Louisiana State University Student Health Insurance … State University 2015-2016 Student Health Insurance Plan For International Students 2 PRIVACY

Louisiana State University (“the Policyholder”)

2015 – 2016 Student Health Insurance Plan for International Students (“the Plan”) Administrator Policy Number: CHH8051916 Underwriter Reference Number: CAS9148872

Insurance underwritten by: National Union Fire Insurance Company of Pittsburgh, Pa., with its principal place of business in New York, NY (“the Company”)

This is only a brief description of the coverage available under policy series S30749NUFIC-LA-LSU(Rev. 4-15). The Policy contains definitions, reductions, limitations, exclusions and termination provisions. Full details of the coverage are contained in the Policy on file with the Policyholder. If there is any conflict between the contents of this brochure and the Policy, the Policy will govern in all cases. Travel Assistance services provided by Travel Guard Group, Inc. (“Travel Guard”). Insurance and services provided by member companies of American International Group, Inc. For additional information, please visit our website at www.AIG.com.

NOTICE: YOUR SHARE OF THE PAYMENT FOR HEALTH CARE SERVICES MAY BE BASED ON THE AGREEMENT BETWEEN YOUR HEALTH PLAN AND YOUR PROVIDER. UNDER CERTAIN CIRCUMSTANCES, THIS AGREEMENT MAY ALLOW YOUR PROVIDER TO BILL YOU FOR AMOUNTS UP TO THE PROVIDER'S REGULAR BILLED CHARGES.

You can now review the 2015-2016 Louisiana State University Student Health Insurance Plan brochure. Please note that information included in this brochure is subject to change subsequent to the Louisiana Department of Insurance’s approval of the policy form.

http://www.aig.com/

Louisiana State University 2015-2016 Student Health Insurance Plan For International Students

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PRIVACY POLICY ................................................................................................................................................................................. 3

ELIGIBILITY ........................................................................................................................................................................................... 3

ALTERNATIVE COVERAGE ................................................................................................................................................................. 3

EFFECTIVE AND TERMINATION DATES ............................................................................................................................................. 3

EXTENSION OF BENEFITS AFTER TERMINATION ............................................................................................................................ 4

CONTINUATION OF COVERAGE ......................................................................................................................................................... 4

TERM OF COVERAGE DATES & PAYMENT OPTIONS ...................................................................................................................... 5

LSU SCHEDULE OF BENEFITS ........................................................................................................................................................... 5

NOTICE TO ENROLLEE REGARDING GENETIC TESTING PURSUANT TO L.A. INS. CODE 22:1023 ........................................... 9

REPATRIATION OF REMAINS AND MEDICAL EVACUATION BENEFITS ....................................................................................... 10

STUDENT HEALTH CENTER (SHC) .................................................................................................................................................... 9

IMPORTANT POLICY PROVISIONS ................................................................................................................................................... 10

STUDENT HEALTH CENTER (SHC) REQUIREMENTS ..................................................................................................................... 10

VERITY HEALTHNET/FIRST HEALTH PREFERRED PROVIDER ORGANIZATIONS (PPO) ........................................................... 11

PROVIDER INFORMATION: ............................................................................................................................................................... 11

PRESCRIPTION DRUG BENEFIT MANAGER: ................................................................................................................................... 11

PRE-CERTIFICATION ......................................................................................................................................................................... 11

STATE MANDATED BENEFITS .......................................................................................................................................................... 11

DEFINITIONS ...................................................................................................................................................................................... 12

EXCLUSIONS AND LIMITATIONS ...................................................................................................................................................... 14

SUBROGATION ................................................................................................................................................................................... 15

FILING A CLAIM .................................................................................................................................................................................. 17

TRAVEL GUARD ................................................................................................................................................................................. 17

WHO IS TRAVEL GUARD ................................................................................................................................................................... 17

WHEN TO CONTACT TRAVEL GUARD ............................................................................................................................................. 17

HOW TO CONTACT TRAVEL GUARD ............................................................................................................................................... 17

STUDENT ASSIST SERVICES ........................................................................................................................................................... 18

VOLUNTARY DENTAL OPTIONAL ..................................................................................................................................................... 18

VOLUNTARY VISION OPTION ........................................................................................................................................................... 20

24-HOUR STUDENT NURSELINE ...................................................................................................................................................... 22

IMPORTANT POLICY CONTACT INFORMATION .............................................................................................................................. 22

Online access to your student insurance: www.LSUstudentinsurance.com

http://www.lsustudentinsurance.com/


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PRIVACY POLICY AIG, Higher Education understands that your privacy is important; therefore, we do not disclose non-public personal information to anyone, except as required by law. Appropriate physical, electronic and procedural safeguards are maintained to ensure the security of your non-public personal information. You may obtain a copy of our privacy policy by visiting www.LSUstudentinsurance.com.

ELIGIBILITY All non-immigrant international students with F or J Visa status enrolled in any amount of credit hours at LSU and LSU Law Center are eligible for coverage and will be automatically enrolled in and billed for coverage under the LSU Student Health Insurance Plan (“the Plan”) for International students each semester unless coverage under the Plan is waived by presenting proof of other comparable health insurance coverage to International Services on campus prior to the applicable waiver deadline.

Waiver/Dependent Enrollment Deadlines Fall Term Waiver: September 17, 2015

Spring Term Waiver: February 5, 2016

Summer Term Waiver: June 16, 2016

A student who initially waived coverage under the Plan but subsequently experiences ineligibility under another creditable coverage may elect to enroll for coverage under the Plan within 31 days of the date of ineligibility under another creditable coverage. If you experience ineligibility under another creditable coverage, please contact AIG, Higher Education for enrollment assistance at 1-888-622-6001.

It is the student’s responsibility to confirm that their premiums are assessed / received / paid timely to avoid a lapse in coverage.

An eligible student must attend classes at the University for at least the first 30 days of the period for which he or she is enrolled. Students who withdraw from school after such 30 days will remain covered under the Plan and no refund will be made. Home study, correspondence, distance education/on-line only, and television (TV) courses do not fulfill the eligibility requirements that the student attended classes. Eligibility requirements must be met each time premium is paid to continue coverage. The Company maintains the right to investigate student status and attendance records to verify that the Policy eligibility requirements have been met. If it is discovered that the Policy eligibility requirements have not been met, the Company’s only obligation is to refund premium, less any claims paid.

Dependents Covered students may also enroll their eligible dependents by going to www.studentinsurance.com/LA/LSU and completing the enrollment process by the enrollment deadline shown above. An eligible dependent is the Covered Student’s spouse and the Covered Student’s or spouse’s child until the date such child attains age 26. A Dependent may become eligible for coverage under the Policy only when the student becomes eligible; or within 31 days of marriage, birth or adoption. A dependent may be enrolled for coverage under the Plan only when the student enrolls; or within 31 days of marriage, birth or adoption.

ALTERNATIVE COVERAGE If you do not meet the eligibility requirements of the Student Health Insurance Plan, please call 1-888-622-6001 for information on alternative coverage. Alternative coverage options can also be explored at www.studentinsurance.com

EFFECTIVE AND TERMINATION DATES The Policy on file at the University becomes effective at 12:01 a.m. on August 14, 2015 and terminates at 11:59 p.m. on August 13, 2016. The coverage of an eligible student, including the student who initially waived coverage and subsequently enrolls within 31 days of ineligibility under another creditable coverage, shall take effect at 12:01 a.m. on the latest of the following dates: 1. the Policy Effective Date; 2. the day after the date for which the first premium for the Covered Student’s coverage is received by the Company; 3. the date the University’s term of coverage begins; or 4. the date the student becomes a member of an eligible class of persons as described in the Description of Class section of the

Schedule of Benefits in the Policy on file with University.

A covered dependent’s coverage shall take effect on the later the following dates: 1. the date the coverage for the Covered Student becomes effective; or 2. the date the dependent is enrolled for coverage, provided premium is paid when due.

http://www.studentinsurance.com/Schools/LA/LSUHSC.

http://www.studentinsurance.com/LA/LSU

http://www.studentinsurance.com/


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Insurance for a Covered Student will end at 11:59 p.m. on the first of these to occur: (a) the date the Policy terminates; (b) the last day for which any required premium has been paid; or (c) the date on which the Covered Student withdraws from the

school: (1) because of entering the armed forces of any country (premiums will be refunded on a pro-rata basis (less any claims paid) when written request is made within 90 days of leaving school); (2) when the withdrawal from school is during the first 30 days of the period for which the student is enrolled. Premiums will be refunded on a pro-rata basis (less any claims paid) when written request is made; or (3) because of departure from the University for his or her home country. Premiums will be refunded on a pro-rata basis (less any claims paid) only upon written proof from the University that the Covered Student is no longer an eligible person.

