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Aetna Student HealthPlan Design and Benefits SummarySUNY Upstate Medical UniversityPolicy Year: 2015 - 2016Policy Number: 867883www.aetnastudenthealth.com(855) 821-9718
This is a brief description of the Student Health Plan. The Plan is mandatory for all SUNY Upstate Medical Universitystudents and is eligible for their dependents. The Plan is underwritten by Aetna Life Insurance Company (Aetna). Theexact provisions governing this insurance are contained in the Certificate of Coverage issued to you and may be viewedonline at www.haylor.com/upstate. If any discrepancy exists between this Benefit Summary and the Certificate, theCertificate of Coverage will govern and control the payment of benefits.SUNY Upstate Medical University Health ServicesStudent Health encompasses medical care, health screening and counseling services for matriculated Upstate MedicalUniversity students at the main campus in Syracuse and the Binghamton clinical campus.The Upstate Medical University Student Health office – Syracuse Campus is located at 175 Elizabeth Blackwell Street,Syracuse, NY, in Jacobsen Hall on the 4th floor. Hours of operation are Monday through Friday 7:30 am 5:00 pm. Afterhours, weekend and holiday coverage is provided through University Internists at (315) 464-6527.If you have any questions about health insurance benefits, claim questions, or how to enroll a dependent, please contactour servicing broker at:Haylor, Freyer & Coon, Inc.866-535-0456Or online atstudent@haylor.comIf you have any questions about our Health Center, please contact:Lori Brooks-SingletonStudent Health SecretaryPhone: (315) 464-5470 ext. 4Email: brooksL@upstate.edu.Coverage PeriodsStudents: Coverage will become effective at 12:01 AM on the Coverage Start Date indicated below, and will terminate at11:59 PM on the Coverage End Date indicated.Eligible Dependents: Coverage for dependents eligible under the Plan for the following Coverage Periods. Coverage will,will become effective at 12:01 AM on the Coverage Start Date indicated below August 1, 2015, and will terminate at11:59 PM on the Coverage End Date indicated July 31, 2016. Coverage for insured dependents terminates in accordancewith the Termination Provisions described in the Master Policy.Coverage PeriodCoverage Start DateCoverage End DateEnrollment/Waiver tudentRatesUndergraduates and Graduate StudentsAnnual 6,327Spouse 6,327One Child 6,327Two or More Children 12,654*Note: Guardian dental, Life, and AD D is added to this cost by the University.SUNY Upstate Medical University 2015-2016Page 2
Student CoverageEligibilityAll students enrolled in a degree program at SUNY Upstate Medical University, who actively attend classes for at leastthe first 31 days after the date when coverage becomes effective. If it is discovered that this eligibility requirement hasnot been met, our only obligation is to refund premium, less any claims paid.EnrollmentMaintaining health insurance coverage is mandatory for all SUNY Upstate students and all students MUST be covered bya domestic health insurance plan. All students are required to enroll in the SUNY Upstate - Sponsored Student HealthInsurance Plan unless an acceptable Waiver is provided in a timely manner. The acceptable coverage to waive the SUNYUpstate - Sponsored Student Health Insurance Plan is a parent's group plan, a spouse's group plan, a student's ownemployer group plan, Medicaid or VA Benefits.If you have active health insurance with benefits which meet the criteria below you may apply for waiver of enrollmentin the SUNY Upstate plan. You will need to have your current insurance ID card and information regarding your planbenefits to complete the process. Once you have submitted the required information you will receive an email verifyingif your waiver meets the SUNY Upstate requirements. Waivers will be accepted through July 31st. Please be aware thatyou will be automatically enrolled in the health insurance and the charge will be added to your student account ifa waiver request is completed and approved. Waiver requests will not be accepted after July 31st.You may submit your waiver request by clicking the “Waiver” tab in the following website:http://www.haylor.com/upstate or contact