Columbia Insurance Coverage

8/4/2019 Columbia Insurance Coverage

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2010-11


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TABLE OF CONTENTS

Welcome..........................................................................................................................4Confidentiality................................................................................................................. 4Special Notice................................................................................................................. 4Considering Your Options

Comparing the Columbia Student Medical Insurance Plan...................................... 5About Our Plan........................................................................................................ 6

2010-11 Columbia Student Medical Insurance Plan SpecificsTwo Levels of Coverage ........................................................................................ 7

-Basic- Comprehensive

Period of Coverage- Policy Period .................................................................................................10- Continuation Privilege ................................................................................... 11

Whats Covered?- Physician Office Visits/Allergy Care .............................................................. 12- Physical Therapy, Chiropractic Care, Radiation and

Chemotherapies, Dialysis, Respiratory Therapy ........................................... 14- Acupuncture .................................................................................................. 16- Hospital Outpatient Services ......................................................................... 19- X-Ray and Laboratory Services ................................................................... 20- Emergency Care ...........................................................................................21- Surgical Services........................................................................................... 24- Inpatient Hospitalization ................................................................................27- Pre-Natal and Maternity Care........................................................................30- Prescriptions.................................................................................................. 32

- Outpatient Mental Health Services at Columbia............................................ 36- Attention Disorders and Learning Disabilities................................................41- Eating Disorders............................................................................................42- Substance Abuse Treatment......................................................................... 43- Additional/Mandated Benefits........................................................................ 45- Dental Services .............................................................................................57- Options for Dental Services Not Covered .....................................................58- Vision Care.................................................................................................... 61- Travel Assistance and Emergency Services ................................................. 61- Medical Evacuation and Return of Mortal Remains ......................................62

Dependent Coverage- Period of Coverage ....................................................................................... 63- Premiums ...................................................................................................... 64- Enrollment ..................................................................................................... 64- Newborn/Newly Adopted Coverage .............................................................. 65- Dependents of Funded Graduate Students................................................... 65- Benefits .........................................................................................................65


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Changes from 2009-10 ......................................................................................... 68Referral Guidelines ..............................................................................................68The Aetna Network...............................................................................................70

General Policy Provisions- Claims ...........................................................................................................70

- Prescription Claims ....................................................................................... 76- Patient Management Program/Pre-Certification............................................77- Coordination of Benefits ................................................................................78- Reimbursement and Subrogation.................................................................. 78- Termination of Insurance/Extension After Termination ................................. 79- Refund Policy ................................................................................................80- Withdrawal Due to Medical Leave.................................................................80- Limitations on Coverage/Pre-Existing Conditions .........................................81- Policy Exclusions........................................................................................... 82- Directory of Providers.................................................................................... 87

Definitions.............................................................................................................89

Enrollment in the Columbia Student Medical Insurance PlanEnrolling in the Plan

- Deadlines ...................................................................................................... 96- Full-time and Residential Students................................................................ 96- Part-time Students......................................................................................... 96- Funded Graduate Students ........................................................................... 97- Students Studying Abroad............................................................................. 97

Plan ID Cards........................................................................................................ 97Requesting to Waive the Plan ............................................................................. 98

- Deadlines ...................................................................................................... 98

- Students in Special Categories .....................................................................99

Member Information Website ........................................................................... 100Contact Information ........................................................................................... 102


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WELCOME

Health Services at Columbia is part of the Universitys Student Services division on theMorningside Campus. We provide integrated and accessible services and programs thatsupport the well-being of the campus community and the personal and academic developmentof students.

Our on-campus programs and services are extensive; however, there may be circumstances inwhich you may need to fill a prescription or receive care from an off-campus provider orhospital. To provide students with access to consistent, efficient care that complements theprograms offered on campus, Columbia offers the Student Medical Insurance Plan. TheAccident and Sickness Plan is underwritten by Aetna Life Insurance Company.

Should you have any questions about Columbias requirements for medical insurance coverage,the Columbia Student Medical Insurance Plan, or its Health Service Program, we encourageyou to visit www.health.columbia.edu.

AN IMPORTANT NOTE ABOUT CONFIDENTIALITYColumbia University, along with Aetna Student Health, adheres to strict standards ofconfidentiality regarding information about health care services rendered, conditions, or anyother privileged information to which Health Services at Columbia, Aetna Student Health, orAetna have access. Furthermore, Aetna protects the privacy of confidential member medicalinformation. Participating Providersare required to keep member information confidential inaccordance with applicable laws. Aetna (including its affiliates and authorized agents,collectively Aetna) and Participating Providersrequire access to member medical informationfor a number of important and appropriate purposes. Accordingly, for these purposes, membersauthorize the sharing of member medical information about themselves and their dependentsbetween Aetna and Participating Providersand health delivery systems. You have the right, withsome restrictions, to access your medical records by appointment from Participating Providers.

SPECIAL NOTICE

Please keep this Brochure, as it provides a general summary of your coverage. A completedescription of the benefits and full terms and conditions may be found in the Master Policyissued to Columbia University. If any discrepancy exists between this Brochure and the Policy,the Master Policy will govern and control the payment of benefits. The Master Policy may beviewed at the Universitys Insurance Office, during business hours.

This student Plan fulfills the definition of Creditable Coverage explained in the Health InsurancePortability and Accountability Act (HIPAA) of 1996. At any time should you wish to receive a

certification of coverage, please call the customer service number on your ID card.


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CONSIDERING YOUR OPTIONS

Comparing Other Plans with the Columbia Student Medical Insurance Plan

Review the types of coverage included below, all of which are available through the ColumbiaStudent Medical Insurance Plan.

Coverage in New York and worldwide Maximum per condition/per lifetime benefit of $300,000 (Basic Plan) or

$1,000,000 (Comprehensive Plan) Option to see providers outside the plans Preferred Provider Network Pharmacy benefits Coverage remains available as long as the student is registered or on an

approved medical leave of absence Coverage for pre-existing conditions Benefits for inpatient and outpatient mental health care Coverage for injuries resulting from the practice or play of athletics Payments made directly to hospitals for inpatient services Coverage for specialized therapeutic services, such as physical therapy Travel assistance services Option to enroll an eligible spouse, domestic partner as well as other eligible

dependents.

If you are unsure about how your current plan compares to the Columbia Student MedicalInsurance Plan, contact your insurance carrier's administrator for details about availablebenefits. Other factors to consider when selecting a medical insurance plan:

Will you age-out of your current insurance plan, carried by parents or legalguardians?

If you are hoping to extend coverage provided through a previous employer(through COBRA), what are the costs involved? Compare these with thepremiums for the Columbia Student Medical Insurance Plan.


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About Our Plan

The Columbia Student Medical Insurance Plan provides coverage for a broad range of healthcare needs, both while students are in the United States and abroad:

Benefits are designed to complement the services available on-campus Access to services is streamlined and paperwork is limited

In general, students pay only a modest copay for visits with consulting providersoff campus (when referred by their on-campus provider) and for prescriptionmedications

The Plan offers access to the nationwide Aetna network of specialists,representing providers in most areas of medical specialty. This can be ofparticular benefit while traveling or living away from campus for the summer

Benefits are included for emergency assistance while traveling outside the UnitedStates

The Plan extends over the full year, starting September 1 and ending August 31of the following year

Note: Under the Columbia Student Medical Insurance Plan, on-campus providers serve as your

primary care provider, see referral guidelines on page 68.


