Undergraduate Student Health Insurance Plan

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QUESTIONS AND ANSWERS
Undergraduate Student Health
Insurance Plan (USHIP) 2009-2010

Health Insurance is mandatory for all undergraduate students at UCSB. You will automatically be enrolled in USHIP unless you waive out. The plan year dates are September 20, 2009 through September 18, 2010, with premiums paid three times a year. Dependents must enroll four times per year - the enrollment form is on the Student Health Service website. If you have comparable independent insurance coverage and can access primary care within 25 miles of UCSB, you may submit a Waiver Request form to waive out of USHIP. Please read the brochure for a full understanding of benefits. Your identification card may be printed from the website in September when the plan begins. It should be carried with you at all times. Insurance information, including the brochure, waiver request form and claim form, are available from the Student Health Service (SHS) website at: http://sa.ucsb.edu/studenthealth/insurance

What's new for 2009-2010 (by USHIP Committee consensus)

Immunization benefit expanded to include flu shot, and Pneumococcal, and Hepatitis B benefit increased to 100% ($300 annual maximum). Benefit only applicable to immunizations at Student Health Service – deductible waived. See brochure for list of covered inoculations.
Accutane benefit increased to same as other eligible medications (previously paid at 75%
HIV testing – one visit per year at Student Health Service - no charge to student
Pap test - one per plan year at Student Health Service - no charge to student (HPV testing is not included).
Air emergency medical transportation increased to $20,000.
Two quarters lifetime continuation of coverage if withdraw from UCSB
Five non post-surgical off campus physical therapy visits.
Mental Health outpatient – Pre-existing clause does not apply; deductible waived for all mental health conditions.

Cost:

Students: $327.45/quarter; the annual cost is $982.35

Spouse/domestic partner: $417/quarter (paid four times a year)

Child: $371.50/quarter (paid four times a year)

Children: $392/quarter (paid four times a year)

May I see any doctor that I want to see?

You are required to be evaluated at SHS first if you are within a 50-mile radius of Santa Barbara. If a SHS practitioner feels that you need more specialized care than SHS can provide, you will be given a written referral to an outside practitioner. Without this referral, no benefits will be paid. If you are 50 miles or more outside of Santa Barbara, you may see a physician without first coming to SHS. Remember, you have a 20% coinsurance if you see a physician within the Preferred Provider Organization (Foundation for Medical Care in California or First Health Network) outside of California – provider list available on Student Health website) and a 50% coinsurance for non-emergency care in California if the provider is not with the Foundation. You are responsible for determining if a provider is a member of the PPO (see below).

What is a deductible?

A deductible is the amount of money for which you are responsible before the insurance company pays any eligible expenses. You have a $300 deductible per academic year, September to September. The deductible requirement begins again with the new plan year (each September).

What is coinsurance?

Coinsurance is the portion for which you are responsible after your deductible has been satisfied. If you have already satisfied your $300 deductible and your total bill is $200, 20% coinsurance amounts to $40; 50% coinsurance is $100.

What is a copayment?

A copayment is a predetermined charge that you pay for a particular service. Your pharmacy copayment is $25 for a 30-day supply of a prescribed medication. If the prescription costs less than $25 and is filled at SHS, only the cost of the prescription is charged.

How does the six-month pre-existing condition clause work?

If you have been seen for an illness within six months prior to enrolling in SHIP, your condition is considered pre-existing and will not be covered by benefits for six months. However, if you had other comparable insurance with not more than a 63-day lapse between insurance plans, the pre-existing clause is waived. Please see the brochure for a more detailed explanation.

What is the Foundation for Medical Care?

The Foundation for Medical Care is the Preferred Provider Organization (PPO) for USHIP. It is a regionally divided, statewide-managed care group that contracts with hospitals and physicians for reduced member rates. Members have access to any Foundation provider in the state of California. If within a 50-mile radius of UCSB, you must first visit Student Health Service (except in case of an emergency.) If medical services are required that SHS cannot provide, you will be referred to an outside provider. You may pick up a list of local PPO providers from an Insurance Advisor in SHS or print from www.cfmcnet.org. After your deductible has been met, you are eligible for 80% reimbursement only when you visit a member of the Foundation, 50% when a provider is not a member of the Foundation (except in emergencies.) You are responsible for any additional payments not covered by your policy. It is your responsibility to verify your charges. Reimbursement is based on eligible expenses. Please see the USHIP brochure for more details about the Foundation and for a definition of eligible expenses.

What is First Health Network?