If withdrawal from the University is for other than (1), (2) or (3) above, no premium refund will be made. Covered Students will be covered for the Policy term for which they are enrolled and for which premium has been paid.

EXTENSION OF BENEFITS AFTER TERMINATION If the Covered Person is confined to a Hospital on the date his or her coverage terminates as a result of Sickness or Injury for which benefits were payable prior to the date his or her coverage terminated, benefits will be payable for the Eligible Expenses incurred until the earliest of: 1. the end of Sickness or Injury; 2. the end of the 90 day period following the date his or her coverage terminated; or 3. the date the applicable Maximum Amount is reached.

If the Covered Person is receiving treatment for a covered pregnancy on the date the Plan terminates, benefits will be payable for the Eligible Expenses incurred for that pregnancy until the earliest of the following: (a) the date the pregnancy ends; (b) the end of the 9 month period following the date of termination of insurance; or (c) the date applicable Maximum Amount is reached.

The Extension of Benefits will apply only to the extent the Covered Person will not be covered under the Plan or any other health insurance policy in the ensuing term of coverage.

CONTINUATION OF COVERAGE The right to continue coverage under the Plan is available to the Covered Student who is no longer eligible because he or she has graduated. The Covered Student has the option to continue coverage for up to 6 months beginning on the date coverage would otherwise terminate. Continuation of coverage will be subject to payment of premium and all the terms of this Policy.

If the Covered Student becomes ineligible under the Plan due to Injury or Sickness which occurred while covered under the Plan, he or she may continue coverage for up to the end of the Policy Year with the payment of any required premium. Written request for continued coverage and payment of premium must be made within 31 days of the date the Covered Student became ineligible under the Policy. Continuation of coverage will be subject to the terms of the Policy. If the Covered Student’s coverage ceases due to his or her death, the surviving spouse who is 50 years old or older may continue coverage under the Plan, provided written request is made 90 days after the date of the Covered Student’s death. The coverage to be continued will be identical in scope to that provided for the spouse prior to the Covered Student’s death. If this continued coverage option is exercised by the spouse, coverage will continue uninterrupted unless one of the following occurs:

(a) the spouse fails to make timely payment of the required premium;

(b) the spouse becomes eligible for Medicare;

(c) the spouse becomes insured under another accident and health plan; or

(d) the spouse remarries.

Call AIG, Educational Markets at 1-888-622-6001 or email [email protected] to obtain information about the continuation coverage and enrollment.


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TERM OF COVERAGE DATES & PAYMENT OPTIONS

ANNUAL FALL SPRING/ SUMMER NEW STUDENTS

SPRING/ SUMMER

NEW STUDENTS SUMMER

08/14/15 - 08/13/16

08/14/15 - 01/05/16

01/06/16 – 08/13/16

01/06/16 – 08/13/16

06/05/16 -08/13/16

LSU SCHEDULE OF BENEFITS Aggregate Maximum Benefit per Injury or Sickness per Policy Year: UNLIMITED

AC indicates Allowable Charge R&C indicates Reasonable & Customary

ELIGIBLE EXPENSES IN-NETWORK OUT- OF-NETWORK

Deductible Amount per Policy Year*: Per Covered Person Per Family *PPO and Non-PPO Deductibles apply separately. *The Deductible Amounts do not apply to the Eligible Expenses listed on the Louisiana State University Student Health Center fee schedule when services are rendered at a Policyholder owned and operated facility.

$500

$1,000

$1,000 $2,000

Out-of-Pocket Limit per Policy Year: Per Covered Person Per Family The Out-of-Pocket Limit is reached when the amount of Eligible Expenses incurred by the Covered Person during the Policy Year, for which the Covered Person is responsible due to Covered Percentages being less than 100%, reach the Out-of Pocket Limit. The Out-of-Pocket Limit includes deductibles, copays and coinsurance. The Out-of-Pocket Limit does not include charges in excess of R&C; charges in excess of any specified maximum; or charges incurred for any services not covered under the Plan. When this benefit becomes applicable to a Covered Person during a Policy Year, covered percentages are increased to 100% for all Eligible Expenses incurred by the Covered Person in the remainder of that Plan Year up to any benefit maximum that may apply. If, in any Policy Year, the sum of Eligible Expense used toward the Out-of-Pocket Limit of a Covered Student and his or her covered dependents equals the Family Out-of-Pocket amount, the Out-of-Pocket Limit will be deemed to be met with respect to Eligible medical Expense incurred by such Covered Student and his covered dependents for the rest of that Policy Year. When the Family Out-of-Pocket Limit is reached, the covered percentage will be increased to 100% of the Eligible Expenses incurred for the remainder of that year. *PPO and Non-PPO Out-of-Pocket Limits apply separately.

$3,500 $7,000

$7,000

$10,000

RATES ANNUAL FALL SPRING/ SUMMER

NEW STUDENTS SPRING/SUMMER

NEW STUDENTS SUMMER

ONLY

Student $2,089 $1,054 $1,054 $1,045 $532

Dependent Coverage (Amounts shown below are in addition to the Student Rate.) Enrollment of dependents is available on-line through www.LSUstudentinsurance.com Spouse $2,089 $1,054 $1,054 $1,045 $532 Child(ren) $2,089 $1,054 $1,054 $1,045 $532




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INPATIENT BENEFITS

Room and Board, except intensive care unit, limited to the average semi-private room rate

75% of AC 50% of R&C

Hospital Miscellaneous, includes expenses incurred for anesthesia and operating room; laboratory tests and X-rays (including professional fees), oxygen tent; drugs, medicines, dressings; blood transfusions, including cost of whole blood, blood plasma and expanders, processing charges, equipment and supplies; and other Medically Necessary and prescribed Hospital expenses.


Pre-Admission Testing (Hospital confinement must occur within 14 days of the testing)


Private Duty Nursing rendered by a Registered Nurse (RN) or Licensed Practical Nurse (LPN)


Physiotherapy/Occupational Therapy/Speech Therapy 75% of AC 50% of R&C

Surgical Expense (includes benefit for Assistant Surgeon) 75% of AC 50% of R&C

Anesthetist 75% of AC 50 % of R&C

Doctor’s Fees (other than the Doctor who performed surgery or administered anesthesia) Includes consultant during Hospital confinement when required and approved by attending Doctor.


Psychiatric Conditions Severe Mental Illness Mental and Nervous Disorders

Paid the same as any other Sickness Paid the same as any other Sickness


Alcoholism and Substance Abuse Paid the same as any other Sickness

Paid the same as any other Sickness

OUTPATIENT BENEFITS

Surgical Expense (includes benefit for Assistant Surgeon)


Anesthetist 75% of AC 50% of R&C

Day Surgery Facility/Miscellaneous, when scheduled surgery is performed in a Hospital or outpatient facility, including: use of the operating room; laboratory tests and x-ray examinations (including professional fees); anesthesia; infusion therapy; drugs or medicines and supplies; therapeutic services (excluding physiotherapy). Reasonable and Customary Charges for Day Surgery Miscellaneous are based on the most recent edition of the Outpatient Surgical Facility Charge Index.


Hospital Emergency Room and Non-Scheduled Surgery, for use of Hospital Emergency Room, including attending Doctor’s charges, operating room, laboratory and x-ray examinations, supplies. (A copay amount of $400 will apply to each visit to the Hospital Emergency Room unless the Covered Person is admitted to the Hospital as an inpatient.) For treatment of an Emergency Medical Condition Only.

100% of AC 100% of R&C

Urgent Care Expense 75% of AC, subject to a $75 copay per visit

50% of R&C, subject to a $75 copay per visit


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Preventive Services mandated by the Patient Protection and Affordable Care Act The following websites indicate the services included in the Preventive Services benefit. United States Preventive Services Task Force (“USPSTF”) Recommendations for Adults: https://www.healthcare.gov/preventive-care-benefits/ United States Preventive Services Task Force (“USPSTF”) Recommendations for Children and Adolescents: http://uspreventiveservicestaskforce.org/tfchildcat.htm Health Resources and Services Administration (“HRSA”) Guidelines for Women’s Care: http://www.hrsa.gov/womensguidelines

100% of AC, not subject to deductible or copay amounts

50% of R&C

Laboratory and X-ray Examinations (not otherwise covered under Preventive Services)


CAT Scan/MRI/PET Scan 75% of AC 50% of R&C

Radiation Therapy and Chemotherapy 75% of AC 50% of R&C

Rehabilitative Care (speech therapy/language pathology, hearing therapy, physical therapy, occupational therapy, cardiac/pulmonary and chiropractic)


Dialysis and Filtration Procedures 75% of AC 50% of R&C

Intravenous Home Therapy 75% of AC 50% of R&C

Durable Medical Equipment, Orthotic Devices and Orthopedic Braces and Appliance. No benefits will be payable for rental charges in excess of the purchase price.