Haylor, Freyer & Coon Inc. at (866) 535-0456 for assistance or atstudent@haylor.com.Dependent CoverageEligibilityStudents enrolling for coverage in the SUNY Upstate - Sponsored Student Health Insurance Plan may also enroll theireligible dependents. An eligible dependent is a spouse (or domestic partner) and/or any child(ren) under the age of 26.Students must also enroll their dependents for coverage within 30 days of their initial eligibility.EnrollmentIf a student's dependents have coverage that ends during the academic year, the dependents may be enrolled in theSUNY Upstate - Sponsored Student Health Insurance Plan provided the request for enrollment is submitted within 30days of the date of loss of prior coverage.Additionally, if a student acquires dependents during the academic year as a result of marriage, birth, adoption, orplacement for adoption, they may enroll their new dependents provided the request for enrollment is made within 30days after the marriage, birth, adoption, or placement for adoption.For enrollment requests at times other than open enrollment please contact Haylor, Freyer & Coon Inc. at (866) 5350456 or at student@haylor.com.If you withdraw from school within the first 31 days of a coverage period, you will not be covered under the Policy andthe full premium will be refunded, less any claims paid. After 31 days, you will be covered for the full period that youhave paid the premium for, and no refund will be allowed. (This refund policy will not apply if you withdraw due to acovered Accident or Sickness.)SUNY Upstate Medical University 2015-2016Page 3
Dependent CoverageEligibilityCovered students may also enroll their lawful spouse, including same-sex marriage, domestic partner and dependentchildren up to the age of 26.EnrollmentTo enroll the dependent(s) of a covered student, please contact Haylor, Freyer & Coon Inc. at (866) 535-0456 or atstudent@haylor.com and request an Enrollment Form. Please refer to the coverage Periods section of this documentfor coverage dates and deadline dates. Dependent enrollment applications will not be accepted after the enrollmentdeadline, unless there is a significant life change that directly affects their insurance coverage. (An example of asignificant life change would be loss of health coverage under another health plan.) The completed Enrollment Formand premium must be sent to Aetna Student Health.Special Enrollment PeriodsYou, your spouse or child can also enroll for coverage within 60 days of the loss of coverage in a health plan if coveragewas terminated because you, your spouse or child are no longer eligible for coverage under the other health plan dueto:1.2.3.4.5.6.7.Termination of employment;Termination of the other health plan;Death of the Spouse;Legal separation, divorce or annulment;Reduction of hours of employment;Employer contributions toward a health plan were terminated; orA Child no longer qualifies for coverage as a Child under another health plan.You, your spouse or child can also enroll 60 days from exhaustion of your COBRA or continuation coverage.We must receive notice and premium payment within 60 days of the loss of coverage. The effective date of yourcoverage will depend on when we receive your application. If your application is received between the first andfifteenth day of the month, your coverage will begin on the first day of the following month. If your application isreceived between the sixteenth day and the last day of the month, your coverage will begin on the first day of thesecond month.In addition, you, your spouse or child, can also enroll for coverage within 60 days of the following event:1. You, or your spouse or child lose[s] eligibility for Medicaid or a state child health plan.We must receive notice and premium payment within 60 days of this event.Participating Provider NetworkAetna Student Health has arranged for you to access a Participating Provider Network in your local community. Tomaximize your savings and reduce your out-of-pocket expenses, select a Participating Provider. It is to your advantageto use a Participating Provider because savings may be achieved from the Negotiated Charges these providers haveagreed to accept as payment for their services.SUNY Upstate Medical University 2015-2016Page 4
