective date, you will be considered ineligible forcoverage, your coverage will be terminated retroactively and any premiums collected will be refunded. If thewithdrawal is more than 31 days after the policy effective date, your coverage will remain in force through the endof the period for which payment has been received and no premiums will be refunded. If you withdraw fromclasses to enter the armed forces of any country, coverage will terminate as of the effective date of such entry and apro rata refund of premiums will be made if you submit a written request within 90 days of withdrawal fromclasses.In-network Provider NetworkAetna Student Health offers Aetna’s broad network of In-network Providers. You can save money by seeing Innetwork Providers because Aetna has negotiated special rates with them, and because the Plan’s benefits arebetter.If you need care that is covered under the Plan but not available from an In-network Provider, contact MemberServices for assistance at the toll-free number on the back of your ID card. In this situation, Aetna may issue a pre approval for you to receive the care from an Out-of-network Provider. When a pre-approval is issued by Aetna, thebenefit level is the same as for In-network Providers.PrecertificationYou need pre-approval from us for some eligible health services. Pre-approval is also called precertification. Your innetwork physician is responsible for obtaining any necessary precertification before you get the care. [When you goto an out-of-network provider, it is your responsibility to obtain precertification from us for any services andsupplies on the precertification list. If you do not precertify when required, there is a 500 penalty for each type ofeligible health service that was not precertified. The penalty will not exceed the cost of the eligible health services.For a current listing of the health services or prescription drugs that require precertification, contact MemberServices or go to www.aetnastudenthealth.com.Precertification CallPrecertification should be secured within the timeframes specified below. To obtain precertification, call MemberServices at the toll-free number on your ID card. This call must be made:Non-emergency admissions:You, your physician or the facility will need to call and requestprecertification at least 14 days before the date you are scheduled to beadmitted.An emergency admission:You, your physician or the facility must call within 48 hours or as soon asreasonably possible after you have been admitted.An urgent admission:You, your physician or the facility will need to call before you arescheduled to be admitted. An urgent admission is a hospital admissionby a physician due to the onset of or change in an illness, the diagnosisof an illness, or an injury.Outpatient non-emergency servicesrequiring precertification:You or your physician must call at least 14 days before the outpatientcare is provided, or the treatment or procedure is scheduled.Towson University 2021-2022Page 7
We will provide a written notification to you and your physician of the precertification decision, where required bystate law. If your precertified services are approved, the approval is valid for 30 days as long as you remain enrolledin the plan.Coordination of Benefits (COB)Some people have health coverage under more than one health plan. If you do, we will work together with yourother plan(s) to decide how much each plan pays. This is called coordination of benefits (COB). A completedescription of the Coordination of Benefits provision is contained in the certificate issued to you.Description of BenefitsThe Plan excludes coverage for certain services and has limitations on the amounts it will pay. While this PlanSummary document will tell you about some of the important features of the Plan, other features that may beimportant to you are defined in the Certificate. To look at the full Plan description, which is contained in theCertificate issued to you, go to www.aetnastudenthealth.com.This Plan will pay benefits in accordance with any applicable Maryland Insurance Law(s).Select care coverageIn-network coverageOut-of-network coveragePolicy year deductiblesYou have to meet your policy year deductible before this plan pays for benefits.StudentNone 550 per policy year, reduced to 350 when referredfrom the Student Health Center to In-Network providersSpouseNone 550 per policy year, reduced to 350 when referredfrom the Student Health Center to In-Network providersEach childNone 550 per policy year, reduced to 350 when referredfrom the Student Health Center to