Transcription

Quality health plans & benefitsHealthier livingFinancial well-beingIntelligentsolutionsAetna Student HealthPlan Design and Benefits SummaryOA Elect Choice EPOSan Jose State UniversityPolicy Year: 2021–2022Policy Number: 867866www.aetnastudenthealth.com(877) 480-4161

This is a brief description of the Student Health Plan. The plan is available for San Jose State University students. Theplan is insured by Aetna Life Insurance Company (Aetna). The exact provisions, including definitions, governing thisinsurance are contained in the Certificate issued to you and may be viewed online at www.aetnastudenthealth.com. Ifthere is a difference between this Plan Summary and the Certificate, the Certificate will control.On Campus Health CareInsured students are strongly encouraged to consult with the SJSU Student Wellness Center located across from theEvent Center.Hours of Operation: Mon, Tues & Thurs: 8:45am – 4:00pm and Wed & Fri: 8:45am -4:00pm*. For more information orto schedule an appointment, please call SJSU Student Wellness Center at (408) 924-6122.*Telemedicine available - call to schedule an appointmentCoverage Dates and RatesStudents: Coverage for all insured students enrolled for coverage in the Plan for the following Coverage Periods.Coverage will become effective at 12:01 AM on the Coverage Start Date indicated below and will terminate at 11:59 PMon the Coverage End Date indicated.International StudentsCoverage PeriodCoverage Start DateCoverage End 2021Spring/Summer01/01/202207/31/2022International GatewaysCoverage PeriodCoverage Start DateCoverage End DateFall08/07/202112/31/2021Fall 108/07/202110/15/2021Fall 210/16/202112/31/2021Fall 2 / Spring ing 101/01/202203/11/2022Spring 2 New03/07/202205/29/2022Spring 2 Continuing03/12/202205/29/2022Spring 2 / Summer New03/07/202208/06/2022San Jose State University 2021-2022Page 2

Spring 2 / 2208/06/2022RatesThe rates below reflect premiums for the Plan underwritten by Aetna Health and Life Insurance Company (Aetna), aswell as a San Jose State University administrative fee.StudentInternational StudentsAnnualFall 1,805 760Spring/Summer 1,046International GatewaysStudentFallFall 1Fall 2Fall 2 /Spring 1SpringSpring 1Spring 2New 687 328 359 687 696 328 391Spring 2 /Continuing 368Spring 2 /SummerNew 714Spring 2 /SummerContinuing 691Summer 333Student CoverageWho is eligible?All international students, visiting faculty, scholars or other persons possessing and maintaining a current passport andvalid visa status (F-1, J-1 or M-1, etc.), engaged in educational activities at San Jose State University who are temporarilylocated outside their home country and have not been granted permanent residency status, are required to be insuredunder the Policy and must directly enroll before registering for classes.Coverage is available for students engaged in "Practical Training." OPT students may purchase a maximum of 12consecutive months of coverage from the OPT effective date. OPT extension coverage beyond 12 months is notallowed. Enrollment must be completed within 30 days of the expiration of prior coverage on the school's studenthealth insurance plan. A gap in coverage is not allowed. A copy of a valid EAD or OPT application or receipt (I-765 or I 797c) is required to enroll.San Jose State University 2021-2022Page 3