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2010-11 COLUMBIA STUDENT MEDICAL INSURANCE PLAN SPECIFICS

Two Levels of Coverage

Basic Plan

The Basic Level of the Columbia Student Medical Insurance Plan is designed to provide a level

of coverage that is adequate for many people attending college or graduate programs. It isappropriate for students who:

Do not expect to need health care services frequently Are interested in utilizing a pay-as-you-go strategy: participants pay a lower

insurance premium at the outset but a higher proportion of the cost of anyservices that may be utilized

The total maximum per condition/per lifetime benefit available in the Basic Level of the Plan is$300,000.

Comprehensive Plan

The Comprehensive Level of the Columbia Student Medical Insurance Plan includes all of the

benefits provided by the Basic Level of the Plan as well as more extensive benefits in certainareas:

Enhanced benefits for prescription drugs, physical therapy, and other health careservices.

The total maximum per condition/per lifetime benefit available in the Comprehensive Level ofthe Plan is $1,000,000.

For students who have chronic health conditions or take prescription drugs regularly this level ofthe Plan may be appropriate. Students will:

Pay a higher insurance premium up front Pay less in out-of-pocket expenses as services are actually used

In addition to the Plans Aggregate Maximum the Policy may contain benefit levelmaximums. Please review the Whats Covered section of this brochure for anyadditional benefit level maximums. For complete benefit information please refer to theMaster Policy. Information regarding the Master Policy is on page 4.


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COLUMBIA STUDENT MEDICAL INSURANCE PLAN STUDENT PREMIUMS

TYPE OFCOVERAGE

FALLPREMIUM

SPRINGPREMIUM

TOTAL ANNUALPREMIUM

SUMMERTRIMESTERPREMIUM+

Basic Plan $701 $1,077 $1,778 $701

ComprehensivePlan

$1,000 $1,542 $2,542 $1,000

+Please note dependents are not eligible to enroll for the Summer Trimester Insuranceprogram.

The rates above include both premium for the student medical insurance plan underwritten byAetna Life Insurance Company, as well as Columbia University fees for dental services provided

by Columbia Morningside Dental.

Aetna also compensates Columbia for certain medical services provided by Health Services atColumbia to covered students* as well as for certain administrative expenses associated withservicing the insurance plan (including certain personnel expenses incurred by the HealthServices at Columbia, Health Services Insurance Office for providing services which otherwisewould be provided by Aetna Student Health).

In addition, based on aggregate claims experience, Aetna may issue a refund to Columbia to beapplied toward future premiums.

* These medical services provided by Health Services at Columbia include services provided by

Columbia University EMS (also know as Columbia Area Volunteer Ambulance (CAVA)) and thecost of certain immunizations; rabies services; and contraceptive devices.


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COVERAGE FOR SPECIFIC SERVICES PROVIDED BY THE HEALTHSERVICE FEE

This coverage is arranged through the Aetna Student Health and is underwritten by Aetna LifeInsurance Company. It is available to all students who pay the Health Service Fee regardless ofthe type of health insurance plan a student carries. There are limits and restrictions on this

special coverage. Please review the full coverage descriptions and procedures for utilizing thebenefits at the Health Services at Columbia website.

For questions about any of these benefits, please contact the Health Services Insurance Officeat 212-854-3286 or [email protected].

Coverage is provided for: Treatment of accidental injury or medical emergencies

o Emergency room careo Emergency inpatient hospital careo Physician services related to the treatment of accidental injury or medical

emergencies

Elective termination of pregnancy up to $500 Off-campus mental health services ** Outpatient treatment for chemical abuse**

Coverage also includes: Services provided by Columbia Area Volunteer Ambulance Cost of immunization for measles, mumps, rubella, hepatitis A, hepatitis B,

hepatitis A & B, tetanus diphtheria, tetanus diphtheria pertusis

** Coverage is available only after a referral has been provided by a Counseling andPsychological Services provider.


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PERIOD OF COVERAGE

The Columbia Student Medical Insurance Plan covers a full year of care: September 1, 2010 August 31, 2011.

The coverage year is divided into two terms:

Fall Term September 1, 2010 January 17, 2011

Spring Term January 18, 2011 August 31, 2011

*Please note that insurance coverage is officially established upon registration for the academicterm associated with the period of coverage.

For students enrolling in the Fall Term and continuing as a registered student in the SpringTerm, coverage becomes effectiveat 12:00 a.m. on September 1, 2010, and terminatesat11:59 p.m. on August 31, 2011, unless the student has a significant life change and waives outof, or wishes to enroll in, the Spring term insurance. See below for more information aboutwaiver and enrollment procedures and policies.

Students completing their programs in December in anticipation of a February graduation willhave coverage through 11:59 p.m. on January 17, 2011. Students expecting to graduate inOctober 2010 are not eligible to enroll in the Student Medical Insurance Plan, but may enroll inthe Continuation Plan offered by Aetna Student Health. The deadline to enroll in theContinuation Plan for May graduates is October 15, 2010. The deadline to enroll for Februarygraduates is March 4, 2011.

For all students enrolling in their first termof classes for the Spring Term, coverage becomeseffectiveat 12:00 a.m. on January 18, 2011, and terminatesat 11:59 p.m. on August 31, 2011.

For all students enrolling in their first termof classes for the Summer Trimester Term, coverage

becomes effectiveat 12:00 a.m. on June 1, 2011, and terminatesat 11:59 p.m. on August 31,2011.

Summer Trimester Term June 1, 2011 August 31, 2011

Please note that for students who have not actively enrolled in the Plan, coverage is stillretroactive to September 1, 2010. However, all expenses for prescriptions filled beforeSeptember 30, 2010, will need to be submitted to Aetna Pharmacy Management forreimbursement. For full details about prescription coverage during this period, please contactAetna Student Health.

Enrollment for dates other than those above is allowed only upon the loss of other healthinsurance coverage (i.e. student ages out of family plan or family loses coverage).Documentation of loss of coverage is required. The Health Services Insurance Office must becontacted within 31 days of the loss of other coverage. Upon documentation of loss ofcoverage, students may select their insurance plan. Once the plan is selected there is no optionto upgrade or downgrade coverage. If a student has enrolled in the student medical insuranceplan (even by default) and loses coverage under another insurance plan, they may not change(upgrade or downgrade) their insurance selection under the student medical insurance plan.


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CONTINUATION PRIVILEGE

An optional Continuation Plan is available for students whose registration at Columbia is ending.To be eligible to participate in the Continuation Plan, students and eligible dependents musthave been enrolled in the Columbia Student Medical Insurance Plan in their final term as aregistered student.

Aetna Student Health must receive applications and payment for the full premium within 45 daysafter the expiration of coverage under the student plan. The Coverage period must beselected at the time of enrollment and the total premium paid, at the time of enrollment.Additional periods of coverage may not be purchased after the initial enrollment.Premiums paid will be considered to be non-refundable. Detailed information about theContinuation Plan and applications for enrollment are available atwww.aetnastudenthealth.com/columbiadirect.html. You may enroll online by submitting yourapplication and using a credit card or e-check for payment.

The maximum length of coverage under the Continuation Plan is 12 consecutive months forstudents enrolling for coverage effective September 1, 2010 or seven months for students

enrolling for coverage effective January 18, 2011. If a student is eligible for additional coverageafter August 31, 2011, the new Plan rates and benefit modifications may apply.

