Aetna Student Health Plan Design And Benefits Summary - USC

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Quality health plans & benefitsHealthier livingFinancial well-beingIntelligent solutionsAetna Student HealthPlan Design and Benefits SummaryUniversity of Southern CaliforniaPolicy Year: 2018 - 2019Policy Number: 474947www.aetnastudenthealth.com(877) 626-2299

This is a brief description of the Student Health Plan. The Plan is available for University of Southern California students.The Plan is underwritten by Aetna Life Insurance Company (Aetna). The exact provisions, including definitions,governing this insurance are contained in the Certificate of Coverage issued to you and may be viewed online atwww.aetnastudenthealth.com. If there is a difference between this Benefit Summary and the Certificate of Coverage,the Certificate will control.USC Student Health ServicesIf you are enrolled in the ON Campus Insurance Plan, you must first visit USC Student Health Services for non-emergencycare, while classes are in session in the Fall and Spring semesters.USC Student Health Services is where you receive your primary medical care. Once you’ve seen a medical professional atthe Student Health Services and it is determined that you require additional medical care, you will be given a referral.USC Student Health Services will make every attempt to refer you to a USC Designated Tier 1 Provider; however it is yourresponsibility to verify that the doctor you’ve been referred to is actually a USC Designated Tier 1 Provider.Satellite Campus and Off Campus Online Degree Program Students are not subject to the referral requirements orpenalties for non-compliance.Coverage PeriodsCoverage will become effective at 12:01 AM on the Coverage Start Date indicated below, and will terminate at 11:59 PMon the Coverage End Date indicated.Coverage PeriodCoverage Start DateCoverage End DateEnrollment/Waiver 908/18/201901/25/2019University of Southern California 2018-2019Page 2

RatesThe rates below include both premiums for the Plan underwritten by Aetna Life Insurance Company (Aetna), as well as aUniversity of Southern California administrative fee.Rates ON Campus StudentsStudentAnnualFall SemesterSpring/Summer Semester 2,041 730 1,311Rates OFF Campus StudentsStudentAnnualFall SemesterSpring/Summer Semester 3,869 1,339 2,530Student CoverageUSC requires that ALL students have comprehensive health insurance. This will help to cover the cost of care that cannotbe obtained on campus, especially in emergency situations where hospitalization may be required.EligibilityAll students registered in six (6) units or more are automatically enrolled in, and charged for, the USC Student HealthInsurance Plan. All International and Health Sciences campus students and PhD candidates are required to have healthinsurance and are automatically enrolled in this plan, even if they carry less than six (6) units. Enrolled students taking lessthan six units are eligible to enroll on a voluntary basis.Enrollment Process/ProcedureAll students registered in six (6) units or more will be automatically enrolled in this plan, unless the completed Requestfor Waiver Form has been received by the University of Southern California by the applicable enrollment/waiverdeadline dates listed in the previous section of this Plan Design and Benefits Summary and the Request for Waiver hasbeen approved. All students registered in less than six (6) units are eligible to enroll in the plan voluntarily. To enrollonline or obtain an enrollment application for voluntary coverage, log on to www.aetnastudenthealth.com/usc thenclick on Enroll/Request to Waive to begin the enrollment process.Exception: A Covered Person entering the armed forces of any country will not be covered under the Policy as of thedate of such entry. A pro rata refund of premium will be made for such person, upon written request received by Aetnawithin 90 days of withdrawal from school.University of Southern California 2018-2019Page 3