Services Subject to Pre-authorizationPre-authorization is required before you receive certain covered services. You are responsible for requesting preauthorization for the out-of-network services listed in the Schedule of Benefits section of the Certificate. ParticipatingProviders are responsible for requesting pre-authorization for in-network services and you are responsible for requestingpre-authorization for the out-of-network services listed in the Schedule of Benefits section of the Certificate.Preauthorization/Notification ProcedureIf you seek coverage for services that require preauthorization, you must call Aetna at the number on your ID card.You must contact Aetna to request preauthorization as follows:At least two (2) weeks prior to a planned admission or surgery when your provider recommends inpatienthospitalization. If that is not possible, then as soon as reasonably possible, during regular business hours prior to theadmission.Within the first three (3) months of a pregnancy, or as soon as reasonably possible and again within 48 hours after theactual delivery date if your hospital stay is expected to extend beyond 48 hours for a vaginal birth or 96 hours forcesarean birth.Before air ambulance services are rendered for a non-emergency condition.You must contact Aetna to provide notification as follows:As soon as reasonably possible when air ambulance services are rendered for an emergency condition.If you are hospitalized in cases of an emergency condition, you must call Aetna within 48 hours after your admission oras soon thereafter as reasonably possible.After receiving a request for approval, Aetna will review the reasons for your planned treatment and determine ifbenefits are available. Criteria will be based on multiple sources which may include medical policy, clinical guidelines,and pharmacy and therapeutic guidelines.Description of BenefitsThe Plan excludes coverage for certain services and contains limitations on the amounts it will pay. While this PlanDesign and Benefits Summary document will tell you about some of the important features of the Plan, other featuresmay be important to you and some may further limit what the Plan will pay. To look at the full Plan description, which iscontained in the Certificate of Coverage issued to you, you may access it online at www.aetnastudenthealth.com. Ifany discrepancy exists between this Benefit Summary and the Certificate, the Certificate of Coverage will govern andcontrol the payment of benefits.All coverage is based on the Allowed Amount.“Allowed Amount” means the maximum amount We will pay for the services or supplies covered under the certificate,before any applicable Copayment, Deductible and Coinsurance amounts are subtracted. We determine Our AllowedAmount as follows:The Allowed Amount for Participating Providers will be the amount We have negotiated with the Participating Provider.SUNY Upstate Medical University 2015-2016Page 5
The Allowed Amount for Non-Participating Providers will be determined as follows:1.Facilities.For Facilities, the Allowed Amount will be 100% of the Medicare rate.2.For All Other Providers.For all other Providers, the Allowed Amount will be 100% of the Medicare rate.Our Allowed Amount is not based on UCR. The Non-Participating Provider’s actual charge may exceed Our AllowedAmount. You must pay the difference between Our Allowed Amount and the Non-Participating Provider’s charge.Contact us at the number on your ID card or visit our website www.aetnastudenthealth.com for information on yourfinancial responsibility when you receive services from a Non-Participating Provider.Medicare based rates referenced in and applied under this section shall be updated no less than annually.This Plan will pay benefits in accordance with any applicable New York Insurance of-Pocket Limit**IndividualFamily*Applicable to benefits unless indicated otherwise below.** This limit never includes your Premium, Balance Billing charges orthe cost of health care services We do not cover.OUTPATIENT AND PROFESSIONAL SERVICES(for other than Mental Health and Substance Use)Office Visits - Primary Care (or home visits)Office Visits - Specialists (or home visits)SUNY Upstate Medical University 2015-2016ParticipatingMemberResponsibility ty forCost-Sharing 100N/A 300N/A 2,000 4,000 6,000 12,000ParticipatingMemberResponsibility forCost-Sharing 20 Copaymentthen you pay 0%Non-ParticipatingMemberResponsibility forCost-Sharing 40 Copaymentthen you pay 0%Not subject toDeductible 20 Copaymentthen you pay 0%Not subject toDeductible 40 Copaymentthen you pay 0%Not subject toDeductibleNot subject toDeductiblePage 6