WHATS COVERED UNDER COLUMBIAS STUDENT MEDICAL INSURANCE PLAN

The Columbia University Student Medical Insurance Plan may not cover all of your health careexpenses. The Plan excludes coverage for certain services and contains limitations on theamounts it will pay. Please read the Columbia Plan Brochure carefully before deciding whetherthis Plan is right for you. While this document will tell you about some of the important featuresof the Plan, other features may be important to you and some may further limit what the Planwill pay.

Subject to the terms of the Master Policy, benefits are available for you and your eligibledependents only for the coverage listed on the next page, and only up to the maximum amountsshown. Please refer to the dependent coverage section of this brochure for details regardingdependent coverage which may differ in certain respects from student coverage. If afterreviewing this brochure you have further questions please refer to the Master Policy for acomplete description of the benefits available. To review the Master Policy please contact theInsurance Office to make an appointment.


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Outpatient Physician Office Visits/Allergy CareBenefits

PHYSICIAN OFFICE VISITSBenefits are available for the services specified as well as care by consulting specialists asdescribed in the chart below.

Preferred Care Non-Preferred Care

Basic Plan 100% of the negotiatedcharge

$25 copay per visit

70% of reasonable charges upto $10,000

100% of reasonable chargesthereafter

$25 deductible per visit

ComprehensivePlan

100% of the negotiatedcharge

$10 copay per visit




CONSULTANT OR SPECIALIST EXPENSECovered Medical Expenses include the expenses for the services of a consultant orspecialist, when referred by Health Services at Columbia. The services must be requestedby your primary care provider for the purpose of confirming or determining a diagnosis.



$25 copay per visit




ComprehensivePlan


$10 copay per visit





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ALLERGY TESTING EXPENSEBenefits include charges incurred for diagnostic testing of allergies and immunologyservices.

Covered Medical Expenses include coverage of injections and sera (including mixing ofsera) up to a maximum of $500 per condition per policy year.

The $500 per condition maximum excludes the cost of the office visit or services fordiagnostic testing.


Basic Plan 80% of the negotiated chargeup to $10,000

100% of the negotiatedcharge thereafter

$25 copay per visit




ComprehensivePlan


$10 copay per visit





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OUTPATIENT PHYSICAL THERAPY EXPENSECovered Medical Expenses for physical therapy are payable as follows when provided by alicensed physical therapist.


Basic Plan

Benefits are limited to amaximum of $500 percondition per policy year.This limitation does notapply to post-surgicaltherapy or accidentalinjuries.


$25 copay per visit




ComprehensivePlan


$10 copay per visit





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OUTPATIENT MUSCULOSKELETAL/CHIROPRACTICTHERAPY EXPENSECovered Medical Expenses include charges for Musculoskeletal Therapy provided on anoutpatient basis. For purposes of this benefit; Musculoskeletal Therapy means thediagnosis; and treatment; by manual or mechanical means; of the musculoskeletal structure;due to lack of normal nerve; muscle; and /or joint function; following an injury . Benefits forchiropractic care will be paid on the same basis as those payable for care or servicesprovided by other health professionals in the diagnosis, treatment and management of thesame or similar conditions, injuries, complaints, disorders or ailments.



$25 copay per visit




ComprehensivePlan


$10 copay per visit





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OUTPATIENT ACUPUNCTURE EXPENSEAcupuncture is a Covered Medical Expense when it is administered for the followingindications by a health care provider, who is a legally qualified physician, who is practicingwithin the scope of their license:

Adult postoperative and chemotherapy nausea and vomiting Nausea of pregnancy Postoperative dental pain Fibromyalgia/myofacial pain Chronic low back pain secondary to osteoarthritis


Basic Plan 100% of the negotiated

charge $25 copay per visit

70% of reasonable charges up

to $10,000 100% of reasonable charges

thereafter $25 deductible per visit

ComprehensivePlan


$10 copay per visit





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ACUPUNCTURE IN LIEU OF ANESTHESIA EXPENSECovered Medical Expenses include acupuncture therapy, when acupuncture is used in lieuof other anesthesia, for a surgical or dental procedure covered under this Plan. Theacupuncture must be administered by a health care provider who is a legally qualified

physician, practicing within the scope of their license.






ComprehensivePlan

100% of the negotiatedcharges




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OUTPATIENT CHEMOTHERAPY EXPENSECovered Medical Expenses for chemotherapy, including anti-nausea drugs used inconjunction with the chemotherapy, radiation therapy, tests and procedures, physiotherapy(for rehabilitation only after a surgery), and expenses incurred at a radiological facility.

Covered medical expenses also include expenses for the administration of chemotherapyand visits by a health care professional to administer the chemotherapy. Such expenses arepayable as follows:



$25 copay per visit




ComprehensivePlan


$10 copay per visit





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Outpatient Hospital Services

Benefits are available for the services specified as well as care by consulting specialists asdescribed in the chart below.

HOSPITAL OUTPATIENT SERVICES




$25 copay per visit




ComprehensivePlan


$10 copay per visit


100% of reasonable charges

thereafter $10 deductible per visit


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Outpatient X-Ray and Laboratory Services

Benefits are available for the services specified as well as care by consulting specialists asdescribed in the chart below.

OUTPATIENT X-RAY, DIAGNOSTIC IMAGING AND LABORATORY SERVICES




$25 copay per visit For services rendered by

Westside Radiology andLabcorp, after referral by aHealth Services at Columbia

provider, coverage is 100%with no copay




ComprehensivePlan


$10 copay per visit For services rendered by

Westside Radiology andLabcorp providers, afterreferral by a Health Servicesat Columbia provider,coverage is 100% with no

copay


100% of the charge thereafter $10 deductible per visit


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Emergency Care

Emergency treatment is covered for severe injury or sudden, acute medical or psychiatricillness. If you are not sure whether emergency treatment is needed, Health Services atColumbia providers are available to help assess your condition and determine the mostappropriate course of action. Please be mindful of the following points regarding utilization of

this benefit: It is not necessary to obtain a referral from your Health Services at Columbia

provider prior to receiving emergency care. Aetna Student Health does require that they be contacted within one business day

following a hospital or emergency room inpatient admission- by the patient, thepatient's representative, or the hospital.

In a true emergency situation, care received at a preferred hospital and nonpreferred hospital would be reimbursed at the same rate. Examples of trueemergencies include severe chest pain, appendicitis, and fractures.

Any follow-up care that is needed through a consulting specialist, followingemergency care, will require a referral from your on-campus provider. Please see theReferral Requirements section for details.

ACCIDENTAL INJURY AND MEDICAL EMERGENCIESAs covered through the Health Service Fee


Enrolled in Health ServiceFee and carryingalternate coverage


$25 copay per visit Maximum of $2,000 per

condition per policy year

80% of reasonablecharges

$25 deductible per visit Maximum of $2,000 per


Basic Plan 80% of the negotiatedcharges






Comprehensive Plan 80% of the negotiatedcharges







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ELECTIVE TERMINATION OF PREGNANCY EXPENSEEligible expenses are payable at 100% of negotiated or reasonable and customary chargesup to $500 per condition per policy year.