To be an Insured Person under the Policy:* the student must have paid the required premium; and* the student must actively attend classes on campus for 45 consecutive days following the effective date for the termpurchased and/or pursuant to the student’s visa requirements for the period for which coverage is purchased, with theexception of school-authorized breaks. A once-per-lifetime exception may be made in cases of a student’s medicalwithdrawal, when approved by the school and any applicable regulatory authority.Aetna and JCB Insurance Solutions maintain the right to investigate student status and attendance records to verify thatthe Policy eligibility requirements have been met. If and whenever Aetna and/or JCB Insurance Solutions discover thatthe Policy eligibility requirements have not been met, the only obligation is a pro-rata refund of premium.Eligible students who involuntarily lose coverage under another group insurance plan are also eligible to purchase theStudent Health Insurance Plan within 30 days of loss of coverage. These students must provide JCB Insurance Solutionswith proof that they have lost insurance through another group (certificate and letter of ineligibility) within 30 days ofthe qualifying event. The effective date would be the later of: a) term effective date, or b) the day after prior coverageends if enrollment request is received by JCB Insurance Solutions within 30 days from loss of prior coverage. For ques tions regarding eligibility for this plan, please call JCB Insurance Solutions at (408) 220-9341.If it is discovered that the eligibility requirement has not been met, our only obligation is to refund premium, less anyclaims paid.EnrollmentEligible students may enroll in the insurance plan online at www.jcbins.com.Exception: A Covered Person entering the armed forces of any country will not be covered under the Policy as of thedate of such entry. A pro rata refund of premium will be made for such person, and any covered dependents, uponwritten request received by Aetna within 90 days of withdrawal from school.If you withdraw from school within the first 31 days of a coverage period, you will not be covered under the Policy andthe full premium will be refunded, less any claims paid. After 31 days, you will be covered for the full period that youhave paid the premium for, and no refund will be allowed. (This refund policy will not apply if you withdraw due to acovered Accident or Sickness.)Dependent CoverageDependent Coverage is not available.San Jose State University 2021-2022Page 4

Medicare Eligibility NoticeYou are not eligible to enroll in the student health plan if you have Medicare at the time of enrollment in this studentplan. The plan does not provide coverage for people who have Medicare.Termination and RefundsAll refund requests must be sent to the University who will confirm nonstudent status with JCB, and submit the refundrequest on behalf of the student. Only refunds submitted by the University before the refund deadline will beconsidered. Credit card refunds must be requested and processed within 120 days of the date of purchase and beforethe refund deadline. No refunds will be considered after the refund deadline. All refunds will be processed back to theoriginal form of payment only, no exceptions. All refunds will be assessed a 35 processing fee. Please allow 30business days for us to receive and process the refund request, then an additional 3-5 business days to receive therefund from your financial institution. Pro-rated/partial refunds are not allowed.NOTE: You can check to see if your return has been processed by logging in to your JCB account.In-network Provider NetworkAetna Student Health offers Aetna’s broad network of In-network Providers. You can save money by seeing In-networkProviders because Aetna has negotiated special rates with them, and because the Plan’s benefits are better.If you need care that is covered under the Plan but not available from an In-network Provider, contact Member Servicesfor assistance at the toll-free number on the back of your ID card. In this situation, Aetna may issue a pre-approval foryou to receive the care from an Out-of-network Provider. When a pre-approval is issued by Aetna, the benefit level isthe same as for In-network Providers.Service areaYour plan generally pays for eligible health services only within a specific geographic area, called a service area. Thereare some exceptions, such as for emergency services, urgent care and transplants.PrecertificationYou do not need to obtain pre-certification for any services. However, your provider is required to obtain pre certification for certain Preferred Care services. Refer to the Precertification provisions in the Coverage section of theCertificate of Coverage for a complete description of the precertification programs including the types of services,treatments, procedures, visits or supplies that require precertification. No penalty will be applied to you for a PreferredCare service that was not pre-certified.Coordination of Benefits (COB)Some people have health coverage under more than one health plan. If you do, we will work together with your otherplan(s) to decide how much each plan pays. This is called coordination of benefits (COB). A complete description of theCoordination of Benefits provision is contained in the certificate issued to you.San Jose State University 2021-2022Page 5

Description of BenefitsThe Plan excludes coverage for certain services and has limitations on the amounts it will pay. While this Plan Summarydocument will tell you about some of the important features of the Plan, other features that may be important to youare defined in the Certificate. To look at the full Plan description, which is contained in the Certificate issued to you, goto www.aetnastudenthealth.com.This Plan will pay benefits in accordance with any applicable California Insurance Law(s).In-network coverageOut-of-network coveragePolicy year deductiblesStudent 150 per policy yearNonePolicy year deductible waiverThe policy year deductible is waived for all of the following eligible health services: In-Network Care for Preventive care and wellness, Pediatric Dental Care, Well Newborn Nursery Care,Pediatric Vision Care Services and Supplies and Outpatient Prescription DrugsMaximum out-of-pocket limitsStudentEligible health servicesRoutine physical examsPerformed at a physician’s officeMaximum age and visit limits perpolicy year through age 21Covered persons age 22 and over:Maximum visits per policy yearPreventive care immunizationsPerformed in a facility or at aphysician's officeMaximumsSan Jose State University 2021-2022In-network coverage 4,000 per policy yearOut-of-network coverageNoneIn-network coverageOut-of-network coverage100% (of the negotiated charge) pervisitNot CoveredNo copayment or policy yeardeductible appliesSubject to any age and visit limits provided for in the comprehensive guidelinessupported by the American Academy of Pediatrics/Bright Futures//HealthResources and Services Administration guidelines for children and adolescents.1 visit100% (of the negotiated charge) pervisitNot CoveredNo copayment or policy yeardeductible appliesSubject to any age limits provided for in the comprehensive guidelinessupported by Advisory Committee on Immunization Practices of the Centers forDisease Control and PreventionPage 6