PREVENTIVE CAREParticipatingMemberResponsibility ty forCost-SharingPreventive services are not subject to Cost-Sharing (Copayments, Deductibles or Coinsurance) when performed by aParticipating Provider and provided in accordance with the comprehensive guidelines supported by the HealthResources and Services Administration (“HRSA”), or if the items or services have an “A” or “B” rating from the UnitedStates Preventive Services Task Force (“USPSTF”), or if the immunizations are recommended by the AdvisoryCommittee on Immunization Practices (“ACIP”).Well-Baby and Well-Child Care*Covered in full0% CoinsuranceNot subject toDeductibleAdult Annual Physical Examinations*Covered in full0% CoinsuranceNot subject toDeductibleAdult Immunizations*Covered in full0% CoinsuranceWell-Woman Examinations *Covered in full0% CoinsuranceNot subject toDeductibleMammograms*Covered in full0% CoinsuranceNot subject toDeductibleFamily Planning and Reproductive Health Services *We cover family planning services which consist of FDA-approvedcontraceptive methods prescribed by a Provider, not otherwise coveredunder the Prescription Drug Coverage section of the certificate,counseling on use of contraceptives and related topics, and sterilizationprocedures for women.Covered in full20% Coinsuranceafter DeductibleWe do not cover services related to the reversal of electivesterilizations.VasectomyWe do not cover services related to the reversal of electivesterilizationsBone Mineral Density Measurements or Testing*10% Coinsuranceafter Deductible30% Coinsuranceafter DeductibleCovered in fullScreening for Prostate CancerCovered in full30% Coinsuranceafter Deductible30% Coinsuranceafter DeductibleAll other preventive services required by USPSTF and HRSA.Covered in fullSUNY Upstate Medical University 2015-201630% Coinsuranceafter DeductiblePage 7
PREVENTIVE CARE (continued)*When preventive services are not provided in accordance with thecomprehensive guidelines supported by USPSTF and HRSA.You may contact Us at the number on your ID card or visit Our websiteat www.aetnastudenthealth.com for a copy of the comprehensiveguidelines supported by HRSA, items or services with an “A” or “B”rating from USPSTF, and immunizations recommended by ACIP.EMERGENCY CAREEmergency Ambulance Transportation (Pre-Hospital EmergencyMedical Services)We do not cover travel or transportation expenses, unless connected toan Emergency Condition or due to a Facility transfer approved by Us,even though prescribed by a Physician.We do not cover non-ambulance transportation such as ambulette, vanor taxi cab.Non-Emergency Ambulance ServicesEmergency Services*Copayment /Coinsurance waived if Hospital admission.In the event that You require treatment for an Emergency Condition,seek immediate care at the nearest Hospital emergency department orcall 911. Emergency Department Care does not requirePreauthorization. However, only Emergency Services for the treatmentof an Emergency Condition are covered in an emergency department.ParticipatingMemberResponsibility forCost-SharingUse Cost Sharing forAppropriate Service(Primary Care OfficeVisit; SpecialistOffice Visit;DiagnosticRadiology Services;LaboratoryProcedures &Diagnostic Testing)ParticipatingMemberResponsibility forCost-Sharing 100 Copaymentafter Policy YearDeductible then youpay 0%Non-ParticipatingMemberResponsibility forCost-SharingUse Cost Sharing forAppropriate Service(Primary Care OfficeVisit; SpecialistOffice Visit;DiagnosticRadiology Services;LaboratoryProcedures &Diagnostic Testing)Non-ParticipatingMemberResponsibility forCost-Sharing 100 Copaymentafter Policy YearDeductible then youpay 0% 100 Copaymentafter Policy YearDeductible then youpay 0% 100 Copaymentthen you pay 10% 100 Copaymentafter Policy YearDeductible then youpay 0% 100 Copaymentthen you pay 10%Not subject toDeductibleNot subject toDeductibleWe do not cover follow-up care or routine care provided in a Hospitalemergency department.The amount We pay a Non-Participating Provider for EmergencyServices will be the greater of: the amount We have negotiated withParticipating Providers for the Emergency Service (and if more than oneamount is negotiated, the median of the amounts); 100% of theAllowed Amount for services provided by a Non-Participating Provider(i.e., the amount We would pay in the absence of any Cost-Sharing thatwould otherwise apply for services of Non-Participating Providers); orthe amount that would be paid under Medicare.SUNY Upstate Medical University 2015-2016Page 8