As covered through the Health Service Fee


Health Service Fee 100% of the negotiated charge 100% of reasonable charge

EMERGENCY CARE EXPENSE



100% of the negotiated chargethereafter

$25 copay per visit

80% of the reasonablecharge up to $10,000

100% of the reasonablecharge thereafter


ComprehensivePlan

100% of the negotiated charge $10 copay per visit

100% of reasonable charges $10 deductible per visit


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URGENT CARE EXPENSEBenefits include charges for treatment by an urgent care provider. Please note: A coveredperson should not seek medical care or treatment from an urgent care provider if theirillness, injury, or condition, is an emergency condition. The covered person should go

directly to the emergency room of a hospital or call 911 (or the local equivalent) forambulance and medical assistance.

Benefits include charges for an urgent care provider to evaluate and treat an urgentcondition. No benefit will be paid under any other part of this Plan for charges made by anurgent care provider to treat a non-urgent condition.

Non-urgent care includes, but is not limited to, the following: routine or preventive care (this includes immunizations), follow-up care, physical therapy, elective surgical procedures, and

any lab and radiologic exams which are not related to the treatment of the urgentcondition.

Please note: Services, including urgent care rendered without an appropriate referral will notbe covered under the Columbia Plan. In the event of an urgent medical need when HealthServices is closed, you must contact the Clinician-on-call at 212-854-9797 for medical adviceor to obtain a referral for an Urgent Care facility if it is indicated. Immediate medicaltreatment received at off-campus Urgent Care facilities is not covered without a referralobtained in advance of the visit; emergency room care is excluded from this requirement.



$25 copay per visit




ComprehensivePlan


$10 copay per visit





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Surgical Benefits (Inpatient and Outpatient)

Surgeons are included in the Aetna network of providers. Many services are now performed inan outpatient setting, in stand-alone clinics or providers' offices. Please be mindful of thefollowing points regarding utilization of this benefit:

A referral is needed for non-emergency surgical care. Pre-certification by Aetna Student Health is requiredfor any inpatient hospital stayassociated with surgical services. Please see the Inpatient Hospital Caresection for

more information. Surgical procedures for gender reassignment are not covered under this Plan*.

*This benefit is pending filing and approval from the NY Department of Insurance.

SURGICAL CARE EXPENSECovered Medical Expenses for charges for surgical services, performed by a Physician, arepayable as follows:

Preferred Care Non-Preferred CareBasic Plan 80% of the negotiated charge

up to $10,000 100% of the negotiated

charge thereafter

$75 copay per surgery



$75 deductible per surgery

ComprehensivePlan


$75 copay per surgery



$75 deductible per surgery


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SECOND SURGICAL OPINION EXPENSE

Covered Medical Expenses will include expenses incurred for a second opinionconsultation by a specialist on the need for surgery which has been recommended by thecovered persons physician. The specialist must be board certified in the medical fieldrelating to the surgical procedure being proposed. Coverage will also be provided for anyexpenses incurred for required X-rays and diagnostic tests done in connection with thatconsultation. Aetna must receive a written report on the second opinion consultation.


Basic Plan 100% of the negotiatedcharge up to a maximum of$150 per consultation

$25 copay per visit

70% of reasonable charges upto a maximum of $150 perconsultation


ComprehensivePlan

100% of the negotiatedcharge up to a maximum of$150 per consultation

$10 copay per visit

70% of reasonable charges upto a maximum of $150 perconsultation


ANESTHETIST AND ASSISTANT SURGEON EXPENSECovered Medical Expenses for the charges of an anesthetist and an assistant surgeon,during a surgical procedure, are payable as follows:



100%of the negotiatedcharge thereafter


100%of the reasonable chargethereafter

ComprehensivePlan



100% of the reasonable charge

thereafter


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AMBULATORY SURGICAL EXPENSECovered Medical Expenses for outpatient surgery performed in an ambulatory surgicalcenter are payable as follows. Covered Medical Expenses must be incurred on the day ofthe surgery or within 48 hours after the surgery.




50%of reasonable charges upto $10,000

100% of the reasonable chargethereafter

ComprehensivePlan



100% of the reasonable chargethereafter


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Inpatient Hospitalization Benefits

Inpatient services are covered under the Columbia Student Medical Insurance Plan for bothemergency medical and psychiatric treatment and non-emergency planned admissions. Pleasebe mindful of the following points regarding utilization of this benefit:

Aetna Student Health requires that they be contacted within one business day of an

emergency inpatient hospital admission - by the patient, the patients representative,or the hospital. Aetna Student Health must be contacted for pre-certificationat least three business

daysprior to a pre-planned admission. Contact should be made by the patient,patient's representative, health care provider, or hospital.

The pre-certification process includes review of the anticipated length of stay. Pre-certification does not guarantee the payment of benefits for your inpatient admission.Each claim is subject to medical policy review in accordance with the exclusions andlimitations contained in the Policy, as well as a review of eligibility, adherence tonotification guidelines, and benefit coverage under the Columbia Student MedicalInsurance Plan.

If pre-certification for a planned admission or notification of an emergency

hospitalization is not secured, your hospital bill will be subject to a Deductibleof $200per admission, in addition to any other Deductible.

INPATIENT HOSPITAL ROOM AND BOARD EXPENSEThis applies to treatment for medical conditions. For coverage of mental or nervous disordersplease refer to the section below.



100% of the negotiated charge

thereafter $25 copay per admission



thereafter $25deductible per admission

ComprehensivePlan

100% of the negotiated charge $10 copay per admission



$10 deductible per admission


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INTENSIVE CARE UNIT EXPENSE




$25 copay per admission




ComprehensivePlan




$10deductible per admission

INPATIENT PHYSICIAN VISIT/CONSULTATION EXPENSECovered Medical Expenses for charges for the non-surgical services of the attendingPhysician, or a consulting Physician, are payable as follows. Benefits are limited to one visitper day.


Basic Plan 80% of the negotiated charge

up to $10,000 100% of the negotiated chargethereafter

$25 copay per visit


to $10,000 100% of reasonable chargesthereafter

$25deductible per visit

ComprehensivePlan






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PRE-ADMISSION TESTING EXPENSECovered Medical Expenses for Pre-Admission testing charges while outpatient beforescheduled surgery are payable as follows:




$25 copay per visit




ComprehensivePlan



100%of reasonable chargesthereafter


MISCELLANEOUS HOSPITAL EXPENSECovered Medical Expenses include, but are not limited to: laboratory tests, x-rays, surgicaldressings, anesthesia, supplies and equipment use, and medicines.


Basic Plan 80% of the negotiated charge

up to $10,000 100% of the negotiated charge

thereafter $25 copay per admission


to $10,000 100% of reasonable charges

thereafter $25 deductible per admission

ComprehensivePlan






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Pre-Natal and Maternity Care

MATERNITY EXPENSECovered Medical Expenses include inpatient care of the covered person and any newbornchild for a minimum of 48 hours after a vaginal delivery and for a minimum of 96 hours aftera cesarean delivery. Coverage includes prenatal lead testing. Any decision to shorten such

minimum coverages shall be made by the attending Physician, in consultation with themother. In such cases, covered medical expenses may include at least one home carevisit. This home care visit may be requested at any time within 48 hours of the time of avaginal delivery, or within 96 hours of a delivery, and shall be delivered within 24 hours afterdischarge, or 24 hours of the mothers request; whichever is later. The home care visit willnot be subject to any deductible, copay or insurance. A referral is not required for thisbenefit.

Covered Medical Expenses for pregnancy, childbirth, and complications of pregnancy arepayable on the same basis as any other sickness.

Covered Medical Expenses include services of a licensed midwife unless those services

duplicate the services already provided by the covered persons physician.