Eligible health servicesIn-network coverageOut-of-network coverageRoutine gynecological exams (including Pap smears and cytology tests)Performed at a physician’s,100% (of the negotiated charge) perNot Coveredobstetrician (OB), gynecologistvisit(GYN) or OB/GYN officeNo copayment or policy yeardeductible appliesMaximum visits per policy year1 visitPreventive screening and counseling servicesPreventive screening and100% (of the negotiated charge) perNot Coveredcounseling services for Obesityvisitand/or healthy diet counseling,Misuse of alcohol & drugs,No copayment or policy yearTobacco Products, Depressiondeductible appliesScreening, Sexually transmittedinfection counseling & Genetic riskcounseling for breast andovarian cancerStress management counseling100% (of the negotiated charge) perNot Coveredoffice visitsvisitNo copayment or policy yeardeductible appliesChronic condition counseling officevisitsRoutine cancer screeningsMaximum:Lung cancer screening maximumsPrenatal and postpartum careservices -Preventive care servicesonly (includes participation in theCalifornia Prenatal ScreeningProgram)San Jose State University 2021-2022100% (of the negotiated charge) pervisitNo copayment or policy yeardeductible applies100% (of the negotiated charge) pervisitNot CoveredNot CoveredNo copayment or policy yeardeductible appliesSubject to any age; family history; and frequency guidelines as set forth in themost current: Evidence-based items that have in effect a rating of A or B in the currentrecommendations of the United States Preventive Services Task Force; and The comprehensive guidelines supported by the Health Resources andServices Administration.1 screening every 12 months*100% (of the negotiated charge) pervisitNot CoveredNo copayment or policy yeardeductible appliesPage 7

Eligible health servicesLactation support and counselingservicesIn-network coverage100% (of the negotiated charge) pervisitBreast pump supplies andaccessoriesNo copayment or policy yeardeductible applies100% (of the negotiated charge) peritemOut-of-network coverageNot CoveredNot CoveredNo copayment or policy yeardeductible appliesFamily planning services – female contraceptivesFemale contraceptive counseling100% (of the negotiated charge) perNot Coveredservicesvisitoffice visitNo copayment or policy yeardeductible appliesFemale contraceptive prescription100% (of the negotiated charge) perNot Covereddrugs and devices provided,itemadministered, or removed, by aNo copayment or policy yearprovider during an office visitdeductible appliesFor each 30 day supply or 12month supplyFemale Voluntary sterilization100% (of the negotiated charge)Not CoveredInpatient & Outpatient providerservicesNo copayment or policy yeardeductible appliesThe following are not covered under this benefit: Services provided as a result of complications resulting from a female voluntary sterilization procedureand related follow-up care Any contraceptive methods that are only "reviewed" by the FDA and not "approved" by the FDA Male contraceptive methods, sterilization procedures or devicesPhysicians and other health professionalsPhysician, specialist including 20 copayment then the plan paysNot CoveredConsultants Office visits (non 100% (of the balance of thesurgical/non-preventive care by anegotiated charge) per visitphysician and specialist) (includestelemedicine consultations)Allergy testing and treatmentAllergy testing & Allergy injectionsCovered according to the type ofNot Coveredtreatment including Allergy serabenefit and the place where theand extracts administered viaservice is received.injection performed at a physician’sor specialist’s officeSan Jose State University 2021-2022Page 8