EMERGENCY CARE (continued)ParticipatingMemberResponsibility forCost-Sharing 100 Copaymentthen you pay 10%Non-ParticipatingMemberResponsibility forCost-Sharing 100 Copaymentthen you pay 10%Not subject toDeductibleNot subject toDeductible 50 Copaymentthen you pay 10% 75 Copaymentthen you pay 30%Not subject toDeductibleNot subject toDeductibleAdvanced Imaging Services (Performed in a Freestanding RadiologyFacility or Office Setting)ParticipatingMemberResponsibility forCost-Sharing10% Coinsuranceafter DeductibleNon-ParticipatingMemberResponsibility forCost-Sharing30% Coinsuranceafter DeductibleAdvanced Imaging Services (Performed as Outpatient HospitalServices)10% Coinsuranceafter Deductible30% Coinsuranceafter DeductibleAllergy Testing and Treatment (Performed in a PCP Office)10% Coinsuranceafter Deductible30% Coinsuranceafter DeductibleAllergy Testing and Treatment (Performed in a Specialist Office)10% Coinsuranceafter Deductible30% Coinsuranceafter DeductibleAmbulatory Surgery Center10% Coinsuranceafter Deductible30% Coinsuranceafter DeductibleAnesthesia Services (all settings)10% Coinsuranceafter Deductible30% Coinsuranceafter DeductibleAutologous Blood Banking Services10% Coinsuranceafter Deductible30% Coinsuranceafter DeductibleCardiac & Pulmonary Rehabilitation (Performed in a Specialist Office)10% Coinsuranceafter Deductible30% Coinsuranceafter DeductibleCardiac & Pulmonary Rehabilitation (Performed as OutpatientHospital Services)10% Coinsuranceafter Deductible30% Coinsuranceafter DeductibleEmergency Services (continued)The amounts described above exclude any Copayment or Coinsurancethat applies to Emergency Services provided by a Participating Provider.You are responsible for any Copayment, Deductible or Coinsurance.You will be held harmless for any Non-Participating Provider chargesthat exceed your Copayment, Deductible or Coinsurance.Urgent Care CenterUrgent Care is medical care for an illness, injury or condition seriousenough that a reasonable person would seek care right away, but notso severe as to require Emergency Department Care.OUTPATIENT AND PROFESSIONAL SERVICES(for other than Mental Health and Substance Use)Cardiac & Pulmonary Rehabilitation (Performed as Inpatient HospitalServices)Included As Part of Inpatient HospitalService Cost-SharingChemotherapy (Performed in a PCP Office)10% Coinsuranceafter Deductible30% Coinsuranceafter DeductibleChemotherapy (Performed in a Specialist Office)10% Coinsuranceafter Deductible10% Coinsuranceafter Deductible30% Coinsuranceafter Deductible30% Coinsuranceafter DeductibleChemotherapy (Performed as Outpatient Hospital Services)SUNY Upstate Medical University 2015-2016Page 9
OUTPATIENT AND PROFESSIONAL SERVICES(for other than Mental Health and Substance Use)ParticipatingMemberResponsibility forCost-Sharing10% Coinsuranceafter DeductibleNon-ParticipatingMemberResponsibility forCost-Sharing30% Coinsuranceafter DeductibleClinical TrialsUse Cost-Sharing forAppropriate ServiceUse Cost-Sharing forAppropriate ServiceDiagnostic Testing - Performed in a PCP OfficeWe cover x-ray, laboratory procedures and diagnostic testing, servicesand materials, including diagnostic x-rays, x-ray therapy, fluoroscopy,electrocardiograms, electroencephalograms, laboratory tests, andtherapeutic radiology services.10% CoinsuranceNot subject toDeductible30% CoinsuranceNot subject toDeductibleDiagnostic Testing - Performed in a Specialists Office10% Coinsuranceafter Deductible30% Coinsuranceafter DeductibleDiagnostic Testing - Performed as Outpatient Hospital Services10% Coinsuranceafter Deductible30% Coinsuranceafter DeductibleDialysis - Performed in a PCP Office10% Coinsuranceafter