First Health Network is the Preferred Provider Organization (PPO) for USHIP outside of California. Members have access to any First Health provider in the nation. The number of this organization is on your identification card and you may access provider names via the Student Health website. The same benefits apply as with the Foundation for Medical Care network (see details in question immediately above this one.

What if I Have an Emergency?

Emergencies will be covered at 80%, or 100% if admitted to the hospital directly from the emergency facility if within a 50-mile radius of UCSB when Student Health is closed. An additional $100 emergency room copay applies to each visit that does not result in admission. Be sure and ask for enough medication to last until you can come to SHS to fill a prescription. Please refer to the “Emergency” definition in your brochure (In some cases an Urgent Care Center might be a more appropriate choice). You must call SHS within one day of receiving medical care outside of Student Health.

If I am outside of Santa Barbara and need non-emergency medical services, how can I find out if a doctor is a preferred provider?

For providers in California, you may call the claims administrators, Personal Insurance Administrators (PIA), at (800) 468-4343 or CFMC at (800) 334-7341 or access the CFMC website http://www.cfmcnet.org.

Outside of California throughout the nation, you may call First Health Network (800) 226-5116 or access the website www.myfirsthealth.com.

How much do I pay for my prescription medication?

There is a $25 copayment for a 30-day prescription, $40 for 60 days and $50 for 90 days. After this copayment, coverage is as follows:

100% if filled at the SHS
100% if filled outside of SHS if the medication is not carried at SHS
100% if filled outside of SHS if SHS is closed on that day
100% if filled outside of a 50-mile radius of Student Health
50% if filled outside SHS for convenience

Brand name or generic prescriptions for Accutane will be paid at 75%.

The pre-existing condition clause, the secondary insurance clause and the necessity of satisfying your deductible do not apply if your prescription is filled at SHS or if SHS does not carry the medication

If your prescription is filled outside of SHS, you will have to pay the full cost of the medication. To receive reimbursement, you must send your receipt, a claim form and a note stating the medication is not available at SHS (if applicable) to the claims administrators (PIA.)

Is there a monetary limit to what the insurance will pay?

There is a $300,000 plan year maximum benefit for each accident or illness. You have a pharmacy maximum benefit of $8,000 each plan year. This is comprised of the actual cost of the drug, not the aggregate copayments.

Is there a monetary limit to what I will have to pay?

Yes. When an Insured has incurred $4,000.00 ($5,000.00 for out-of-network providers - could be a total of $9,000) of out-of-pocket Covered Charges for all Conditions per plan year (including deductibles and pharmacy copays) the Company payment will increase to 100%, up to the plan year maximum of $300,000 per Sickness or Injury.

Does Student Health Service bill the insurance company for me?

No, Student Health Service provides no insurance billing (except for dependents who have met their $500 deductible and for all prescriptions filled at SHS.) All PPO providers outside of SHS, however, have agreed to bill the insurance company. You are responsible for submitting a claim to the claims administrators (PIA) for each eligible medical expense. You may submit a claim online at PIAclaims.com. Another option would be to complete a claim form available at http://studenthealth.sa.ucsb.edu/Insurance If you have questions, please contact an Insurance Advisor at (805) 893-2592 or email: Insurance@sa.ucsb.edu.

Am I covered during the summer and during school breaks?

Yes if you were a registered student for the preceding quarter. The Spring Quarter insurance premium for undergraduate students provides coverage throughout the summer until the new policy begins in September. A dependent must enroll for each term in which they wish to be enrolled, including summer.

Does my insurance cover routine eye and dental care?

Student Health has a vision plan that provides discounts for routine vision care provide at Student Health Service Eye Clinic. Care for medical conditions affecting your eyes is covered under your medical plan. Please refer to the online brochure for specifics regarding this coverage. USHIP covers only accidental injury to natural teeth (see brochure), not routine dental care.

Is Physical Therapy covered?

After satisfying your deductible, Physical Therapy is covered at 100% up to a maximum of $500 per condition per plan year if received at Student Health Service, and the post- surgical requirement does not apply. SHS has a high-quality Physical Therapy Department that you may access with a referral from a practitioner. Physical Therapy services received at a facility outside of SHS are covered post-surgically only, with benefits at either 80% (PPO) or 50% (non-PPO) up to a maximum of $500 per condition per year. The $300 deductible applies for all physical therapy charges.

Is pregnancy covered?

Yes, pregnancy is covered at the same benefit level as any other medical condition. California Code mandates that the six-month pre-existing clause does not apply to a pregnancy. If you are pregnant before you enroll in USHIP and have not been covered by a comparable insurance plan, you will now receive benefits from your enrollment date. A newborn baby is covered for any illness or accident for 31 days. A newborn's nursery stay is an eligible benefit. To continue a newborn's coverage beyond 31 days, you must enroll him/her in the insurance plan whether or not an additional premium is required.