Eligible health servicesIn-network coverageOut-of-network coveragePhysician and specialist surgical servicesInpatient surgery performed during 100% (of the negotiated charge)Not Coveredyour stay in a hospital or birthingcenter by a surgeon(includes anesthetist and surgicalassistant expenses)The following are not covered under this benefit: The services of any other physician who helps the operating physician A stay in a hospital (Hospital stays are covered in the Eligible health services and exclusions – Hospital andother facility care section) Services of another physician for the administration of a local anestheticOutpatient surgery performed at a 100% (of the negotiated charge) perNot Coveredphysician’s or specialist’s office orvisitoutpatient department of ahospital or surgery center by asurgeon (includes anesthetist andsurgical assistant expenses)The following are not covered under this benefit: The services of any other physician who helps the operating physician A stay in a hospital (Hospital stays are covered in the Eligible health services and exclusions – Hospital andother facility care section) A separate facility charge for surgery performed in a physician’s office Services of another physician for the administration of a local anestheticAlternatives to physician office visitsWalk-in clinic visits 20 copayment then the plan paysNot Covered(non-emergency visit)100% (of the balance of thenegotiated charge) per visitHospital and other facility care100% (of the negotiated charge) perNot CoveredInpatient hospital (room andadmissionboard) and othermiscellaneous services andsupplies)Includes birthing center facilitychargesIn-hospital non-surgical physicianservicesAlternatives to hospital staysOutpatient surgery (facilitycharges) performed in theoutpatient department of ahospital or surgery centerSan Jose State University 2021-2022100% (of the negotiated charge) pervisitNot Covered100% (of the negotiated charge) pervisitNot CoveredPage 9

Eligible health servicesIn-network coverageOut-of-network coverageThe following are not covered under this benefit: The services of any other physician who helps the operating physician A stay in a hospital (See the Hospital care – facility charges benefit in this section) A separate facility charge for surgery performed in a physician’s office Services of another physician for the administration of a local anestheticHome health Care100% (of the negotiated charge) perNot CoveredvisitThe following are not covered under this benefit: Nursing and home health aide services or therapeutic support services provided outside of the home (such asin conjunction with school, vacation, work or recreational activities) Transportation Services or supplies provided to a minor or dependent adult when a family member or caregiver is notpresent Homemaker or housekeeper services Food or home delivered services Maintenance therapyHospice-Inpatient100% (of the negotiated charge) perNot CoveredadmissionHospice-Outpatient100% (of the negotiated charge) perNot CoveredvisitThe following are not covered under this benefit: Funeral arrangements Financial or legal counseling which includes estate planning and the drafting of a will Homemaker or caretaker services that are services which are not solely related to your care and may include:Sitter or companion services for either you or other family membersTransportationMaintenance of the houseSkilled nursing facility100% (of the negotiated charge) perNot CoveredInpatientadmissionHospital emergency room 250 copayment then the plan paysPaid the same as in-network coverage100% (of the balance of thenegotiated charge) per visitNon-emergency care in a hospitalNot coveredNot coveredemergency roomImportant note: As out-of-network providers do not have a contract with us the provider may not accept payment of your costshare, (copayment/coinsurance), as payment in full. You may receive a bill for the difference between theamount billed by the provider and the amount paid by this plan. If the provider bills you for an amount aboveyour cost share, you are not responsible for paying that amount. You should send the bill to the address listedon the back of your ID card, and we will resolve any payment dispute with the provider over that amount.Make sure the ID card number is on the bill. A separate hospital emergency room copayment/coinsurance will apply for each visit to an emergency room.If you are admitted to a hospital as an inpatient right after a visit to an emergency room, your emergencyroom copayment/coinsurance will be waived and your inpatient copayment/coinsurance will apply. Covered benefits that are applied to the hospital emergency room copayment/coinsurance cannot be appliedto any other copayment/coinsurance under the plan. Likewise, a copayment/coinsurance that applies toother covered benefits under the plan cannot be applied to the hospital emergency roomSan Jose State University 2021-2022Page 10