Diagnostic Services and Medical Procedures performed by a Doctor (other than Doctor’s visits, physiotherapy, x-rays and lab procedures) (not otherwise covered under Preventive Services)


Doctor’s Fees • Doctor (other than Specialist) • Specialist • Eligible Expenses include:

Infusion Therapy; Injections administered in the Doctor’s office; and Nutritional Counseling.

100% of AC, subject to a $35 copay per visit 100% of AC, subject to a $55 copay per visit Not subject to the deductible amount.

50% of R&C 50% of R&C

Consultant’s Fees 100% of AC, subject to a $55 copay per visit Not subject to the deductible amount.

50% of R&C

Psychiatric Conditions Severe Mental Illness Mental and Nervous Disorders



Alcoholism and Substance Abuse Paid the same as any other Sickness

Paid the same as any other Sickness


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Prescribed Medicines Expense This benefit applies to all prescribed FDA-approved birth control methods. The copay will be waived for prescribed FDA-approved birth control. The prescriptions must be filled at Catamaran RX Pharmacies. Go to www.catamaranrx.com for a list of participating pharmacies.

Copay amount per prescription or refill (limited to a 30 day supply): Generic: $10 Formulary Brand Name: $40 Non-Formulary Brand Name: $70 This benefit is not subject to the deductible amount.

No Benefit

OTHER

Ambulance Expense 75% of R&C 70% of R&C

Dental Treatment Expense (Injury Only) 75% of R&C 70% of R&C

Maternity Paid the same as any other Sickness

Pediatric Vision Care Expense (applicable to Covered Persons under age 19 only) Eligible Expenses include charges made for vision examination by an optometrist or ophthalmologist, including (a) one routine eye examination every Policy Year; (b) one pair of standard eyeglass lenses or contact lenses every Policy Year; (c) one frame every Policy Year. Please see the Policy on file with the University for additional details.

75% of R&C, subject to the following copay amount per visit: • Examination: $100 • Materials: $100

Vision Care Expense (applicable to Covered Persons age 19 and older) Benefits are limited to one pair of lenses per Policy Year; and one frame per Policy Year.

60% of R&C, subject to the following copay amount per visit: • Examination: $35 • Materials: $35 Maximum Amount Policy Year: Standard Plastic Lenses: • Single vision: $25 • Bifocal: $25 • Trifocal: $25 • Lenticular: $25 • Progressive: $25 Frames: $25 Contact Lenses (In lieu of eyeglass lenses) and fames) Fit, Follow-up & Materials: • Effective: $25 • Medically Necessary: $25

Pediatric Dental Treatment Expense (applicable to Covered Persons under 19 only) Basic Services • For Diagnostic and Treatment Services • For Preventive Services • Additional Proce4dures coverage as Basic Services Intermediate Services • For Minor Restorative Services • For Endodontic Services • For Periodontal Services • For Prosthodontic Services

100% of AC 100% of AC 100%of AC

75% of AC 75% of AC 75% of AC

100% of R&C 100% of R&C 100% of R&C

75% of R&C 75% of R&C 75% of R&C

http://www.catamaranrx.com/


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• For Oral Surgery Major Services • For Major Restorative Services • For Endodontic Services • For Periodontal Services • For Prosthodontic Services Orthodontic Services • For Orthodontic Services Please see the Policy on file with the University for additional details.

75% of AC 75% of AC

50% of AC 50% of AC 50% of AC 50% of AC

50% of AC

75% of R&C 75% of R&C

50% of R&C 50% of R&C 50% of R&C 50% of R&C

50% of R&C

As required by the Women’s Health and Cancer Rights Act of 1998, the Plan provides benefits for mastectomy-related services including all stages of reconstruction and surgery to achieve symmetry between the breasts, prostheses, and complications resulting from a mastectomy, including lymphedema. Call Customer Service at 888-622-6001 for more information.

NOTICE TO ENROLLEE REGARDING GENETIC TESTING PURSUANT TO L.A. INS. CODE 22:1023 Pursuant to L.A. Insurance Code 22:1023, the Company will not, on the basis of any genetic information concerning an individual or family member or on the basis of an individual's or family member's request for or receipt of genetic services, or the refusal to submit to a genetic test or make available the results of a genetic test: (a) Terminate, restrict, limit, or otherwise apply conditions to the coverage of an individual or family member under the policy or plan, or restrict the sale of the policy or plan to an individual or family member; (b) Cancel or refuse to renew the coverage of an individual or family member under the policy or plan; (c) Deny coverage or exclude an individual or family member from coverage under the policy or plan; (d) Impose a rider that excludes coverage for certain benefits or services under the policy or plan; (e) Establish differentials in premium rates or cost sharing for coverage under the policy or plan; or (f) Otherwise discriminate against an individual or family member in the provision of insurance.

In addition: The Company will not require an applicant for coverage under the policy or plan, or an individual or family member who is presently

covered under a policy or plan, to be the subject of a genetic test or to be subjected to questions relating to genetic information. The Company will not request, require or purchase genetic information either: of an individual or family member of an individual for

underwriting purposes; or with respect to any individual or family member of an individual prior to such individual's enrollment under the plan or coverage in connection with such enrollment.

The Company will not request or require that an individual, a family member of such individual, or a group member undergo a genetic test.

The Company will not establish rules for eligibility, including continued eligibility, of any individual or an individual's family member to enroll or continue enrollment based on genetic information.

The Company will not adjust premium or contribution amounts for an individual or group health plan on the basis of genetic information concerning the individual or a family member of the individual.

REPATRIATION OF REMAINS AND MEDICAL EVACUATION BENEFITS REPATRIATION OF REMAINS – MAXIMUM AMOUNT $1,000,000* If a Covered Person suffers loss of life due to Injury or emergency Sickness while outside his or her home country, the Company will pay for Eligible Expenses reasonably incurred to return his or her body to his or her current place of primary residence, but not exceeding the Maximum Amount per Covered Person.

Eligible Expenses include, but are not limited to: (1) embalming or cremation; (2) the most economical coffins or receptacles adequate for transportation of the remains; and (3) transportation of the remains by the most direct and economical conveyance and route possible.

Travel Guard must make all arrangements and must authorize all expenses in advance for this benefit to be payable. The Company reserves the right to determine the benefit payable, including any reductions, if it was not reasonably possible to contact Travel Guard in advance. Please see page 17 for a description of the Travel Guard services and for procedures on how to contact Travel Guard.

*In no event will the Maximum Amount payable for Repatriation of Remains exceed $1,000,000.00 when combined with the amount paid for Medical Evacuation Expense Benefit.


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MEDICAL EVACUATION – MAXIMUM AMOUNT $1,000,000* The Company will pay for Eligible Medical Evacuation Expenses reasonably incurred if the Covered Person suffers an Injury or emergency Sickness that warrants his or her Medical Evacuation while outside his or her home country but not exceeding the Maximum Amount per Covered Person for all Medical Evacuations due to all Injuries from the same accident or all Emergency Sicknesses from the same or related causes.

The Doctor ordering the Medical Evacuation must certify: (a) that the severity of the Covered Person’s Injury or Emergency Sickness warrants his or her Medical Evacuation; and (b) the Covered Person has been Hospital Confined for at least five (5) consecutive days prior to Medical Evacuation. All Transportation arrangements made for the Medical Evacuation must be by the most direct and economical conveyance and route possible.

Travel Guard must make all arrangements and must authorize all expenses in advance for any Medical Evacuation benefits to be payable. The Company reserves the right to determine the benefits payable, including reductions, if it is not reasonably possible to contact Travel Guard in advance. Please see page 17 for a description of the Travel Guard services and for procedures on how to contact Travel Guard.

*In no event will the Maximum Amount payable for Medical Evacuation exceed $1,000,000.00 when combined with the amount paid for Repatriation of Remains Expense Benefit.

STUDENT HEALTH CENTER (SHC) Students MUST use the SHC as primary access to medical care. See Student Health Center Requirements section on page 11 for complete details.