During the initial 48 or 96 hours; no pre-certification is required for the mother; or her newlyborn child. Pre-certification is required; after the 48; or 96 hours.


Basic Plan Payable as any othercondition

Payable as any othercondition

Comprehensive

Plan

Payable as any other

condition


condition


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WELL NEWBORN NURSERY CARE EXPENSEBenefits include charges for routine care ofa covered persons newborn child as follows:

hospital charges for routine nursery care during the mothers confinement, but not morethan four days for a normal delivery,

physicians charges for circumcision, and physicians charges for visits to the newborn child in the hospital and consultations, but

not more than 1 visit per day.



100%of the negotiated charge

thereafter



thereafter

ComprehensivePlan



100%of reasonable chargesthereafter


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PRESCRIPTION DRUG COVERAGE

The prescription coverage included in the Columbia Student Medical Insurance Plan is designedto meet the basic needs of most college students. Your Aetna I.D. card functions asconfirmation of your coverage through the Columbia Student Medical Insurance Plan. Noseparate prescription card is needed. You may contact Aetna Pharmacy Management at

1-800-AETNA Rx (238-6279) for assistance in determining your remaining availableprescription benefit at any time.

The Aetna Preferred Drug List will be used as part of the prescription benefit coverage. Theprescription copay will depend on whether your prescribed medication is a generic or brandname drug and for brand name drugs, whether the prescribed medication is listed on AetnasPreferred Drug List. The prescription copays are as follows:

$40 for Tier Three (covered Brand Name medications not on the Preferred Drug List) $25 for Tier Two (covered Brand Name medications on the Preferred Drug List) $7 for Tier One (covered Generic medications)

You may find Aetnas Brand Name Preferred Drug List by visiting the Aetna Student Health

website or by calling Aetna Student Health at 800-859-8471.Prior authorization is required for the following medications:

Growth hormones Drugs used for the treatment of malaria More than a 90-day supply per Prescription or refill

The following is a partial list of some medications not covered under the Columbia StudentMedical Insurance Plan. For a complete list of excluded medications or drugs available withprior authorization, please contact Aetna Pharmacy Management at1-800-AETNA Rx (238-6279).

Allergy sera Drugs whose sole purpose is to promote or stimulate hair growth

Appetite suppressants Smoking deterrents Immunization agents and vaccines, unless provided by the Health Center

(specifically, those for measles, mumps, rubella, hepatitis A, hepatitis B, hepatitis A &B, tetanus diphtheria, and tetanus diphtheria pertusis, as well as rabies medications)

Non-self injectables

The plan does not currently cover mail-order prescriptions or those ordered over the Internet, fortwo main reasons:1. Many students change their address multiple times. This can make it difficult to deliver

prescriptions in a safe and secure manner.2. Most mail-order prescription services provide medications in bulk. The majority of students

utilize prescription medicines temporarily and/or are in the process of finding the correctdosage with the assistance of their health care provider. For this reason, orderingmedications in large quantity is not of benefit to most students.


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The least expensive approach to obtaining prescriptions is to fill them, when possible, asgenerics at Preferred Pharmacies. Aetna maintains a wide network of Preferred Pharmacies,where students will need to pay only a copay for each prescription, until they reach thePrescription Drug Policy Year maximum.

A listing of Preferred Pharmacylocations can be obtained through Aetna Pharmacy

Management at 800-238-6279 or on Aetna Student Healths website. Once on the site, click onFind Your School. From the school specific Aetna Student Health web page, you will find theDocfind option to the left. Students may also obtain a listing of Preferred Pharmaciesin thecampus vicinity at the Health Services Insurance Office in Wien Hall.

You will need to discuss with your health care provider whether use of a generic prescription ispossible at the time the prescription is written.

The Columbia Student Medical Insurance Plan also allows you to fill prescriptions at Non-Preferred Pharmacies. However, you will be required to pay in full at the time of service for allprescriptions dispensed and submit a claim form to Aetna Pharmacy Management. Claims arereimbursed at the rates described in the following chart. Reimbursement claim forms are

available at website www.aetnastudenthealth.com/columbiadirect.htmlor the HealthServices Insurance Office. Please be aware that by New York State mandate, all contraceptivedevices and medications, except those available over the counter, are covered under theColumbia Student Medical Insurance Plan.

Aetna Specialty Pharmacy provides specialty medications and support to members livingwith chronic conditions. The medications offered may be injected, infused or taken bymouth. This is an optional service available to members. For additional information please go towww.AetnaSpecialtyRx.com.


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PRESCRIPTION MEDICATIONS BENEFIT(See text on the previous page for medications excluded from coverage)

Preferred Pharmacy Non-Preferred Pharmacy

Basic Plan

Prescriptionbenefits up to$1,500 per policyyear.

100% of the negotiated charge $7for Tier One (Covered Genericmedications)

$25 for Tier Two (Covered BrandName medications on the PreferredDrug List)

$40 for Tier Three (Covered BrandName medications NOT on thePreferred Drug List)

Note:Prescriptions for Insulin, syringes anddiabetic testing supplies are covered at a $25copay for Generic or Brand Name medicationsup to the medical plan maximum.

Coverage for IUDs is available under medicalportion of this plan. Please note, IUDs areavailable at Health Services at Columbia and ifprovided there to covered students, the devicesare covered at 100% of the negotiated charge.Diaphragms are covered under the pharmacybenefit.

For all services by Non-Preferred Pharmacies,payment must be made in full to the pharmacy at timeof service; claim for reimbursement of prescriptionbenefit should then be submitted to Aetna StudentHealth.

70% of the reasonable charge $7 for Tier One (Covered Generic

medications) $25 for Tier Two (Covered Brand Name

medications on the Preferred Drug List) $40 for Tier Three (Covered Brand Name

medications NOT on the Preferred DrugList)

Note:Prescriptions for Insulin, syringes and diabetictesting supplies are covered at a $25 copay for Genericor Brand Name medications up to the medical planmaximum.

Coverage for IUDs is available under medical portion ofthis plan. Please note, IUDs are available at HealthServices at Columbia and if provided there to coveredstudents, the devices are covered at 100% of thenegotiated charge. Diaphragms are covered under thepharmacy benefit.

Comprehensive

Plan

Prescriptionbenefits up to$7,500 per policyyear.


$7 for Tier One (Covered Genericmedications)

$25 for Tier Two (Covered BrandName medications on the PreferredDrug List)

$40 for Tier Three (Covered BrandName medications NOT on thePreferred Drug List)

Note:Prescriptions for Insulin, syringes anddiabetic testing supplies are covered at $10 forGeneric or Brand Name medications up to themedical plan maximum.

Coverage for IUDs is available under medicalportion of this plan. Please note, IUDs areavailable at Health Services at Columbia and ifprovided there to covered students, the devicesare covered at 100% of the negotiated charge.Diaphragms are covered under the pharmacybenefit.

For all services by Non-Preferred Pharmacies,payment must be made in full to the pharmacy at time

of service; claim for reimbursement of prescriptionbenefit should then be submitted to Aetna StudentHealth.

70% of the reasonable charge $7 for Tier One (Covered Generic

medications) $25 for Tier Two (Covered Brand Name

medications on the Preferred Drug List) $40 for Tier Three (Covered Brand Name

medications NOT on the Preferred DrugList)

Note:Prescriptions for Insulin, syringes and diabetictesting supplies are covered at $10 for Generic orBrand Name medications up to the medical planmaximum.