Deductible30% Coinsuranceafter DeductibleDialysis - Performed in a Freestanding Center or Specialist OfficeSetting10% CoinsuranceNot subject toDeductible30% CoinsuranceNot subject toDeductibleDialysis - Performed as Outpatient Hospital Services10% Coinsuranceafter Deductible30% Coinsuranceafter DeductibleHabilitation Services - Physical Therapy, Occupational Therapy, orSpeech Therapy0% Coinsurance0% CoinsuranceNot Subject toDeductible10% Coinsuranceafter DeductibleNot Subject toDeductible30% Coinsuranceafter DeductibleUse Cost Sharing forAppropriate Service(Office Visit;DiagnosticRadiology Services;Surgery; Laboratory& DiagnosticProcedures)PreauthorizationRequiredUse Cost Sharing forAppropriate Service(Office Visit;DiagnosticRadiology Services;Surgery; Laboratory& practic ServicesHome Health CareInfertility ServicesWe cover services for the diagnosis and treatment (surgical andmedical) of infertility when such infertility is the result of malformation,disease or dysfunction. Such coverage is available as follows:Basic Infertility Services. Basic infertility services will be provided to aMember who is an appropriate candidate for infertility treatment. Inorder to determine eligibility, We will use guidelines established by theAmerican College of Obstetricians and Gynecologists, the AmericanSociety for Reproductive Medicine, and the State of New York.However, Members must be between the ages of 21 and 44 (inclusive)in order to be considered a candidate for these services.Services include: Initial evaluation; Semen analysis; Laboratoryevaluation; Evaluation of ovulatory function; Postcoital test;Endometrial biopsy; Pelvic ultra sound; Hysterosalpingogram; Sonohystogram; Testis biopsy; Blood tests; and Medically appropriatetreatment of ovulatory dysfunction.SUNY Upstate Medical University 2015-2016Page 10
OUTPATIENT AND PROFESSIONAL SERVICES (continued)(for other than Mental Health and Substance Use)ParticipatingMemberResponsibility forCost-SharingUse Cost Sharing forAppropriate Service(Office Visit;DiagnosticRadiology Services;Surgery; Laboratory& articipatingMemberResponsibility forCost-SharingUse Cost Sharing forAppropriate Service(Office Visit;DiagnosticRadiology Services;Surgery; Laboratory& DiagnosticProcedures)PreauthorizationRequired10% Coinsuranceafter Deductible30% Coinsuranceafter Deductible10% Coinsuranceafter Deductible30% Coinsuranceafter DeductibleInfusion Therapy - Performed as Outpatient Hospital Services10% Coinsuranceafter Deductible30% Coinsuranceafter DeductibleInfusion Therapy - Home Infusion Therapy10% Coinsuranceafter Deductible30% Coinsuranceafter DeductibleLaboratory Procedures - Performed in a PCP Office10% Coinsuranceafter Deductible30% Coinsuranceafter DeductibleLaboratory Procedures - Performed in a Specialist Office10% Coinsuranceafter Deductible30% Coinsuranceafter DeductibleLaboratory Procedures - Performed as Outpatient Hospital Services10% Coinsuranceafter Deductible30% Coinsuranceafter DeductibleInfertility Services (continued)Additional tests may be covered if the tests are determined to beMedically Necessary.Comprehensive Infertility Services. If the basic infertility services donot result in increased fertility, We cover comprehensive infertilityservices.Services include: Ovulation induction and monitoring; Pelvic ultrasound; Artificial insemination; Hysteroscopy; Laparoscopy; andLaparotomy.Exclusions and Limitations. We do not cover:In vitro fertilization, gamete intrafallopian tube transfers or zygoteintrafallopian tube transfers; Costs for an ovum donor or donor sperm;Sperm storage costs; Cryopreservation and storage of embryos;Ovulation predictor kits; Reversal of tubal ligations; Reversal ofvasectomies; Costs for and relating to surrogate motherhood(maternity services are covered for Members acting as surrogatemothers); Cloning; orMedical and surgical procedures that are experimental orinvestigational, unless Our denial is overturned by an External AppealAgent.All services must be provided by Providers who are qualified to providesuch services in accordance with the guidelines established andadopted by the American Society for Reproductive Medicine.Infusion Therapy - Performed in a PCP OfficeWe cover infusion therapy which is the administration of drugs usingspecialized delivery systems which otherwise would have required youto be hospitalized. Drugs or nutrients administered directly into theveins are considered infusion therapy.Infusion Therapy - Performed in a Specialists OfficeSUNY Upstate Medical University 2015-2016Page 11