In-Network providersfor dependents over age 16. Dependents under age 16can have their deductible reduced to 350 if they initiatetreatment with an In-Network providerPolicy year deductible waiverThe policy year deductible is waived for all of the following eligible health services: In-network care for Preventive care and wellness Any service identified as “no policy year deductible applies” in the schedule of benefitsIndividual deductibleThis is the amount you incur for in-network and out-of-network eligible health services each policy year beforethe plan begins to pay for eligible health services. This policy year deductible applies separately to you and eachof your covered dependents. After the amount you incur for eligible health services reaches the policy yeardeductible, this plan will begin to pay for eligible health services for the rest of the policy year.Maximum out-of-pocket limitsSelect care coverageIn-network coverageOut-of-network coverageStudentNone 8,550 per policy year 8,550 per policy yearSpouseNone 8,550 per policy year 8,550 per policy yearEach childNone 8,550 per policy year 8,550 per policy yearFamilyNone 17,100 per policy yearNoneEligible health services applied to the out-of-network maximum out-of-pocket limit will not be applied to satisfythe in-network maximum out-of-pocket limit and eligible health services applied to the in-network maximumout-of-pocket limit will not be applied to satisfy the out-of-network maximum out-of-pocket limit.Towson University 2021-2022Page 8
Referral penaltyYou may get a referral from school health services for off-campus care.If you get a referral, we will reduce the in-network or out-of-network policy year deductible by 200.You can request a referral to a specialist or a non-physician specialist who is not part of Aetna’s or the schoolhealth services provider panel.Exceptions Treatment for an emergency medical condition Obstetric and gynecological care Preventive/Routine Services (services considered preventive according to Health Care Reform and/orservices rendered not to diagnosis or treat an Accident or Sickness). Pediatric care The school health services is closed You are more than 50 miles from the school health servicesYour dependent children under age 16 do not use the school health services for care so they don’t need to getreferrals.Eligible health servicesSelect care coverageIn-network coverageOut-of-network coverage100% per visit100% (of the negotiatedcharge) per visit80% (of the recognizedcharge) per visitRoutine physical examsPerformed at a physician’sofficeNo copayment or policyyear] deductible appliesMaximum age and visitlimits per policy yearthrough age 21Subject to any age and visit limits provided for in the comprehensive guidelinessupported by the American Academy of Pediatrics/Bright Futures/Health Resourcesand Services Administration guidelines for children and adolescents.Covered persons age 22and over: Maximum visitsper policy yearSubject to any age limits provided for in the comprehensive guidelines supported bythe Health Resources and Services Administration.Preventive care immunizationsPerformed in a facility orat a physician's office100% per visit100% (of the negotiatedcharge) per visit80% (of the recognizedcharge) per visitNo copayment or policyyear deductible appliesMaximumsTowson University 2021-2022Subject to any age limits provided for in the comprehensive guidelines supported byAdvisory Committee on Immunization Practices of the Centers for Disease Controland PreventionPage 9
Eligible health servicesSelect care coverageIn-network coverageOut-of-network coverageRoutine gynecological exams (including Pap smears and cytology tests)100% (of the negotiatedcharge) per visit80% (of the recognizedcharge) per visitNo copayment or policyyear deductible appliesNo policy year deductibleappliesPerformed at aphysician’s, obstetrician(OB), gynecologist (GYN)or OB/GYN office100% per visitMaximumsSubject to any age limits provided for in the comprehensive guidelines supported bythe Health Resources and Services Administration.Preventive screening and counseling servicesPreventive screening andcounseling services forObesity and/or healthydiet counseling, Misuse ofalcohol & drugs,Depression Screening,Sexually transmittedinfection counseling &Genetic risk counseling forbreast and ovarian cancerServices not availablePreventive screening andcounseling services forTobacco Products100% per visit100% (of the negotiatedcharge) per visit80% (of the recognizedcharge) per visitNo copayment or policyyear deductible applies100% (of the negotiatedcharge) per visit80% (of