Coverage for IUDs is available under medical portion ofthis plan. Please note, IUDs are available at HealthServices at Columbia and if provided there to coveredstudents, the devices are covered at 100% of thenegotiated charge. Diaphragms are covered under thepharmacy benefit.


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DIABETIC TREATMENT AND SUPPLIES EXPENSECovered Medical Expenses include expenses incurred in connection with the treatment ofdiabetes, including diabetic testing supplies and equipment, including: Blood glucosemonitors (including monitors for the legally blind), data management systems, test strips;

insulin injecting aids, cartridges for the legally blind, syringes, insulin pumps andappurtenances, insulin infusion devices and oral agents for controlling blood sugar.

Treatment is payable as any Sickness and supplies are payable under the Prescription DrugExpense benefit under the plan up to the medical plan maximum.




Comprehensive

Plan


condition


condition

DIABETIC SELF-MANAGEMENT EDUCATION EXPENSECovered Medical Expenses will include training designed to instruct a person in the self-management of diabetes. It may include training in self-care or diet. Such education may beprovided in a group setting, and when medically necessary, diabetic self-managementeducation shall also include home visits.

Please see definition of Diabetic Self-Management Education for more detailed

information on this benefit.




ComprehensivePlan




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PRESCRIPTION CONTRACEPTIVE DRUGS AND DEVICES EXPENSECovered Medical Expenses include:

Charges incurred for contraceptive drugs and devices that by law need a physiciansprescription and that have been approved by the FDA.

Related outpatient contraceptive services such as: Consultations, Exams, Procedures, and Other medical services and suppliesA referral is not required for this benefit.


Basic Plan Payable as any othercondition Payable as any othercondition

ComprehensivePlan



TREATMENT OF MENTAL HEALTH DISORDERS

Mental health services, including a limited number of psychotherapy visits, are available oncampus through Counseling and Psychological Services (CPS). These visits are provided at no

additional charge for all students who have paid the Health Service Fee.

Coverage for off-campus mental health services is also provided through the Health ServiceFee Plan, the Basic Plan and the Comprehensive Plan.

A referral must be obtained through a CPS provider prior to receiving off-campus treatment byany specialist providers or institutional services. Services received off-campus prior to anevaluation at CPS will not be eligible for coverage, except for emergency services.

Benefits are as follows:

Biological Mental Health Disorders and Children with Serious Emotional

DisturbancesIf you have been diagnosed with a biologically based mental illness such asschizophrenia/psychotic disorders, major depression, bipolar disorder, delusional disorders,panic disorder, obsessive-compulsive disorder, bulimia and anorexia, benefits are payable asdescribed in this section. If you are under 18 with a serious emotional disturbance and havesuicidal symptoms, psychotic symptoms, at risk to cause harm, or risk removal from thehousehold, benefits are covered as described in this section.


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Inpatient Care

Covered Medical Expenses include expenses incurred by a covered person while confinedas a full-time inpatient in a hospital or residential treatment facility.Includes the chargesmade for treatment received for partial hospitalization or intensive outpatient in a hospital ortreatment facility. Prior review and approval must be obtained on a case-by-case basis. If

approved, benefits will replace an inpatient admission, whereby 2 days of partial hospitalizationor intensive outpatient treatment may be exchanged for 1 day of full hospitalization.

COVERAGE FOR BIOLOGICALLY BASED CONDITIONSINPATIENT CARE

HEALTH SERVICE FEE BASIC PLAN COMPREHENSIVE PLAN

No Coverage $25 copay/deductible peradmission

Preferred Care:80% of thenegotiated charge up to

$10,000; 100% of thenegotiated charge thereafter upto the plan maximum.Non Preferred Care:50%ofthe reasonable charge up to$10,000; 100% of thereasonable charge thereafter upto the planmaximum.

$10 copay/deductible peradmission

Preferred Care:100% of thenegotiated charge up to the

plan maximum.Non Preferred Care:70%ofthe reasonable charge up to$10,000; 100% of thereasonable charge thereafterup to the plan maximum.


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Outpatient Care

Covered Medical Expenses include expenses while a covered person is not confined as afull-time inpatient in a hospital, for the treatment of Biologically based Mental Illness.

Not Covered are Charges for Services:

While being investigated for criminal charges. Provided solely because such services are ordered by a court.

COVERAGE FOR BIOLOGICALLY BASED CONDITIONSOUTPATIENT CARE


$10 copay/deductible pervisit

Preferred Care:100% of thenegotiated charge up to 7

visits.Non Preferred Care:70% ofthe reasonable charge forvisits 1- 7 up to $10,000;100% of the reasonablecharge thereafter.


Preferred Care:100% of thenegotiated charge beginning

with visit 8, up to the planmaximum.Non Preferred Care:70% ofthe reasonable chargebeginning with visit 8 up to$10,000; 100% of thereasonable charge thereafterto the plan maximum.


Preferred Care:100% of thenegotiated charge beginning

with visit, 8 up to the planmaximum.Non Preferred Care:70%ofthe reasonable chargebeginning with visit 8 up to$10,000; 100% of thereasonable charge thereafterup to the plan maximum.


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Other than Biologically Based Mental Illness and Children with Serious EmotionalDisturbances

If you have been diagnosed with a non biological mental illness such as dysthymia, generalizedanxiety disorder, post-traumatic stress disorder and many others benefits are payable asdescribed below.

Inpatient Care

Covered Medical Expenses include expenses incurred by a covered person while confinedas a full-time inpatient in a hospital or residential treatment facility.Includes the chargesmade for treatment received for partial hospitalization or intensive outpatient in a hospital ortreatment facility. Prior review and approval must be obtained on a case-by-case basis. Ifapproved, benefits will replace an inpatient admission, whereby 2 days of partial hospitalizationor intensive outpatient treatment may be exchanged for 1 day of full hospitalization.

COVERAGE FOR NON BIOLOGICALLY BASED CONDITIONSINPATIENT CARE


No Coverage $25 copay/deductible peradmission

Preferred Care:80% of thenegotiated charge up to$10,000; 100% thereafter up to30 days per policy year.Non Preferred Care:50%of thereasonable charge up to$10,000; 100% thereafter up to30 days per policy year.

Maximum of 30 days per policyyear.

$10 copay/deductible peradmission

Preferred Care:100% of thenegotiated charge up to 30days per policy year.Non Preferred Care:70%ofthe reasonable charge up to$10,000; 100% thereafter upto 30 days per policy year.

Maximum of 30 days perpolicy year.


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Outpatient Care

Covered Medical Expenses include expenses while a covered person is not confined as a full-time inpatient in a hospital.

Not covered Charges for Services:

While being investigated for criminal charges. Provided solely because such services are ordered by a court.

COVERAGE FOR NON BIOLOGICALLY BASED CONDITIONSOUTPATIENT CARE


$10 copay/deductibleper visit

Preferred Care:100% ofthe negotiated charge up to

7 visits.Non-Preferred Care:70%of the reasonable charge forvisits 1-7 up to $10,000;100% of the reasonablecharge thereafter.


Preferred Care:100% of thenegotiated charge for visits

8-20 per policy year.Non-preferred Care:70% ofthe reasonable charge up to$10,000; 100% thereafter forvisits 8-20 per policy year.

Maximum of 20 visits perpolicy year.