Waiver Process/ProcedureIf you already have a health insurance plan (or you are on your parents’ plan) you may be eligible to waive enrollment inthe USC Student Health Insurance Plan by providing proof of comparable coverage (see criteria below).To waive the USC Student Health Insurance Plan, your insurance plan must meet the following requirements: Students taking courses at our UPC or HSC Campuses: Must be comprehensive with no major exclusions and have innetwork providers (hospital and doctors) in the Los Angeles area. Satellite Campus and Online Distance Learners: Must be comprehensive with no major exclusions and have innetwork providers in the zip code where you live and take classes. Provide continuous year-round coverage while you are a student at the University of Southern California. Your insurance plan must meet Affordable Care Act (ACA) criteria. Only plans compliant with ACA criteria will beaccepted. Cover preventive care services at 100%. Your plan must have no pre-existing condition exclusion; if the plan has a pre-existing condition waiting period, thatperiod has expired Your plan must have no per-injury or per-illness maximum benefit limits Your plan must cover medical services for injury from participation in all types of recreational activities or amateursports. Have an annual out-of-pocket expense of individual less than 7,350 / family less than 14,700.Upon request, all students must be able to provide a copy of: Verifiable proof of coverage with student’s name (ID card, insurance policy or letter from insurance carrier.)*Plan document(s) in English, with currency amounts converted to U.S. dollars, and an insurance company contactphone number in the U.S. is mandatory and all claims must be processed in the U.S. and paid directly to U.S. providers.If you are eligible to waive coverage, you must submit a request for waiver online before the deadline date. To submit arequest to waive out of the USC Student Health Insurance Plan, you will begin by going to www.usc.edu/studenthealth.Under the Student Health Insurance tab click Waiving Coverage. The link at the top of the page will bring you to theAetna Student Health online waiver system where you will follow the instructions to complete your online request forwaiver. Before you begin the request for waiver process, please make sure you have your current insurance card withyou as you will need information off this card to submit a request for waiver.University of Southern California 2018-2019Page 4

Medicare Eligibility NoticeYou are not eligible for health coverage under this student policy if you have Medicare at the time of enrollment in thisstudent plan.If you obtain Medicare after you enrolled in this student plan, your health coverage under this plan will not end.As used here, “have Medicare” means that you are entitled to benefits under Part A (receiving free Part A) or enrolled inPart B or Premium Part A.In-network Provider NetworkAetna Student Health offers Aetna’s broad network of In-network Providers. You can save money by seeing In-networkProviders because Aetna has negotiated special rates with them, and because the Plan’s benefits are better.If you need care that is covered under the Plan but not available from an In-network Provider, contact Member Servicesfor assistance at the toll-free number on the back of your ID card. In this situation, Aetna may issue a pre-approval foryou to receive the care from an Out-of-network Provider. When a pre-approval is issued by Aetna, the benefit level isthe same as for In-network Providers.PrecertificationYou need pre-approval from us for some eligible health services. Pre-approval is also called precertification.Precertification for medical services and suppliesIn-network careYour in-network physician is responsible for obtaining any necessary precertification before you get the care. If your innetwork physician doesn't get a required precertification, we won't pay the provider who gives you the care. You won'thave to pay either if your in-network physician fails to ask us for precertification. If your in-network physician requestsprecertification and we refuse it, you can still get the care but the plan won’t pay for it. You will find additional details onrequirements in the Certificate of Coverage.Out-of-network careWhen you go to an out-of-network provider, it is your responsibility to obtain precertification from us for any servicesand supplies on the precertification list. If you do not pre-certify there may be a penalty. Refer to your schedule ofbenefits for this information. The list of services and supplies requiring precertification appears later in this sectionPrecertification 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:An emergency admission:University of Southern California 2018-2019You, your physician or the facility will need to call and requestprecertification at least 14 days before the date you are scheduled tobe admitted.You, your physician or the facility must call within 48 hours or as soonas reasonably possible after you have been admitted.Page 5