STUDENT HEALTH CENTER SERVICES

Medical Services • Primary Care • Specialty Care • Lab & X-ray

Mental Health Counseling • Emotional difficulties • Substance abuse • Marital and family

distress • Academic concerns

Pharmacy • Prescription medication • Over the counter supplies • Over the counter drugs

Preventive & Wellness Services • Screenings/Exams • Immunizations/Vaccines • Health Promotion Consults • Health Workshops

STUDENT HEALTH CENTER - HOURS OF OPERATION:

Fall and Spring Semesters: Monday-Friday (8:00 a.m. to 5:00 p.m.) *Saturday (8:00 a.m. to 11:30 a.m.) Medical Clinic & Pharmacy only

*SHC is closed in the Fall on home game Saturdays The Medical Clinic is closed on Wednesdays from 11:30 a.m. to 1:00 p.m. except for emergencies.

Summer and between semesters:

Monday-Friday (8:00 a.m. to 4:15 p.m.) The Medical Clinic is closed on Wednesdays from 11:30 a.m. to 1:00 p.m. except for emergencies.

Location: Corner of Infirmary Road and West Chimes Street across from the School of Music.

IMPORTANT POLICY PROVISIONS The cost containment features listed below are included in the Plan to keep student health care cost more affordable. Electing to not use these features can result in higher out-of-pocket cost for services. Any additional cost is the responsibility of the student.

STUDENT HEALTH CENTER (SHC) REQUIREMENTS A referral from the Student Health Center is required before benefits are payable. This provision does not apply: (a) if covered service is rendered at another facility during school breaks or vacation times; (b) if medical care is received when Covered Student is more than 25 miles from campus; (c) if medical care is obtained by a student who is not eligible to use the Student Health Center; (d) for maternity; (e) for annual routine gynecological/obstetrical services; or (f) for an Emergency Medical Condition; however, the Covered Student must return to the Student Health Center for necessary follow-up care. In addition, no authorization or referral requirement shall apply to obstetrical or gynecological care provided by a PPO provider. Benefits for Eligible Expenses incurred for medical care or treatment rendered for which a referral is required but not obtained will be excluded from coverage. Benefits for Emergency Medical Condition will be payable at the PPO level whether treatment is received from a PPO provider or non-PPO provider. This referral requirement does not apply to the Covered Student’s dependent(s).


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VERITY HEALTHNET/FIRST HEALTH PREFERRED PROVIDER ORGANIZATIONS (PPO) Preferred Providers are the Doctors, Hospitals and other health care providers who have contracted to provide specific medical care at negotiated prices. Preferred Providers are Verity Healthnet Hospitals and Doctors and First Health.

The Baton Rouge General Hospital is in your preferred provider network.

Out of Network providers have not agreed to any prearranged fee schedules. Charges in excess of the insurance payment are the Covered Person’s responsibility.

Emergency Services treatment or care rendered by a non-PPO provider is mandated by the Patient Protection and Affordable Care Act to be provided at the same benefit and cost sharing level as services provided by PPO provider.

PROVIDER INFORMATION: Specific information about in-network and out-of-network facility-based physicians can be found at www.LSUstudentinsurance.com or by calling the Customer Service Telephone Number at 1-888-622-6001.

For complete details, please review the Policy on file at the University.

PRESCRIPTION DRUG BENEFIT MANAGER: Specific information about participating Catamaran providers can be found at www.LSUstudentinsurance.com or by calling the Customer Service Telephone Number at 1-888-622-6001.

PRE-CERTIFICATION The following inpatient services should be reported to Utilization Management Corp. (“UMC”) by calling: 866- 352-4404.* (UMC. is not affiliated with National Union Fire Insurance Company of Pittsburgh, Pa.) (a) all inpatient admissions, including length of stay, to a Hospital, convalescent facility, a facility established primarily for the treatment

of substance abuse; and (b) all inpatient maternity care, after the initial 48 hours following a vaginal delivery; 96 hours following a cesarean section.

The following outpatient services should be reported to UMC by calling: 866-352-4404* (a) intensive outpatient programs for severe mental illnesses or mental or nervous disorders; and (b) surgical procedures performed in an outpatient facility or ambulatory surgical center that requires general anesthesia.

The Covered Person is responsible to fulfill the Pre-Certification requirement of the Plan. • Pre-Certification of Non-Emergency, Hospitalizations, inpatient or outpatient services: The patient, Doctor or Hospital should

telephone UMC at: 866-352-4404 at least 48 hours prior to the planned admission or outpatient services.* • Notification of Emergency Admissions: The patient, patient’s representative, Doctor or Hospital should telephone UMC at: 866-352-

4404 within 48 hours of admission.*

All Hospital admissions will be monitored by UMC. Each admission is reviewed to determine the appropriate length of stay and to establish a treatment plan.

*NOTE: If the Covered Person does not secure Pre-Certification for non emergency admissions or outpatient services or provide notification of emergency admissions, his/her Eligible Expenses will be subject to a reduction of 20% per admission or outpatient service. Pre-Certification is not a guarantee that benefits will be paid.

STATE MANDATED BENEFITS The Plan covers all applicable state mandated benefits. For complete details, please review the Policy on file at the University.




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DEFINITIONS “Accident” means an occurrence which (a) is unforeseen; (b) is not due to or contributed to by Sickness or disease of any kind; and (c) causes Injury.

“Allowable Charges (“AC”)” means the charges agreed to by the Preferred Provider Organization for specified covered medical treatment, services and supplies.

“Covered Person” means a Covered Student and his or her dependent(s) insured under the Plan.

“Covered Student” means a student of this Policyholder who is insured under the Plan.

“Doctor” means: (a) legally qualified physician licensed by the state in which he or she practices; and (b) a practitioner of the healing arts performing services within the scope of his or her license as specified by the laws of the state of such practitioner; and (c) certified nurse midwives and licensed midwives while acting within the scope of that certification. The term “Doctor” also includes a chiropractor legally licensed in the State of Louisiana pursuant to R.S. 22:995 of the Louisiana Insurance Code. The term “Doctor” does not include a Covered Person’s immediate family member.

“Elective Treatment” means medical treatment, which is not necessitated by a pathological change in the function or structure in any part of the body, occurring after the Covered Person’s effective date of coverage.

Elective treatment includes, but is not limited to: breast reduction unless as a result of mastectomy; sexual reassignment surgery; submucous resection and/or other surgical correction for deviated nasal septum, other than necessary treatment of covered acute purulent sinusitis; treatment for weight reduction; treatment for learning disabilities that is not Medically Necessary; botox injections; treatment of infertility and routine physical examinations.

“Eligible Expense” means a charge for any treatment, service or supply which is performed or given under the direction of a Doctor for the Medically Necessary treatment of a Sickness or Injury: (a) not in excess of the Reasonable and Customary charges; or (b) not in excess of the charges that would have been made in the absence of this coverage; (c) with respect to the Preferred Provider, is the Allowable Charge; (d) is the negotiated rate, if any; and (e) incurred while the Plan is in force as to the Covered Person except with respect to any expenses payable under the Extension of Benefits provision.

“Emergency Medical Condition” means a medical condition of recent onset and severity, including severe pain, that would lead a prudent layperson, acting reasonably and possessing an average knowledge of medicine and health, to believe that the absence of immediate medical attention could reasonably be expected to result in: (a) placing the health of the person, or with respect to a pregnant woman, the health of the woman or her unborn child in serious jeopardy; (b) serious impairment to such person’s bodily functions; or (c) serious dysfunction of any bodily organ or part of such person.

“Emergency Services” means those medical services necessary to screen, evaluate, and stabilize an Emergency Medical Condition, including:(a) a medical screening examination (as required under section 1867 of the Social Security Act, 42, U.S.C. 1395dd) that is within the capability of the emergency department of a Hospital, including ancillary services routinely available to the emergency department to evaluate such Emergency Medical Condition; and (b) such further medical examination and treatment, to the extent they are within the capabilities of the staff and facilities available at the Hospital, as are required under section 1867 of the Social Security Act (42 U.S.C. 1395dd(e)(3)).

Emergency does not include the recurring symptoms of a chronic illness or condition unless the onset of such symptoms could reasonably be expected to result in the complications listed above in the definition of Emergency Medical Condition.

“Essential Health Benefits” has the meaning found in section 1302(b) of the Patient Protection and Affordable Care Act and as further defined by the Secretary of the United States Department of Health and Human Services and includes ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.

“Experimental/Investigational” means a drug, device or medical care or treatment that meets the following: (a) the drug or device cannot be lawfully marketed without approval of the U.S. Food and Drug Administration and approval for

marketing has not been given at the time the drug or device is furnished; (b) the informed consent document used with the drug, device, medical care or treatment states or indicates that the drug, device,

medical care or treatment is part of a clinical trial, experimental phase or investigational phase, if such a consent document is required by law;

(c) the drug, device, medical care or treatment or the patient’s informed consent document used with the drug, device, medical care or treatment was reviewed and approved by the treating facility’s Institutional Review Board or other body serving a similar function, if federal or state law requires such review and approval;

(d) reliable evidence shows that the drug, device or medical care or treatment is the subject of ongoing Phase I or Phase II clinical


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trials, is the research, experimental study or investigational arm of ongoing Phase III clinical trials, or is otherwise under study to determine its maximum tolerated dose, its toxicity, its safety, it efficacy or its efficacy as compared with a standard means of treatment or diagnosis; or

(e) reliable evidence shows that the prevailing opinion among experts regarding the drug, device, medical care or treatment is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with standard means of treatment of diagnosis.