Preferred Care:100% of thenegotiated charge for visits 8-20

per policy year.Non-preferred Care:70% ofthe reasonable charge up to$10,000; 100% thereafter forvisits 8-20 per policy year.

Maximum of 20 visits per policyyear.


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Attention Disorders and Learning Disability Testing Benefit

DIAGNOSTIC TESTING FOR ATTENTION DISORDERS AND LEARNING DISABILITYTESTING EXPENSE

Covered Medical Expenses for diagnostic testing for: Attention deficit disorder, or Attention deficit hyperactive disorder, or Dyslexia

Once a covered person has been diagnosed with one of these conditions, medical treatmentwill be payable as detailed under the outpatient Treatment of Mental and Nervous Disordersportion of this Policy.

ADD/ADHD Medication Management Visits: Medication management will be covered as aphysicians office visit under the Basic or the Comprehensive Plan.

ADD/ADHD Cognitive Behavioral Therapies: Cognitive behavioral therapies will be coveredas any other outpatient mental health visit (see previous page) under the Health Service Fee,

the Basic Plan or the Comprehensive Plan.

Benefits are limited to $600 maximum per policy year for both levels of the plan .


Basic Plan

Benefits are limitedto $600 maximumper policy year.

After a $100 copay benefits arepayable at 80% of the negotiatedcharge

After a $100 deductible benefitsare payable at 80% of thereasonable charge

ComprehensivePlan

Benefits are limitedto $600 maximumper policy year.

After a $50 copay benefits arepayable at 100% of thenegotiated charge

After a $50 deductible benefitsare payable at 100% of thereasonable charge


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Inpatient Treatment for Eating Disorders

INPATIENT PHYSICIAN VISITS/CONSULTSInpatient treatment for an eating disorder is considered a medical admission, rather than amental health admission, for the purpose of administration of the Columbia Student MedicalInsurance Plan. Benefits are payable based on billed diagnosis of biologically based

condition or non biologically based condition. Benefits are limited to one visit per day.


Basic Plan Payable as any othersickness.

Payable as any othersickness.

ComprehensivePlan



URGENT PSYCHIATRIC HOSPITALIZATIONAs covered through the Health Service Fee


Enrolled in Health ServiceFee with alternativeinsurance coverage

Maximum of $2,000 percondition


$25 copay per visit



Basic Plan

Maximum of $2,000 percondition

80% of the negotiated

charges $25 copay per visit

60% of reasonable

charges $25 deductible per visit

Comprehensive PlanMaximum of $2,000 percondition


$10 copay per visit




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Substance Abuse Treatment

Assessments for concerns about chemical abuse and/or dependency are available on campusat Counseling and Psychological Services. The Health Service Fee covers these services.

The Health Service Fee also includes coverage for outpatient chemical abuse treatment.

Counseling and Psychological Services providers can help students determine the mostappropriate form of treatment for their needs, and if necessary, connect them with off-campusproviders familiar with the issues faced by university students. Students must obtain a referralfor off-campus services. Benefits are provided as follows.

OUTPATIENT CHEMICAL ABUSE EXPENSECovered Medical Expenses for outpatient diagnosis and treatment of a substance abusecondition are payable as follows:


Off-campusservices coveredby Health ServiceFee

Benefits are limitedto 60 visits per PolicyYear, 20 of whichmay be used forfamily counseling ofdependents.

Up to 5 of thecounseling sessionswill be covered evenif medical treatmentof the coveredperson has notbegun.

The ColumbiaStudent MedicalInsurance Plan (atthe Basic orComprehensive

Level) does notoffer any additionalcoverage forstudents forOutpatientChemical AbuseTreatment.

100% of the negotiatedcharge.

100% of the reasonablecharge.


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Inpatient Chemical Abuse Treatment

Students are encouraged to contact Counseling and Psychological Services for urgent oremergency mental health care needs. If, through consultation with an on-campus provider,inpatient treatment is deemed necessary, an appropriate referral will be made.

INPATIENT HOSPITAL CARECHEMICAL ABUSE TREATMENT

Covered Medical Expenses include the treatment of a substance abuse condition whileconfined as an inpatient in a hospital or facility licensed for such treatment. CoveredMedical Expenses also include the charges made for treatment received during partialhospitalization in a hospital or treatment facility. Prior review and approval must be obtainedon a case-by-case basis by contacting Aetna Student Health. When approved, benefits willbe payable in place of an inpatient admission, whereby 2 days of partial hospitalization maybe exchanged for 1 day of full hospitalization. Benefits will include 7 inpatient days fordetoxification in any calendar year and 30 inpatient days for rehabilitation in any calendaryear.





50% of reasonable charges up to$10,000



ComprehensivePlan





thereafter $10 deductible per admission


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INPATIENT PHYSICIAN VISITS/CONSULTS(Coverage limited to one visit per day)

CHEMICAL ABUSE TREATMENT




$25 copay per visit




ComprehensivePlan


$10 copay per visit




ADDITIONAL AND/OR MANDATED BENEFITS COVERED UNDER THE COLUMBIASTUDENT MEDICAL INSURANCE PLAN

AMBULANCE EXPENSE

Health Service Fee

100% with no copay when Columbia University EMS (also known asColumbia Area Volunteer Ambulance (CAVA)) is dispatched as theresponding ambulance.*


Basic Plan 80% of the actual charge upto $10,000

100% of the actual chargethereafter to plan maximum.

$25 copay per trip

80% of the actual charge up to$10,000

100% of the actual chargethereafter to plan maximum.

$25 deductible per trip

Comprehensive

Plan

100% of the actual charge

$10 copay per trip

100% of the actual charge

$10 deductible per trip

* This is not an insured benefit underwritten by Aetna Life Insurance Company.


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BONE DENSITY SCREENING EXPENSECovered Medical Expenses include bone mineral density measurements or tests. Benefitswill be paid for expenses incurred by a covered person for a bone density screening uponthe recommendation of the covered persons physician for:

(1) An individual previously diagnosed as having osteoporosis or having a family history ofosteoporosis; or(2) An individual with symptoms or conditions indicative of the presence; or the significant

risk of osteoporosis; or(3) An individual on a prescribed drug regimen posing a significant risk of osteoporosis; or(4) An individual with lifestyle factors to such a degree as posing a significant risk of

osteoporosis; or(5) With such age; gender; and/or physiological characteristics which pose a significant risk

for osteoporosis.

Benefits will also include drugs and devices approved by the FDA or generic equivalents asapproved substitutes for the treatment of osteoporosis.


Basic Plan Benefits are payable as anySickness.

Benefits are payable as anySickness.

ComprehensivePlan



HOME HEALTH CARE/SERVICES EXPENSECovered Medical Expenses include charges incurred by a covered person for home healthcare services made by a home health agency pursuant to a home health care plan.

Please see definitions for more detailed information on this benefit.



100% of the negotiatedcharge thereafter to the planmaximum.

$25 copay per visit

50% of the reasonable chargeup to $10,000

100% of the reasonable chargethereafter to the planmaximum.


ComprehensivePlan

100% of the negotiatedcharge up to the planmaximum.

$10 copay per visit





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HOSPICE BENEFITCovered Medical Expenses include charges for hospice care provided for a terminally illcovered person during a hospice benefit period, including acute care services at an acutecare facility.

Please see definitions for more detailed information on this benefit.




$25 copay per visit




ComprehensivePlan


$10 copay per visit



thereafter to the planmaximum.