An urgent admission:Outpatient non-emergency servicesrequiring precertification:Delivery: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.You or your physician must call at least 14 before the outpatient careis provided, or the treatment or procedure is scheduled.You, your physician, or the facility must call within 48 hours of thebirth or as soon thereafter as possible. No penalty will be applied forthe first 48 hours after delivery for a routine delivery and 96 hours fora cesarean delivery.We will provide a written notification to you and your physician of the precertification decision, where required by statelaw. If your pre-certified services are approved, the approval is valid for 30 as long as you remain enrolled in the plan.If you require an extension to the services that have been pre-certified, you, your physician, or the facility will need tocall us at the number on your ID card as soon as reasonably possible, but no later than the final authorized day.If precertification determines that the stay or outpatient services and supplies are not covered benefits, the notificationwill explain why and how you can appeal our decision. You or your provider may request a review of the precertificationdecision. See the When you disagree - claim decisions and appeals procedures section of Certificate of Coverage.What if you don’t obtain the required precertification?If you don’t obtain the required precertification: There may be a benefit penalty. See the schedule of benefits Precertification covered benefit penalty section. Any benefit penalty incurred will not count toward your policy year deductibles or maximum out-of-pocketlimits.What types of services and supplies require precertification?Precertification is required for the following types of services and supplies:Inpatient services and suppliesObesity (bariatric) surgeryStays in a hospice facilityStays in a hospitalStays in a rehabilitation facilityStays in a residential treatment facility for treatmentof mental disorders and substance abuseStays in a skilled nursing facility*For a current listing of the prescription drugs and medical injectable drugs that require precertification, contact MemberServices by calling the toll-free number on your ID card in the How to contact us for help section or by logging onto theAetna website atwww.aetnastudenthealth.com.University of Southern California 2018-2019Page 6

Coordination of Benefits (COB)Some people have health coverage under more than one health plan. If you do, we will work together with your otherplan(s) to decide how much each plan pays. This is called coordination of benefits (COB).Here’s how COB works When this is the primary plan, we will pay your medical claims first as if the other plan does not exist When this is the secondary plan, we will pay benefits after the primary plan and will reduce the payment basedon any amount the primary plan paid We will never pay an amount that, together with payments from your other coverage, add up to more than100% of the allowable submitted expensesFor more information about the Coordination of Benefits provision, including determining which plan is primary andwhich is secondary, you may call the Member Services telephone number shown on your ID card. A completedescription of the Coordination of Benefits provision is contained in the Policy issued to School Name, and may beviewed online at www.aetnastudenthealth.com.University of Southern California 2018-2019Page 7

Description of BenefitsThe Plan excludes coverage for certain services (referred to as exceptions in the certificate of coverage) and haslimitations on the amounts it will pay. While this Plan Design and Benefit Summary document will tell you about some ofthe important features of the Plan, other features may be important to you and some may further limit what the Planwill pay. To look at the full Plan description, which is contained in the Certificate of Coverage issued to you, go towww.aetnastudenthealth.com. If any discrepancy exists between this Benefit Summary and the Certificate ofCoverage, the Certificate will control.This Plan will pay benefits in accordance with any applicable California Insurance Law(s).Metallic Level: Gold, Tested at: 83.94%Policy year deductibleSelect Care coverageIn-network coverageYou have to meet your policy year deductible before this plan pays for benefits.Student 450 per policy year CombinedOut-of-network coverage 900 per policy yearPolicy year deductible waiverThe policy year deductible is waived for all of the following eligible health services: Select Care for Preventive care and wellness, Pediatric Preventive Vision Services, Physician Office Visit, Walk-in Clinic VisitExpense, Consultant or Specialist Expense, Immunization Expense, Physical Therapy, Occupational Therapy, ChiropracticExpense, Mental Health Outpatient Expense, and Urgent Care Expenses In-Network Care for Preventive care and wellness, Pediatric Preventive Dental and Vision Services, Physical Therapy,Occupational Therapy, Chiropractic Expense, Mental Health Outpatient Expense, Urgent Care Expenses and EmergencyRoom Expenses Out-of-Network Care for Pediatric Preventive Vision Services, Urgent Care Expenses and Emergency Room ExpensesMaximum out-of-pocket limits per policy yearStudent 6,000 per policy year Combined 12,000 per policy yearPrecertification covered benefit penaltyThis only applies to out-of-network coverage: The certificate of coverage contains a complete description of the precertificationprogram. You will find details on precertification requirements in the Medical necessity and precertification requirements section.Failure to precertify your eligible health services when required will result in the following benefit penalties:- A 500 benefit penalty will be applied separately to each type of eligible health services.If the cost of the benefit to Aetna is less than 500, the penalty will be capped by the cost of the benefit.The additional percentage or dollar amount of the recognized charge which you may pay as a penalty for failure to obtainprecertification is not a covered benefit, and will not be applied to the policy year deductible amount or the maximum out-ofpocket limit, if any.University of Southern California 2018-2019Page 8