Emergency Medical Services, Evacuation, Repatriation

As an insured member of USHIIP you are automatically enrolled as a Member in the MEDEX program. MEDEX provides assistance for emergency medical services which require evacuations and for the repatriation of remains, if necessary. This includes emergency medications, legal assistance, translation services and more. Please see your brochure for a full explanation of these services.
The 24-hour numbers for assistance are (800) 527-0218 or collect, (410) 453-6330.

Do adult dependents enrolled in USHIP have to first be seen at Student Health Service?

Yes, unless they are more than fifty miles from UCSB. There is a visit fee for all non-students using SHS. This fee is an eligible insurance benefit and you may file a claim form with the claims administrators (PIA) for reimbursement of this charge (deductible applies). Children are not seen at SHS, so if your child is covered by this insurance, you may go to a provider of your choice. Remember, reimbursement is at 80% for a provider/facility who is a member of the Foundation for Medical Care and 50% if the provider/facility is not a member.

Are there other insurance alternatives for dependents besides the USHIP plan?

You may choose to call an independent company to inquire about their rates for your dependents or access the website www.ehealthinsurance.com/ehi/index.html for other insurance options.

What if I have a problem with Personal Insurance Administrators (PIA) regarding the filing of a claim?

Call PIA and discuss your situation with a customer service representative. If your problem has not been resolved, please call a UCSBÂ Student Health Service Insurance Advisor at (805) 893-2592 or email at insurance@sa.ucsb.edu.

What if I require emergency medical attention in a foreign country?

As an insured member of USHIP you are automatically enrolled as a Member in the MEDEX program. MEDEX provides assistance for emergency medical services and evacuations, if necessary. This includes emergency medications, legal assistance, translation services and more. Please see your brochure for a full explanation of these services. The 24-hour numbers for assistance are (800) 527-0218 or collect, (410) 453-6330.

What if I am a new student and my department requires me to be in Santa Barbara prior to the September 23 beginning plan date?

If you are required to be in Santa Barbara before September 23 for matriculation purposes, either bring University documentation to that effect to the SHS insurance office or have your department e-mail their request to the Insurance Coordinator at Grimmesey-e@sa.ucsb.edu and your coverage may begin early, but not prior to September 1. This does not apply to the Freshman Summer Start Program student, as their insurance is mandatory from the beginning of their summer program. This does apply to all international students who are required to be in on campus early for orientation and for housing needs.

I am in the Freshman Summer Start Program - When Does my Coverage Begin?

Insurance is mandatory for the Freshman Summer Start Program (FSSP), and you are assessed the premium which will appear on your BARC statement. Your insurance coverage begins the first day of your program (see brochure for dates of coverage).

What can we do as students to help keep the insurance premiums down?

This is important, because the more expensive the services provided, the higher the premium will be for next insurance plan year. You can do four things: 1) Utilize the Student Health Service, 2) Avoid referrals of convenience, 3) Use preferred providers, 4) Visit an Urgent Care Center rather than an Emergency Room if Student Health is closed and your situation is not of an emergent nature. Please read your brochure for the definition of an emergency.

I don't have time to read the USHIP brochure- how can I get more information and have my questions answered?

While we are happy to answer your questions, it is YOUR RESPONSIBILITY to read the information provided in order for you to have a good understanding of your policy and its benefits, limitations and exclusions. The USHIP brochure and claim forms are available on the Website http://studenthealth.sa.ucsb.edu/Insurance If you do have questions, you may email Insurance@sa.ucsb.edu or for a specific claim you may call the claims administrators (PIA) directly at (800) 468-4343.

I have concerns with various aspects of USHIP. With whom may I talk?

The USHIP committee meets, discusses, negotiates and votes on each phase of USHIP. These meetings occur monthly during the school year, and anyone interested is welcome to attend. To ascertain dates and times and/or to place an item on the agenda, please contact the SHS Insurance Coordinator, Elaine Grimmesey, at (805) 893-6133, or by e-mail at Grimmesey-e@sa.ucsb.edu.

I'm graduating. How can I document that I have had continuous insurance coverage?

You may request, either in writing or by phone, a Certification of Group Health Plan Coverage from Renaissance Agencies, Inc.
P.O. Box 2300
Santa Monica, California 90407-2300
Phone: (800) 537-1777

If you enroll in a new plan within 63 days of termination of coverage, no pre-existing clause will apply. You will need the Certificate of Coverage to verify your enrollment in USHIP.