“Reliable” evidence means: published reports and articles in authoritative medical and scientific literature; written protocol or protocols by the treating facility studying substantially the same drug, device, medical care or treatment; or the written informed consent used by the treating facility or other facility studying substantially the same drug, device or medical care or treatment. Eligible Expenses will be considered in accordance with the drug, device, medical care or treatment at the time the Expense is incurred.

“Hospital” means a facility which meets all of these tests: (a) it provides in-patient services for the care and treatment of injured and sick people; and (b) it provides room and board services and nursing services 24 hours a day; and (c) it has established facilities for diagnosis and major surgery; and (d) it is supervised by a Doctor; and (e) it is run as a Hospital under the laws of the jurisdiction in which it is located; and (f) it is accredited by the Joint Commission on

Accreditation of Healthcare Organizations.

Hospital does not include a place run mainly: (a) as a convalescent home; (b) as a nursing or rest home; (c) as a place for custodial or educational care; or (d) as an institution mainly rendering treatment or services for: mental or nervous disorders. The term “Hospital” includes: (a) a substance abuse treatment facility during any period in which it provides effective treatment of substance abuse to the Covered Person; (b) an ambulatory surgical center or ambulatory medical center; and (c) a birthing facility certified and licensed as such under the laws where located. It shall also include rehabilitative facilities if such is specifically for treatment of physical disability. Hospital also includes tax- supported institutions, which are not required to maintain surgical facilities.

“Injury” means bodily injury due to an Accident which: (a) results solely, directly and independently of disease, bodily infirmity or any other causes; (b) occurs after the Covered Person’s effective date of coverage; and (c) occurs while coverage is in force. All injuries sustained in any one Accident, including all related conditions and recurrent symptoms of these injuries, are considered one Injury.

“Medical Necessity/Medically Necessary” means that a drug, device, procedure, service or supply is necessary and appropriate for the diagnosis or treatment of a Sickness or Injury based on generally accepted current medical practice in the United States at the time it is provided.

A service or supply will not be considered as Medically Necessary if: (a) it is provided only as a convenience to the Covered Person or provider; or (b) it is not the appropriate treatment for the Covered Person’s diagnosis or symptoms; or (c) it exceeds (in scope, duration or intensity) that level of care which is needed to provide safe, adequate and appropriate diagnosis

or treatment; or (d) it is Experimental/Investigational or for research purposes; or (e) could have been omitted without adversely affecting the patient’s condition or the quality of medical care; or (f) involves treatment of or the use of a medical device, drug or substance not formally approved by the U.S. Food and Drug

Administration (FDA); or (g) involves a service, supply or drug not considered reasonable and necessary by the Healthcare Financing Administration Medicare

Coverage Issues Manual; or (h) it can be safely provided to the patient on a more cost-effective basis such as outpatient, by a different medical professional or

pursuant to a more conservative form of treatment.

The fact that any particular Doctor may prescribe, order, recommend, or approve a service or supply does not, of itself, make the service or supply Medically Necessary.

“Preventive Services” mandated by the Patient Protection and Affordable Care Act and, in addition to any other preventive benefits described in the Policy or Certificate, means the following services and without the imposition of any cost-sharing requirements, such as deductibles, copayment amounts or coinsurance amounts to any Covered Person receiving any of the following: (a) Evidence-based items or services that have in effect a rating of “A” or “B” in the current recommendations of the United States

Preventive Services Task Force, except that the current recommendations of the United States Preventive Service Task Force regarding breast cancer screening, mammography, and prevention of breast cancer shall be considered the most current other than those issued in or around November 2009;

(b) Immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the Covered Person involved;


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(c) With respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration; and

(d) With respect to women, such additional preventive care and screenings, not described in paragraph 1 above, as provided for in comprehensive guidelines supported by the Health Resources and Services Administration.

The Company shall update new recommendations to the preventive benefits listed above at the schedule established by the Secretary of Health and Human Services.

“Reasonable and Customary (“R&C”)” means the charge, fee or expense which is the smallest of: (a) the actual charge; (b) the charge usually made for a covered service by the provider who furnishes it; (c) the negotiated rate, if any; and (d) the prevailing charge made for a covered service in the geographic area by those of similar professional standing.

“Geographic area” means the three digit zip code in which the services, procedure, devices, drugs, treatment or supplies are provided or a greater area, if necessary, to obtain a representative cross-section of charge for a like treatment, service, procedure, device, drug or supply.

“Sickness” means disease or illness including related conditions and recurrent symptoms of the sickness which begins after the effective date of a Covered Person’s coverage. Sickness also includes pregnancy and complications of pregnancy. All Sicknesses due to the same or a related cause are considered one Sickness.

EXCLUSIONS AND LIMITATIONS The Plan does not cover nor provide benefits for loss or expenses incurred: 1. as a result of dental treatment, or dental x-rays except as specifically provided in the Policy. This exclusion does not apply to

Essential Health Benefits mandated by the Patient Protection and Affordable Care Act. 2. for eye examinations, eyeglasses, contact lenses, replacement of eyeglasses or prescription for such; radial keratotomy or laser

surgery; orthodontic braces and orthodontic appliances or prescriptions or examinations for such; or treatment for visual defects and problems. “Visual defects” means any physical defect of the eye which does or can impair normal vision apart from the disease process. This exclusion does not apply to Essential Health Benefits mandated by the Patient Protection and Affordable Care Act.

3. for hearing examinations or hearing aids; tinnitus maskers or examinations for prescribing them; or other treatment for hearing defects and problems. “Hearing defects” means any physical defect of the ear which does or can impair normal hearing apart from the disease process. This exclusion does not apply with respect to hearing aid coverage for minors as mandated by R.S.22:1038 of the Louisiana Insurance Code.

4. as a result of an Accident occurring in consequence of riding as a passenger or otherwise in any vehicle or device for aerial navigation, except as a fare-paying passenger in an aircraft operated by a commercial scheduled airline maintaining regular published schedules on a regularly established route.

5. for Injury or Sickness resulting from war or act of war, declared or undeclared. 6. as a result of an Injury or Sickness for which benefits are paid under any Workers’ Compensation or Occupational Disease Law. 7. as a result of Injury sustained or Sickness contracted while in the service of the Armed Forces of any country. Upon the Covered

Person entering the Armed Forces of any country, the Company will refund any unearned pro-rata premium. This does not include Reserve or National Guard Duty for training unless it exceeds 31 days.

8. for treatment provided in a government Hospital unless there is a legal obligation to pay such charges in the absence of insurance. 9. for cosmetic surgery. “Cosmetic surgery” shall not include reconstructive surgery when such surgery is incidental to or follows

surgery resulting from trauma, infection or other diseases of the involved part and reconstructive surgery because of a congenital disease or anomaly of a covered dependent newborn child which has resulted in a functional defect. It also shall not include breast reconstructive surgery after a mastectomy.

10. for preventive treatment, testing, immunizations, injections, medicines, serums, vaccines, vitamins anti-toxins or oral contraceptives except as specifically provided in the Plan. This exclusion does not apply to Preventive Services mandated by the Patient Protection and Affordable Care Act.

11. as a result of committing or attempting to commit an assault or felony or participation in a felony, riot, illegal occupation, insurrection or civil commotion. This exclusion does not apply to a Sickness or Injury due to an act of domestic violence or a medical condition (including both physical and mental health conditions).