The coinsurance listed in the schedule of benefits below reflects the plan coinsurance percentage. This is the coinsuranceamount that the plan pays. You are responsible for paying any remaining coinsurance.Eligible health servicesPreventive care and wellnessRoutine physical examsSelect Care coverageIn-network coverageOut-of-network coveragePerformed at a physician’s office100% (of thenegotiated charge) pervisit100% (of thenegotiated charge) pervisit50% (of the recognizedcharge) per visitNo copayment orpolicy year deductibleappliesNo copayment orpolicy year deductibleappliesCovered persons through age 21: Maximumage and visit limits per policy yearCovered persons age 22 and over: Maximumvisits per policy yearSubject to any age and visit limits provided for in the comprehensive guidelinessupported by the American Academy of Pediatrics/Bright Futures//HealthResources and Services Administration guidelines for children and adolescents.For details, contact your physician or Member Services by logging onto yourAetna Navigator secure website at www.aetnastudenthealth.com or calling thetoll-free number on your ID card.1 visitPreventive care immunizationsPerformed in a facility or at a physician'sofficeMaximums100% (of thenegotiated charge) pervisit100% (of thenegotiated charge) pervisitNo copayment orpolicy year deductibleappliesNo copayment orpolicy year deductibleapplies50% (of the recognizedcharge) per visitSubject to any age limits provided for in the comprehensive guidelines supportedby Advisory Committee on Immunization Practices of the Centers for DiseaseControl and PreventionFor details, contact your physician or Member Services by logging onto yourAetna Navigator secure website at www.aetnastudenthealth.com or calling thetoll-free number on your ID card.University of Southern California 2018-2019Page 9

Eligible health servicesSelect Care coverage In-network coverageWell woman preventive visitsRoutine gynecological exams (including Pap smears and cytology tests)Out-of-network coveragePerformed at a physician’s, obstetrician (OB),gynecologist (GYN) or OB/GYN office50% (of the recognizedcharge) per visitMaximums100% (of thenegotiated charge) pervisit100% (of thenegotiated charge) pervisitNo copayment orpolicy year deductibleappliesNo copayment orpolicy year deductibleappliesSubject to any age limits provided for in the comprehensive guidelines supportedby the Health Resources and Services Administration.Preventive screening and counseling servicesObesity and/or healthy diet counseling officevisits100% (of thenegotiated charge) pervisit100% (of thenegotiated charge) pervisitNo copayment orpolicy year deductibleappliesNo copayment orpolicy year deductibleapplies50% (of the recognizedcharge) per visitMaximum visits per policy year (Thismaximum applies only to covered personsage 22 and older.)26 visits (however, of these only 10 visits will be allowed under the plan forhealthy diet counseling provided in connection with Hyperlipidemia (highcholesterol) and other known risk factors for cardiovascular and diet-relatedchronic disease)Misuse of alcohol and/or drugs counselingoffice visits100% (of thenegotiated charge) pervisit100% (of thenegotiated charge) pervisitNo copayment orpolicy year deductibleappliesNo copayment orpolicy year deductibleappliesMaximum visits per policy yearUniversity of Southern California 2018-201950% (of the recognizedcharge) per visit5 visitsPage 10

Eligible health servicesSelect Care coverageIn-network coverageOut-of-network coverageUse of tobacco products counseling officevisits100% (of thenegotiated charge) pervisit100% (of thenegotiated charge) pervisit50% (of the recognizedcharge) per visitNo copayment orpolicy year deductibleappliesNo copayment orpolicy year deductibleappliesMaximum visits per policy yearDepression screening counseling office visits8 visits100% (of thenegotiated charge) pervisit100% (of thenegotiated charge) pervisitNo copayment orpolicy year deductibleappliesNo copayment orpolicy year deductibleappliesMaximum visits per policy yearSexually transmitted infection counselingoffice visits1 visit100% (of thenegotiated charge) pervisit100% (of thenegotiated charge) pervisitNo copayment orpolicy year deductibleappliesN

University of Southern California 2018-2019 Page 2 This is a brief description of the Student Health Plan. The Plan is available for University of Southern California students. The Plan is underwritten by Aetna Life Insurance Comp