the recognizedcharge) per visitNo copayment or policyyear deductible appliesRoutine cancer screeningsServices not availableBreast cancer screening isnot subject to deductible100% (of the negotiatedcharge) per visit80% (of the recognizedcharge) per visitNo copayment or policyyear deductible appliesNo policy year deductibleappliesMaximum:Subject to any age; family history; and frequency guidelines as set forth in the mostcurrent: Evidence-based items that have in effect a rating of A or B in the currentrecommendations of the United States Preventive Services Task Force; and The comprehensive guidelines supported by the Health Resources and ServicesAdministration.Prenatal care services(Preventive care servicesonly)Services not available100% (of the negotiatedcharge) per visit80% (of the recognizedcharge) per visitNo copayment or policyyear deductible appliesTowson University 2021-2022Page 10
Eligible health servicesSelect care coverageIn-network coverageOut-of-network coveragePreventive screening and counseling services (continued)Lactation support andcounseling servicesServices not available100% (of the negotiatedcharge) per visit80% (of the recognizedcharge) per visitNo copayment or policyyear deductible appliesMaximumsBreast pump supplies andaccessoriesSubject to any age and visit limits provided for in the comprehensive guidelinessupported by the Health Resources and Services Administration.Services not available100% (of the negotiatedcharge) per item80% (of the recognizedcharge) per itemNo copayment or policyyear deductible appliesFamily planning services – female contraceptivesFemale contraceptivecounseling servicesoffice visitServices not available100% (of the negotiatedcharge) per visit80% (of the recognizedcharge) per visitNo copayment or policyyear deductible appliesMaximumsSubject to any age and visit limits provided for in the comprehensive guidelinessupported by the Health Resources and Services Administration.Female contraceptiveprescription drugs anddevices provided,administered, or removed,by a provider during anoffice visit100% per itemFemale Voluntarysterilization - Inpatient &Outpatient providerservicesServices not available100% (of the negotiatedcharge) per item80% (of the recognizedcharge) per itemNo copayment or policyyear deductible applies100% (of the negotiatedcharge)80% (of the recognizedcharge)No copayment or policyyear deductible appliesPhysicians and other health professionalsPhysician & specialistincluding ConsultantsOffice visitsNurse visit: 8 copayment then theplan pays 100% per visitIncludes telehealthconsultationPhysician visit: 15 copayment then theplan pays 100% per visitTowson University 2021-202280% (of the negotiatedcharge) per visit60% (of the recognizedcharge) per visitPage 11
Eligible health servicesSelect care coverageIn-network coverageOut-of-network coverageCovered according to thetype of benefit and theplace where the service isreceivedCovered according to thetype of benefit and theplace where the service isreceivedAllergy testing and treatment (including allergy serum)Allergy testing & Allergyinjections treatmentincluding Allergy sera andextracts administered viainjection performed at aphysician’s or specialist’sofficeServices not availablePhysician and specialist surgical servicesInpatient surgeryperformed during yourstay in a hospital orbirthing center by asurgeonServices not available80% (of the negotiatedcharge)60% (of the recognizedcharge)AnesthetistServices not available80% (of the negotiatedcharge)60% (of the recognizedcharge)Surgical assistantServices not available80% (of the negotiatedcharge)60% (of the recognizedcharge)Outpatient surgeryperformed at a physician’sor specialist’s office oroutpatient department ofa hospital or surgerycenter by a surgeonServices not available80% (of the negotiatedcharge) per visit60% (of the recognizedcharge) per visitAnesthetistServices not available80% (of the negotiatedcharge) per visit60% (of the recognizedcharge) per visitSurgical assistantServices not available80% (of the negotiatedcharge) per visit60% (of the recognizedcharge) per visit 25 copayment then theplan pays 80% (of thebalance of the negotiatedcharge) per visit 25 copayment then theplan pays 60% (of thebalance of the recognizedcharge) per visitServices not available 100 copayment then theplan pays 80% (of thebalance of the negotiatedcharge) per adm
Towson University Health Center . The Towson University Health Center is the University’s on-campus health facility. Staffed by physicians, nurse practitioners and physician assistants, it is open weekdays from 8:00 a