12. for Elective Treatment or elective surgery except as specifically provided. 13. after the date insurance terminates for a Covered Person except as may be specifically provided in the Extension of Benefits

provision. 14. for services normally provided without charge by the school and covered by the school fee for services. 15. for any services rendered by a Covered Person’s immediate family member. 16. for any treatment, service or supply which is not Medically Necessary. This exclusion does not apply to Preventive Services


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mandated by the Patient Protection and Affordable Care Act. 17. as a result of suicide or any attempt at suicide, including drug overdose or intentionally self-inflicted Injury or any attempt at

intentionally self-inflicted Injury. 18. for loss sustained or contracted in consequence of the Covered Person’s being intoxicated or under the influence of narcotics

unless administered on the advice of a Doctor. 19. for surgery and/or treatment of: acupuncture; gynecomastia; biofeedback-type services; breast implants or breast reduction except

as a result of reconstructive breast surgery after a mastectomy performed while covered under the Policy, pursuant to R.S. 22: 1077 of the Louisiana Insurance Code;”; circumcision; family planning except as specifically provided; routine foot care and cutting or removal of corns, calluses and bunions except for Covered Persons who have been diagnosed with diabetes; fertility tests; infertility(male or female), including any services or supplies rendered for the purpose or with the intent of inducing conception , except that coverage for diagnosis and treatment of a correctable medical condition otherwise covered under the Policy that results in infertility will not be excluded; hair growth or removal; impotence, organic or otherwise; premarital examinations; sexual reassignment surgery and related therapy; sleep disorders, including testing thereof, except as a result of Medically Necessary sleep study obtained in a facility that is accredited by the Joint Commission or the American Academy of Sleep Medicine (AASM) and associated sleep disorder treatment; and weight reduction. This exclusion does not apply to Preventive Services mandated by the Patient Protection and Affordable Care Act.

20. for routine physical examinations, health examinations or preschool physical examinations. This exclusion does not apply to Preventive Services mandated by the Patient Protection and Affordable Care Act.

21. as a result of a motor vehicle accident if the Covered Person is not properly licensed to operate the motor vehicle within the jurisdiction in which the Accident takes place, except in a Driver’s Education program.

22. for Injury resulting from travel in or upon a snowmobile, ATV (all terrain or similar type two or three-wheeled vehicle; or bungee jumping.

23. for voluntary or elective abortions. 24. for Injury resulting from: the practicing for, participating in, or traveling as a team member to and from interscholastic,

intercollegiate, intercollegiate, professional and semi-professional sports; hang gliding; parasailing; sky diving; glider flying; parachuting; or ballooning.

25. for rest cures or custodial care. 26. for treatment in the Hospital emergency room which is not due to an Emergency Medical Condition. 27. for Injury resulting from fighting, except in self-defense. This exclusion does not apply to a Sickness or Injury due to an act of

domestic violence or a medical condition (including both physical and mental health conditions). 28. for treatment of obesity, including, but not limited to the following: weight reduction or dietary control programs; prescription or

nonprescription drugs or medications such as vitamins (whether taken orally or by injection), minerals, appetite suppressants, or nutritional supplements; and any complication resulting from weight loss treatments or procedures. This exclusion does not apply to Preventive Services mandated by the Patient Protection and Affordable Care Act.

29. for eye surgery such as radial keratotomy when the primary purpose is to correct myopia (near-sightedness), hyperopia (far-sightedness) or astigmatism (blurring). This exclusion does not apply to Essential Health Benefits mandated by the Patient Protection and Affordable Care Act.

30. for treatment, services, drugs, device, procedures or supplies that are Experimental or Investigational. This exclusion does not apply to drugs that are approved by the Food and Drug Administration for a particular indication but that are recognized for treatment of the covered indication in a standard reference compendia or as shown in the results of controlled clinical studies published in at least two peer reviewed national professional medical journals and all Medically Necessary services associated with the administration of the drug.

31. within the Covered Person’s home country of domicile with respect to a Covered Person who is not a United States Citizen. 32. for botox injections. 33. for treatment, service or supply for which a charge would not have been made in the absence of insurance.

Non-Duplication of Coverage If the benefits in the Plan are payable under more than one provision, then benefits will be provided only under the provision providing the greater benefit.

SUBROGATION In the event any payments for benefits provided to a Covered Person are because of an Injury or Sickness caused by a Third Party’s wrongful act or negligence, the Company, to the extent of that payment, will be subrogated to any recovery or right of recovery the Covered Person has against that Third Party, provided: (a) the Covered Person is entitled to payment for Hospital, surgical or medical services as the result of a Third Party settlement or court judgment; and (b) such settlement or judgment specified an amount or portion of payment that represents payment for such benefits; and (c) the Company has paid benefits to the Covered Person under the Plan for


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the same services or benefits covered by the settlement or judgment.

The Covered Person agrees to make a decision on pursuing a claim against a Third Party within 30 days of the date the Company requires that the Covered Person provide notice of claim for the Injury or Sickness for which benefits under the Plan are sought and to notify the Company of his or her decision within such 30 day period.

In the event the Covered Person decides not to pursue payment of claim against such Third Party, the Covered Person: (a) authorizes the Company to pursue, sue, compromise or settle any such payment of claim in the name of the Covered Person; (b) authorizes the Company to execute any and all documents necessary; and (c) agrees to cooperate fully with the Company in the prosecution of any such payment of claim.

If the Company exercises its rights under this provision, it will recover no more than the amount paid under the Plan for such benefits. The Covered Person will execute and deliver such instruments and papers which may be needed to secure the rights described above.

If required by the jurisdiction in which the recovery action occurs, the Company will pay its share of any fees or costs associated with the pursuit of a claim, cause of action or right by or on behalf of a Covered Person against any Third Party or coverage if the Company seeks recovery or subrogation.

“Subrogation” means the Company’s right to recover any benefit payments made under this plan: (a) because of an Injury or Sickness to a Covered Person caused by a Third Party’s wrongful act or negligence; and (b) which become recoverable from the Third Party or the Third party’s insurer.

The Company’s right of subrogation will not be enforced until the Covered Person has been made whole, as determined by a court of law, as a result of Injury or Sickness.

“Third Party” means any person or organization other than the Company, this Policyholder or the Covered Person.

This provision will not apply if it is prohibited by law.

COORDINATION OF BENEFITS (Applies to Sickness Only) The benefits available under the Plan will be coordinated with any other valid and collectible insurance as outlined in the Policy. Please see the Policy on file with the University for details.

EXCESS PROVISION (Applies to Injury Only) Benefits payable for the Eligible Expenses will be limited to that part of the Eligible Expense, if any, which is in excess of the total benefits payable for the same Injury, on a provision of service basis or on an expense incurred basis under any other valid and collectible insurance. If the other valid and collectible insurance provides benefits on an excess coverage basis, benefits will be paid first by the insurer or service plan whose policy or service contract has been in effect for the longer period of time at the date of such Injury.

For purposes of this Plan, a Covered Person’s entitlement to other valid and collectible insurance will be determined as if this Plan did not exist and will not depend on whether timely application for benefits from other valid and collectible insurance is made by or on behalf of the Covered Person.

Benefits under this Plan will be reduced to the extent that benefits for Expenses are covered by any other valid and collectible insurance whether or not a claim is made for such benefits.

In the event the Covered Person is eligible under this Plan for benefits in excess of other coverage and the Covered Person has other coverage that is primary under a health maintenance organization, preferred provider organization or similar health service program, a penalty will apply if he or she does not use the facilities or services of the health maintenance organization, preferred provider organization or similar health service program. In such case, the benefits otherwise payable under the Excess provision in this Plan will be excluded. This exclusion shall not apply to emergency treatment required within 24 hours of an Accident when the Accident occurs outside the geographic area served by the health maintenance organization, preferred provider organization or similar health service program.


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FILING A CLAIM A written notice of claim must be received by the Claims Office at the address provided below within 90 days after the occurrence or commencement of any loss covered by this Plan, or as soon thereafter as is reasonably possible. The written notice of claim must include: • The itemized medical and/or Hospital bills; • Name of Covered Person; • Covered Student’s name, address and copy of LSU ID; • A completed Company claim form (required for all claims) which can be found

at www.studentinsurance.com/Schools/LA/LSU (the claim form can either be printed and mailed to the Company or completed online at the above web address); and

• For Students Only – any required Referral (see “SHC Requirement” section on page 11 to see if the Referral requirement applies).

Mail Claims to:

AIG, Higher Education Mail Center P.O. Box 26050, Overland Park, KS 66225

A Covered Person has the right to appeal any adverse determination on a claim. Please see the Policy on file with the University for the Appeal and Grievance procedures.

TRAVEL GUARD DESCRIPTION OF TRAVEL ASSIST AND STUDENT ASSIST SERVICES Procedures on How to Access Travel Guard and Student Assist Services 24-Hour Assistance Call Center

WHO IS TRAVEL GUARD Multi-lingual/multi-cultural Travel Assistance Coordinators (TACs) are trained professionals ready to help participants should the need arise while traveling.

The Travel Guard Medical Staff consists of full-time, on-site Registered Nurses and Emergency Doctors who work as a team to provide the best outcome for our clients. This team is directed by a dedicated Medical Director (MD) and Manager of Medical Services (RN). Nursing staff is on-site 24-hours; a doctor has daily responsibility for a 24-hour period and is on-site during daytime hours.