LICENSED NURSE EXPENSEBenefits include charges incurred by a covered person who is confined in a hospital as aresident bed-patient, and requires the services of a registered nurse or licensed practicalnurse. A benefit will be paid for the expenses incurred, up to the Daily Maximum of one visitper day. For purposes of determining this maximum, a shift means 8 consecutive hours.

Benefits are limited to one visit per day.




$25 copay per visit




ComprehensivePlan 100% of the negotiatedcharge up to the plan

maximum. $10 copay per visit

70% of the reasonable chargeup to $10,000 100% of the reasonable charge




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SKILLED NURSING FACILITY EXPENSECovered Medical Expenses include charges incurred by a covered person for confinementin a skilled nursing facility for treatment rendered:

In lieu of confinement in a hospital as a full time inpatient, or

Within 24 hours following a hospital confinement and for the same or related cause(s)as such hospital confinement.

Benefits for Skilled Nursing require pre-certification.


Basic Plan 80% of the negotiated chargefor the semi-private room rateup to $10,000

100% of the negotiatedcharge thereafter to the plan

maximum. $25 copay per admission

50% of the reasonable chargefor the semi-private room rateup to $10,000

100% of the reasonable chargethereafter to the plan

maximum. $25 deductible per admission

ComprehensivePlan

100% of the negotiatedcharge for the semi-privateroom rate up to the planmaximum.


70% of the reasonable chargefor the semi-private room rateup to $10,000




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REHABILITATION FACILITY EXPENSECovered Medical Expenses include charges incurred by a covered person for confinementas a full time inpatient in a rehabilitation facility. Confinement in the rehabilitation facility mustfollow within 24 hours of, and be for the same or related cause(s) as, a period of hospital or

skilled nursing facility confinement.

Benefits for Rehabilitation Facility expenses require pre-certification.


Basic Plan 80% of the negotiated chargefor the rehabilitation facilitysdaily room and boardmaximum for semi-privateaccommodations up to$10,000



50% of the reasonable chargefor the rehabilitation facilitysdaily room and board maximumfor semi-privateaccommodations $10,000




ComprehensivePlan

100% of the negotiatedcharge for the rehabilitationfacilitysdaily room andboard maximum for semi-privateaccommodations upto the plan maximum.


70% of the reasonable chargefor the rehabilitation facilitysdaily room and board maximumfor semi-privateaccommodations up to $10,000




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TRANSFUSION OR DIALYSIS OF BLOOD EXPENSECovered Medical Expenses include charges for the transfusion or dialysis of blood,including the cost of: whole blood, blood components, and the administration thereof.




$25 copay per visit




ComprehensivePlan


$10 copay per visit





WELL WOMAN CARE SERVICES/PAP SMEAR EXPENSECovered Medical Expenses include one annual routine pap smear screening and office visitfor women 18 years and older. Laboratory testing for chlamydia and/or gonorrhea arecovered when associated with an annual pap smear screening. Pap smear screenings andwomens health care visits are available on campus where a student pays no copay ordeductible and all associated laboratory tests are covered. If additional appropriate

testing is performed as part of an off-campus annual office visit, benefits for the testing willbe payable in accordance with the Policy and the student may be responsible for a portion ofthe laboratory testing.


Basic Plan Payable as any Sickness Payable as any Sickness

ComprehensivePlan

Payable as any Sickness Payable as any Sickness


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WELL WOMAN CARE SERVICES/CHLAMYDIA SCREENING TEST EXPENSECovered Medical Expenses include charges incurred for an annual Chlamydia andgonorrhea screening test for women 18 years and older. If additional appropriate testing isperformed as part of an off-campus annual office visit, benefits for the testing will be payable

in accordance with the Policy and the student may be responsible for a portion of thelaboratory testing.



100% of the negotiatedcharge thereafter to the planmaximum

$25 copay per visit




ComprehensivePlan


$10 copay per visit





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PROSTATE CANCER SCREENINGCovered Medical Expenses include charges incurred for the screening of cancer; asfollows:

For a males age 40 and over, with a family history of prostate cancer or other prostate

cancer risk factors, Standard Diagnostic Testing once each Policy Year. for a males age 50 or over, who are symptomatic, Standard Diagnostic Testing onceeach Policy Year.

For a male, any age, with a prior history of prostate cancer, Standard Diagnostic Testing asrecommended by the covered persons physician. Standard Diagnostic Testing includes, butis not limited to: a digital rectal examination and a prostate-specific antigen test.




$25 copay per visit




ComprehensivePlan


$10 copay per visit





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ROUTINE COLORECTAL CANCER SCREENING TESTCovered Medical Expenses include charges for colorectal cancer examination andlaboratory tests, for any nonsymptomatic person age 50 or more, or a symptomatic personunder age 50, for the following:

One fecal occult blood test every 12 months in a row A Sigmoidoscopy at age 50 and every 3 years thereafter One digital rectal exam every 12 months in a row A double contrast barium enema, once every 5 years A colonoscopy, once every 10 years Virtual colonoscopy Stool DNA

Benefits are payable as follows:



ComprehensivePlan


DURABLE MEDICAL EQUIPMENT EXPENSE


Basic Plan 80% of the negotiated chargeup to $10,000 100% of the negotiated

charge thereafter to planmaximum.

$25 copay per visit

50% of the reasonable chargeup to $10,000 100% of the reasonable charge

thereafter to plan maximum. $25 deductible per visit

ComprehensivePlan


$10 copay per visit


100% of the reasonable chargethereafter to plan maximum.



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DERMATOLOGICAL EXPENSECovered Medical Expenses include charges for the diagnosis and treatment of skindisorders, excluding laboratory fees. Related laboratory expenses are covered under theOutpatient Expense Benefit. Covered Medical Expenses do not include treatment for acne,

or cosmetic treatment and procedures.



ComprehensivePlan


PROSTHETIC DEVICES EXPENSEBenefits include charges for: artificial limbs, or eyes, and other non-dental prostheticdevices, as a result of an accident or sickness.

Covered Medical Expenses do not include: eye exams, eyeglasses, vision aids, hearingaids, communication aids, and orthopedic shoes, foot orthotics, or other devices to supportthe feet.



100% of the negotiatedcharge thereafter to planmaximum.

$25 copay per incident


100% of the reasonable chargethereafter to plan maximum.

$25 deductible per incident

ComprehensivePlan


$10 copay per incident


100% of the reasonable chargethereafter to plan maximum

$10 deductible per incident


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SPEECH AND HEARING THERAPY



$25 copay per visit




ComprehensivePlan


$10 copay per visit




NON PRESCRIPTION ENTERAL FORMULA EXPENSEBenefits include charges incurred by a covered person for non-prescription enteral formulas,for which a physician has issued a written order, and are for the treatment of malabsorptioncaused by:

Crohns Disease, Ulcerative colitis,

Gastroesophageal reflux, Gastrointestinal motility, Chronic intestinal pseudoobstruction, and Inherited diseases of amino acids and organic acids.

Covered Medical Expenses for inherited diseases of amino acids and organic acids, willalso include food products modified to be low protein.

Modified solid food products (MFSP) that are low in protein are covered up to the maximumof $2,500 per Covered Person, per Policy Year.



ComprehensivePlan



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TEMPOROMANDIBULAR JOINT DYSFUNCTION (TMJ)Covered Medical Expenses include charges incurred; by a covered person; for non-surgicaltreatment of Temporomandibular Joint (TMJ)

Documents

Columbia Insurance Coverage