OUTPATIENT AND PROFESSIONAL SERVICES (continued)(for other than Mental Health and Substance Use)Maternity and Newborn Care - Prenatal CareMaternity and Newborn Care - Inpatient Hospital Services andBirthing Center1 Home Care Visit is Covered at no Cost-Sharing if mother is dischargedfrom Hospital earlyMaternity and Newborn Care - Physician and Midwife Services forDeliveryMaternity and Newborn Care - Breast PumpWe cover the cost of renting one breast pump per pregnancy forduration of breast feeding.Maternity and Newborn Care - Postnatal CareOutpatient Hospital Surgery Facility ChargePreadmission TestingDiagnostic Radiology Services - Performed in a PCP OfficeDiagnostic Radiology Services - Performed in a Freestanding RadiologyFacility or Specialists OfficeDiagnostic Radiology - Performed as Outpatient Hospital ServicesTherapeutic Radiology Services - Performed in a FreestandingRadiology Facility or Specialist OfficeTherapeutic Radiology Services - Performed as Outpatient HospitalServicesRehabilitation Services - Physical Therapy, Occupational Therapy orSpeech TherapySUNY Upstate Medical University 2015-2016ParticipatingMemberResponsibility forCost-SharingCovered In FullNon-ParticipatingMemberResponsibility forCost-Sharing30% Coinsurance 50 Copaymentafter Deductiblethen you pay 0%Coinsurance perAdmissionNot subject toDeductible 100 Copaymentafter Deductiblethen you pay 30%Coinsurance perAdmissionPreauthorizationRequired10% Coinsuranceafter DeductibleCovered in FullPreauthorizationRequired30% Coinsuranceafter Deductible20% Coinsuranceafter Deductible0% Coinsurance30% CoinsuranceNot subject toDeductible10% Coinsuranceafter Deductible10% Coinsuranceafter Deductible10% Coinsuranceafter Deductible10% Coinsuranceafter Deductible10% Coinsuranceafter Deductible10% Coinsuranceafter DeductibleNot subject toDeductible30% Coinsuranceafter Deductible30% Coinsuranceafter Deductible30% Coinsuranceafter Deductible30% Coinsuranceafter Deductible30% Coinsuranceafter Deductible30% Coinsuranceafter Deductible10% Coinsuranceafter Deductible0% CoinsuranceNot Subject toDeductible30% Coinsuranceafter Deductible0% CoinsuranceNot Subject toDeductiblePage 12
OUTPATIENT AND PROFESSIONAL SERVICES (continued)(for other than Mental Health and Substance Use)Second Opinions on the Diagnosis of Cancer, Surgery & OtherSURGICAL SERVICES (surgeon, assistant surgeon, anesthetist) Including Oral Surgery; Reconstructive Breast Surgery; OtherReconstructive & Corrective Surgery; Transplants & Interruption ofPregnancyInpatient Hospital SurgeryOutpatient Hospital SurgerySurgery Performed at an Ambulatory Surgical CenterOffice SurgeryADDITIONAL BENEFITS, EQUIPMENT AND DEVICESApplied Behavioral Analysis Treatment for Autism Spectrum Disorder“Applied behavior analysis” means the design, implementation, andevaluation of environmental modifications, using behavioral stimuli andconsequences, to produce socially significant improvement in humanbehavior, including the use of direct observation, measurement, andfunctional analysis of the relationship between environment andbehavior.SUNY Upstate Medical University 2015-2016ParticipatingMemberResponsibility forCost-Sharing 20 Copaymentthen you pay 0%Not subject toDeductibleParticipatingMemberResponsibility forCost-Sharing10% Coinsuranceafter Deductible10% Coinsuranceafter Deductible10% Coinsuranceafter Deductible10% Coinsuranceafter DeductibleParticipatingMemberResponsibility forCost-Sharing0% CoinsuranceNon-ParticipatingMemberResponsibility forCost-Sharing 40 Copaymentthen you pay 0%Not subject toDeductibleSecond Opinions onDiagnosis of Cancerare Covered atParticipating CostSharing for esponsibility forCost-Sharing30% Coinsurancea
Aetna Student Health . Plan Design and Benefits Summary SUNY Upstate Medical University . Policy Year: 2015 - 2016 Policy Number: 867883 . . You, or your spouse or child lose[s] eligibility for Medicaid or a state child health plan. We must receive notice and premium payment within 60 days of this event.