copayment/coinsurance.Separate copayment/coinsurance amounts may apply for certain services given to you in the hospitalemergency room that are not part of the hospital emergency room benefit. These copayment/coinsuranceamounts may be different from the hospital emergency room copayment/coinsurance. They are based on thespecific service given to you. Services given to you in the hospital emergency room that are not part of the hospital emergency roombenefit may be subject to copayment/coinsurance amounts.The following are not covered under this benefit: Non-emergency services in a hospital emergency room facility, freestanding emergency medical care facilityor comparable emergency facilityEligible health servicesIn-network coverageOut-of-network coverageUrgent care 20 copayment then the plan paysNot covered100% (of the balance of thenegotiated charge) per visitNon-urgent use of an urgent careNot coveredNot coveredproviderThe following is not covered under this benefit: Non-urgent care in an urgent care facility (at a non-hospital freestanding facility)Pediatric dental care (Limited to covered persons through the end of the month in which the person turns age 19.Type A services100% (of the negotiated charge) perNot coveredvisit Type B servicesNo copayment or deductible applies100% (of the negotiated charge) pervisitNot coveredType C servicesNo copayment or deductible applies100% (of the negotiated charge) pervisitNot coveredOrthodontic servicesNo copayment or deductible applies100% (of the negotiated charge) pervisitNot coveredDental emergency servicesNo copayment or deductible appliesCovered according to the type ofbenefit and the place where theservice is receivedCovered according to the type ofbenefit and the place where theservice is received.Pediatric dental care exclusionsThe following are not covered under this benefit: Asynchronous dental treatment Cosmetic services and supplies including plastic surgery, reconstructive surgery, cosmetic surgery,personalization or characterization of dentures or other services and supplies which improve alter or enhanceappearance, augmentation and vestibuloplasty, and other substances to protect, clean, whiten bleach or alterthe appearance of teeth; whether or not for psychological or emotional reasons. Facings on molar crowns andpontics will always be considered cosmetic. Crown, inlays, onlays, and veneers unless:- It is treatment for decay or traumatic injury and teeth cannot be restored with a filling material orSan Jose State University 2021-2022Page 11

- The tooth is an abutment to a covered partial denture or fixed bridgeDental implants (that are determined not to be medically necessary mouth guards, and other devices toprotect, replace or reposition teeth Dentures, crowns, inlays, onlays, bridges, or other appliances or services used:- For splinting- To alter vertical dimension- To restore occlusion- For correcting attrition, abrasion, abfraction or erosion Treatment of any jaw joint disorder and treatments to alter bite or the alignment or operation of the jaw,including temporomandibular joint dysfunction disorder (TMJ) and craniomandibular joint dysfunctiondisorder (CMJ) treatment, orthognathic surgery, and treatment of malocclusion or devices to alter bite oralignment, except as covered in the Eligible health services and exclusions – Specific conditions section General anesthesia and intravenous sedation, unless specifically covered and only when done in connectionwith another eligible health service Mail order and at-home kits for orthodontic treatment Orthodontic treatment except as covered in this section Pontics, crowns, cast or processed restorations made with high noble metals (gold) Prescribed drugs Replacement of teeth beyond the normal complement of 32 Services and supplies:- Done where there is no evidence of pathology, dysfunction, or disease other than covered preventiveservices- Provided for your personal comfort or convenience or the convenience of another person, including aprovider- Provided in connection with treatment or care that is not covered under your policy Surgical removal of impacted wisdom teeth only for orthodontic reasons, except as medically necessary Treatment by other than a dental providerEligible health servicesIn-network coverageOut-of-network coverageDiabetic services and suppliesCovered according to the type ofNot covered(including equipment and training) benefit and the place where theservice is received.Podiatric (foot care) treatmentCovered according to the type ofNot coveredPhysician and specialist nonbenefit and the place where theroutine foot care treatmentservice is received.The following are not covered under this benefit: Services and supplies for:The treatment of calluses, bunions, toenails, flat feet, hammertoes, fallen archesThe treatment of weak feet, chronic foot pain or conditions caused by routine activities, such as walking,running, working or wearing shoesSupplies (including orthopedic shoes), foot orthotics, arch supports, shoe inserts, ankle braces, guards,protectors, creams, ointments and other equipment, devices and suppliesRoutine pedicure services, such as cutting of nails, corns and calluses when there is no illness or injury ofthe feetImpacted wisdom teeth100% (of the negotiated charge)Not coveredAccidental injury to sound natural100% (of the negotiated charge)Not coveredteeth San Jose State University 2021-2022Page 12