WHEN TO CONTACT TRAVEL GUARD Before you incur expenses.

• If you are 100+ miles from home and require medical assistance or have a medical emergency. • If you are 100+ miles from home and need assistance with a nonmedical situation such as lost luggage, lost documents,

legal help, etc.

HOW TO CONTACT TRAVEL GUARD Inside the US and Canada, dial 1-877-249-5362 toll-free.

• Outside the US and Canada: • Request an international operator. • Ask the international operator to connect to an AT&T operator. • Request the AT&T operator to place a collect call to the USA at 1-715-295-9625. • Our fax number is 1-262-364-2203.

Travel Guard is available 24-hours-a-day/7-days-a-week/ 365-days-a-year What information will you need to provide when you call:

• Advise Travel Guard who you are insured by • Provide your Policy Number or School Name • Advise Travel Guard regarding the nature of your call and/or emergency. Be sure to provide your contact information at your

current location in the event Travel Guard needs to call you back.

http://www.studentinsurance.com/ViewGoodForMeTips.asp

http://www.studentinsurance.com/Schools/LA/LSU


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Description of Services General Information: Services listed below include advice and information regarding travel documentation, immunization requirements, political/environmental warnings, and information on global weather conditions. Travel Guard can also provide information on available currency, exchange rates, local Bank/Government holidays, and by implementing our databases with the information, provide ATM and Customer Service locations to clients. Travel Guard also provides emergency message storage and relay and translation services.

• Visa & Immunization • Weather & Exchange Rates • Environmental & Political Warnings

Technical: Services listed below include assistance to members in the event of lost or stolen luggage, personal effects, documents and tickets. Travel Guard can arrange cash transfers & vehicle return in the event of illness or accident, provide legal referrals, and help with arrangements for members who encounter enroute emergencies that force them to interrupt their trips.

• Legal Referral • Embassy/Consulate Information • Lost/Stolen Luggage & Personal Effects Assistance • Lost Document Assistance • Cash Transfer Assistance • En-route Travel Assistance • Claims-related Assistance • Telephone Interpretation

Medical: These services are the most complicated of those offered and can last up to several weeks. They involve Travel Guard’s Medical Staff in addition to other network providers and often include post case payment/billing coordination on the traveler’s behalf. These services include physician/dental/ hospital referral, medical case monitoring, shipment of medical records and prescription medications, medical evacuation, repatriation of remains and insurance claims coordination.

Medical Assistance: • Medical Referral • In-patient Assistance • Out-patient Assistance

STUDENT ASSIST SERVICES Concierge Services: You receive the comfort, care, and attention of Travel Guard’s Personal Assistance Coordinators available 24/7 to respond to virtually any request – large or small.

Personal Security Assistance: You can feel safe and secure with Travel Guard’s Personal Security Assistance at home or while traveling. To activate personal security services, please log on to: www.aig.com/travelguardassistance.

To register:

1. Click on “Sign In” in the upper right-hand corner. 2. Click on “Register Here”. 3. Complete required fields: First Name, Last Name, Email Address, Policy # CAS9148872, then click “Submit”.

For more details visit the AIG, Higher Education website at www.studentinsurance.com.

VOLUNTARY DENTAL OPTIONAL

(AlwaysCare Benefits, Inc. is not affiliated with National Union Fire Insurance Company of Pittsburgh, Pa.)

AlwaysCare Benefits, Inc. (a Starmount Life Insurance Company) is an independent, privately owned and operated business headquartered in Baton Rouge, Louisiana. Members may access a national dental PPO network of over 73,000 access points and a national vision network of over 22,000 participating providers, or choose an out-of-network provider. Members may choose different providers for vision exam and materials purchases. Most participating providers, excluding Wal-Mart and Sam’s Club, offer discounts on items purchased after the insurance benefit has been used and on non-covered items.

http://www.studentinsurance.com/Schools/TX/PQC


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• Dental and vision plans are stand-alone options. These Plans are not affiliated with the Louisiana State University Student Health Insurance Plan and are not underwritten by National Union Fire Insurance Company of Pittsburgh, Pa.

• Students will be required to pay for the dental and vision premiums on an annual basis or at the start of each semester. • Students will be required to enroll and terminate coverage in conjunction with their student status.

STAND ALONE DENTAL

STAND ALONE DENTAL

Deductible $50 Plan Year Maximum (3 per family | $150 maximum deductible per family)

Benefit Year Maximum $1,000 per calendar year (applies to Class A, B & C)

Coinsurance after Deductible Class A - 10% Student Responsibility | 90% Insurance Responsibility (Deductible does not apply to Class A Services) Class B - 20% Student Responsibility | 80% Insurance Responsibility Class C - 50% Student Responsibility | 50% Insurance Responsibility

Class A - Preventive Services Waiting Period: None Routine exams (1 per 6 months) Prophylaxis (1 per 6 months) Bitewing X-rays (max 4 films; 1 per 12 months) Fluoride to age 16 (1 per 12 months) Full mouth X-ray (1 per 24 months)

Class B - Basic Services Waiting Period: None Sealants to age 16 (permanent molars, 1 per 36 months) Fillings Simple extractions (all extractions for impacted teeth are excluded)

Class C - Endodontics (root canals)

Waiting Period: 12 months

Reimbursements* In-Network: Fee Schedule Non-Network: 90th Percentile

* Exclusion - All extractions of impacted teeth

CARRYOVER BENEFIT RIDER

Base Plan Annual Maximum Threshold Limit

Carryover Amount

Carryover Amount

Maximum

Total Potential Annual

Maximum

$1,000 $500 $250 $1,000 $2,000

* Carryover Benefit: If an Insured submits Qualifying Claims for Covered Expenses during a benefit year and, in that benefit year, receives benefits that are less than their group’s Threshold Limit, the Insured will be credited a Carryover Benefit. Carryover Benefits will be accrued and stored in the Insured’s Carryover Account to be used in the next benefit year. If, in the next benefit year, an Insured reaches his or her Policy Year Maximum Benefit, we will pay a benefit from the Insured’s Carryover Account up to the amount stored in the Insured’s Carryover Account. The accrued Carryover Benefits stored in the Carryover Account may not be greater than the Carryover Account Maximum


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ANNUAL FALL* SPRING/ SUMMER

THREE PAYMENTS*

NINE PAYMENTS*

NEW STUDENTS

SPRING/ SUMMER

SUMMER

Voluntary Dental - Stand Alone

Student $318 $168 $168 $115 $44 $212 $80

Student + 1 $637 $328 $328 $221 $80 $425 $159

Student + Family

$1,132 $575 $575 $386 $135 $755 $283

*These rates include a $9 per installment administration fee.

Always Dental Exclusions/Limitations AlwaysCare Members whose dental plan includes coverage of crowns and bridges will have the options of choosing an endosteal implant to replace a missing tooth instead of a conventional fixed, 3-unit bridge , when a 3-unit bridge is approved for coverage. Crowns placed on implants will also be covered. Other implants or implant related services are not covered.

The following services are not covered: • Any treatment which is elective or primarily cosmetic in nature and not generally recognized as a generally accepted dental

practice by the American Dental Association, as well as any replacement of prior cosmetic restorations; • The correction of congenital malformations; • The replacement of lost or discarded or stolen appliances; • Replacement of bridges, dentures, crowns, inlays, onlays or dentures unless more than five (5) years old and cannot be made

serviceable; • Appliances, services or procedures relating to (i) the change or maintenance of vertical dimensions; (ii) the restoration of occlusion;

(iii) splinting; (iv) correction of attrition, abrasion, erosion or a fraction; (v) bite regulation or (vi) bite analysis; • Services provided for any type of tempromandibular joint (TMJ) dysfunction, muscular, skeletal deficiencies involving TMJ or

related structures, myofascial pain; • Charges for implants (except noted above), removal of implants, precision or semi-precision attachments, denture duplication,

overdentures and any associated surgery, or other customized services or attachments, and related procedures; • Dentures for teeth missing prior to effective date of coverage; some exceptions apply and are detailed in the Certificate of

Coverages; • Multiple x-rays done on the same date of service will be combined to a full-mouth x-ray; • Cosmetic restorations on posterior permanent teeth and all primary teeth will be given alternate benefit; • Anesthesia is covered with complex oral surgery only. Charges are subject to review. Pre-treatment estimate is recommended.

Details for the Dental program are available via AlwaysCare, toll-free 1-888-729-5433 ext. 2013. In Baton Rouge 1-225- 926-1888 ext. 2013 or online at www.LSUstudentinsurance.com.

Mail claims to P.O. Box 80138, Baton Rouge, LA 70898-0139.

These dental Benefits are not affiliated with or issued by National Union Fire Insurance Company of Pittsburgh, Pa. They are separate from the Student Health Insurance Plan described in this brochure.

VOLUNTARY VISION OPTION

SERVICE IN-NETWORK OUT-OF-NETWORK

Exam $15 co-pay Up to $35

Materials $15 co-pay

Standard Plastic Lenses

Single Vision Covered Up to $25



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Bifocal Covered Up to $40

Trifocal Covered Up to $50

Lenticular $80 allowance Up to $50

Progressive $70 allowance Up to $40

Frames

Member may select any frame available Up to $120 retail allowance Up to $50 retail allowance

Contact Lenses*

Fit, follow-up & materials: - Effective • - Medically Necessary

Up to $120 Up to $210

Up to $100 Up to $210

* In lieu of eyeglass lenses and frames.

Vision Frequencies

Exam 1 per 12 months

Standard Plastic Lenses 1 per 12 months

Frames 1 per 24 months

Contact Lenses 1 per 12 months

ANNUAL FALL* SPRING/ SUMMER

THREE PAYMENTS*

NINE PAYMENTS*

NEW STUDENTS

SPRING/ SUMMER

SUMMER

Voluntary Vision - Stand Alone

Student $132 $75 $75 $53 $24 $87 $33

Student + 1 $250 $134 $134 $92 $37 $166 $63

Student + Family

$420 $219 $219 $149 $56 $280 $105

*These rates include a $9 per installment administration fee.

ALWAYS VISION EXCLUSIONS/LIMITATIONS • This is a primary vision care benefit and it intended to cover only eye examinations and corrective eye ware. Medical or surgical

treatment of eye disease or injury is not provided under this plan. Coverage may not exceed the lesser of actual cost covered services and materials or the limits of the policy.

• Covered Materials that are lost or broken will be replaced only at normal service intervals indicated in the Plan Design; however, these materials and any items not covered below may be purchased at Preferred Pricing from a Participating Provider.

• Benefits are payable only for expenses incurred while the Group and Individual Member coverage is in force. • Laser Vision Correction Network: Membership provides access to Preferred Pricing. Transactions are handled directly between

Members and Providers. Refractive surgery is an elective procedure and may involve potential risks to patients. The Plan cannot and does not guarantee the outcome of any refractive surgical procedure or a total elimination of the need for glasses or contacts. Providers may not be available in all metropolitan areas.

• Orthoptics or vision training and any supplemental training; Plano (non-prescription) lenses; or two pair of eyeglasses in lieu of bifocals or trifocals;


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• Medical or surgical treatment of the eyes; • An eye exam or corrective eye ware required by an employer as a condition of employment; • An injury or illness covered under Workers’ Compensation or similar law, or which is work related; • Plain or prescription sunglasses or tinted lenses; • Sub-normal vision aids; • Charges in excess of Usual and Customary for services and materials; • Experimental or non-conventional treatments of devices; • Safety eyewear; • Spectacle lens styles, materials, treatments or “add-ons” not shown in the Schedule of Benefits. Details of the Vision program are

available via AlwaysCare, toll-free 1-888-729-5433 ext. 2013. In Baton Rouge 1-225-926-2888 ext 2013.

Mail Claims to: P.O. Box 14389, Baton Rouge, LA 70898-4389

These Vision Benefits are not affiliated with or issued by National Union Fire Insurance Company of Pittsburgh, Pa. They are separate from the Student Health Insurance Plan described in this brochure

24-HOUR STUDENT NURSELINE - AMERICAN HEALTH HOLDING, INC.

(American Health Holding, Inc. is not affiliated with National Union Fire Insurance Company of Pittsburgh, Pa.)

For confidential health care advice and information, 24 hours a day, 365 days a year, call toll-free 866-315-8756 • Comprehensive Resources and Advice from Registered Nurses • Direct access to an extensive Health Information Library, covering issues ranging from women’s health to pediatrics. • Detailed directories with topic codes and instructions for access to health-related topics. • Choose to talk directly to a nurse. Discuss a current illness or health issue, or receive counseling on chronic conditions. • Nurses can also educate callers about treatments, lifestyle choices and self-care strategies. • Integrated phone services to specially trained personnel, trained to provide referral services for mental health concerns. • Special Care for Emergencies • Integrated Emergency Support Services are available whenever members are in an emergency room or unexpectedly hospitalized.

In serious emergencies, the clinical team including doctors and registered nurses, assist patients and their families so they can make informed decisions about their care and treatment.

• The clinical team provides emotional reassurance, explains medical terms, discusses hospital culture and common routines, recommends resources and facilitates communications between patient and family to help them through the emergency.

IMPORTANT POLICY CONTACT INFORMATION ENROLLMENT/PREMIUM AIG, Higher Education

Toll Free: 1-888-622-6001

www.studentinsurance.com

Enroll online at www.LSUstudentinsurance.com

Or mail complete enrollment form and premium to:

National Union Fire Insurance Company of Pittsburgh, Pa. P.O. Box 71331 Philadelphia, PA 19176-1321

MEDICAL CLAIMS AND BENEFITS AIG Claims, Inc.

Toll Free: 1-888-622-6001

Mail claims to:

AIG, Higher Education Mail Center Box 26050 Overland Park, KS 66225


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ALWAYS CARE DENTAL AND VISION CLAIMS AND BENEFIT ADMINISTRATION (AlwaysCare Benefits, Inc. (a Starmount Life Insurance Company) is not affiliated with National Union Fire Insurance Company of Pittsburgh, Pa.)

Mail Claims to: P.O. Box 4389 Baton Rouge, LA 70898-4389

In Baton Rouge: 1-225-926-2888, ext. 2013 Online: www.LSUstudentinsurance.com

LSU STUDENT HEALTH CENTER (SHC) Infirmary Road & West Chimes Baton Rouge, LA 70803-2401

1-225-578-6271

www.lsu.edu/shc

24/7 NURSELINE (American Health Holding, Inc. is not affiliated with National Union Fire Insurance Company of Pittsburgh, Pa.)

Toll Free: 866-315-8756

PREFERRED PROVIDER NETWORKS (PPO) INSIDE LOUISIANA:

Verity Healthnet

Local: 225-819-1135

www.verityhealth.com

OUTSIDE LOUISIANA:

First Health

Toll Free: 800-226-5116

www.firsthealth.coventryhealthcare.com/

HOSPITALS AVAILABLE IN THE BATON ROUGE AREA

Verity Network First Health Network

Baton Rouge General Bluebonnet 8585 Picardy Ave. 225-763-4000

Baton Rouge General Mid City 3600 Florida Blvd. 225-387-7000

Lane Memorial Hospital 6300 Main Street 225-658-4000

Neuro-Medical Center Perkins Road 10105 Park Rowe Circle 225-763-9900

Surgical Specialty Center of Baton Rouge 8080 Bluebonnet Blvd. 225-408-8080

Our Lady of the Lake 5000 Hennessy Blvd. 225-765-6565

Woman’s Hospital Airline at Goodwood 9050 Airline Hwy. 225-927-1300

BROKER Michele Zeber, Account Executive Gallagher Benefit Services, Inc.

Ph: 800-605-6102

Fax: 866-641-6799

Email: [email protected]

TRAVEL ASSIST Travel Guard Group, Inc.


http://www.verityhealth.com/

http://www.firsthealth.coventryhealthcare.com/

mailto:[email protected]


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INSIDE U.S. & CANADA: 1-800-626-2427

OUTSIDE US & CANADA

• Request an international operator. • Request an international operator to connect to AT&T operator. • Request the AT&T operator to place a collect call to 1-715-295-9625, FAX: 1-262-364-2203

Visit: www.LSUstudentinsurance.com for: • Benefits & Enrollment Information • ID Cards • Interactive Online Claim Form • “View My Account” - check your claims and coverage status • Locate a PPO Medical Provider and/or Catamaran RX Pharmacy • Optional Enrollment: Dental and Vision

QUESTIONS REGARDING COVERAGE, CLAIMS PROCEDURES AND/OR CLAIMS STATUS SHOULD BE DIRECTED TO: AIG, Higher Education

Toll Free: 1-888-622-6001

Providers should mail claims to: AIG, Higher Education Mail Center P.O. Box 26050 Overland Park, KS 66225

Students are encouraged to file claims online at: www.LSUstudentinsurance.com

At AIG, we value the trust our customers have placed in us. Protecting the privacy of your personal information is of paramount importance to us. For more information please go to www.studentinsurance.com.

©2015. All rights reserved. XXXX.XXX





Documents

Louisiana State University Student Health Insurance … State University 2015-2016 Student Health Insurance Plan For International Students 2 PRIVACY