Eligible health servicesIn-network coverageOut-of-network coverageThe following are not covered under this benefit: The care, filling, removal or replacement of teeth and treatment of diseases of the teeth Dental services related to the gums Apicoectomy (dental root resection) Orthodontics Root canal treatment Soft tissue impactions Bony impacted teeth Alveolectomy Augmentation and vestibuloplasty treatment of periodontal disease False teeth Prosthetic restoration of dental implants Dental implantsTemporomandibular jointCovered according to the type ofNot covereddysfunction (TMJ) andbenefit and the place where thecraniomandibular joint dysfunction service is received.(CMJ) treatmentThe following are not covered under this benefit: Dental implantsBlood and body fluidCovered according to the type ofNot coveredexposurebenefit and the place where theservice is received.The following are not covered under this benefit: Services and supplies provided for the treatment of an illness that results from your clinical related injury asthese are covered elsewhere in the student policyClinical trial (routine patientCovered according to the type ofNot coveredcosts)benefit and the place where theservice is received.Coverage is limited to routine patient services from in-network providers.Dermatological treatmentCovered according to the type ofNot coveredbenefit and the place where theservice is received.The following are not covered under this benefit: Cosmetic treatment and proceduresObesity bariatric Surgery andCovered according to the type ofNot coveredservicesbenefit and the place where theservice is received.Obesity surgery-travel and lodgingMaximum benefit payable for 130Not coveredtravel expenses for each round trip– three round trips covered (onepre-surgical visit, the surgery andone follow-up visit)Maximum benefit payable fortravel expenses per companion foreach round trip – two round tripsSan Jose State University 2021-2022 130Not coveredPage 13

covered (the surgery and onefollow-up visit)Maximum benefit payable for 100 per day up to four daysNot coveredlodging expenses per patient andcompanion for the pre-surgical andfollow-up visitsMaximum benefit payable for 100 per day up to four daysNot coveredlodging expenses per companionfor surgery stayThe following are not covered under this benefit: Weight management treatment or drugs intended to decrease or increase body weight, control weight ortreat obesity, including morbid obesity except as described above and in the Eligible health services andexclusions – Preventive care and wellness section, including preventive services for obesity screening andweight management interventions. This is regardless of the existence of other medical conditions. Examplesof these are:- Drugs, stimulants, preparations, foods or diet supplements, dietary regimens and supplements, foodsupplements, appetite suppressants and other medications- Hypnosis or other forms of therapy- Exercise programs, exercise equipment, membership to health or fitness clubs, recreational therapy orother forms of activity or activity enhancementEligible health servicesIn-network coverageOut-of-network coverageMaternity care that is notCovered according to the type ofNot coveredconsidered preventive carebenefit and the place where the(includes delivery and postpartumservice is received.care services in a hospital orbirthing center)The following are not covered under this benefit: Any services and supplies related to births that take place in the home or in any other place not licensed toperform deliveriesWell newborn nursery100% (of the negotiated charge)Not coveredcare in a hospital orbirthing centerNo policy year deductible appliesFamily planning services – otherVoluntary sterilization100% (of the negotiated charge)Not coveredfor males-surgical servicesReversal of voluntary sterilization100% (of the negotiated charge)Not coveredAbortion100% (of the negotiated charge)Not coveredGender affirming treatmentSurgical, hormone replacementCovered according to the BehavioralNot coveredtherapy, and counseling treatment health sectionSan Jose State University 2021-2022Page 14

Eligible health servicesIn-network coverageOut-of-network coverageAll other cosmetic services and supplies not listed under eligible health services above are not covered under thisbenefit. This includes, but is not limited to the following: Rhinoplasty Face-lifting Lip enhancement Facial bone reduction Blepharoplasty Liposuction of the waist (body contouring) Hair removal (including electrolysis of face and neck) Voice modification surgery (laryngoplasty or shortening of the vocal cords), and skin resurfacing, which areused in feminization Voice and communication therapy Chest binders Chin implants, nose implants, and lip reduction, which are used to assist masculinization, are consideredcosmeticMental Health & Substance Abuse TreatmentCoverage provided under the same

San Jose State University Policy Year: 2021-2022 . Policy Number: 867866 . www.aetnastudenthealth.com (877) 480-4161 . San Jose State University 2021-2022 Page 2 This is a brief description of the Student Health Plan. The plan is available for San Jose State University students. The .