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14 Benefit Brochure Csu Sfsu Intl Essay

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2014-2015
studentinsurance.wellsfargo.com

SAN FRANCISCO
STATE UNIVERSITY
INTERNATIONAL
You can view the standard Summary of Benefits & Coverage (SBC) which is required by Health Care Reform. It summarizes your coverage in a format that all insurance companies now use. To view your plan SBC, go to: studentinsurance.wellsfargo.com or call (800) 853-5899 to request a paper copy free of charge.

The California State University International student health insurance plan is underwritten by Aetna Life Insurance Company (Aetna) and administered by Chickering Claims Administrators, Inc. (CCA). Aetna Student HealthSM is the brand name for products and services provided by Aetna and CCA and their applicable affiliated companies. 15.02.310.1 D

Underwritten by:
Aetna Life Insurance Company
Policy #867861
The Plan Brokered by:
Wells Fargo Insurance Services USA, Inc.
Student Insurance Division

IMPORTANT NOTICE

This is just a brief description of your benefits. For information regarding the full Master Policy (which includes plan benefits, exclusions and limitations, and information about refund requests, how to file a claim, mandated benefits and other important information) please call Aetna Student Health at (866) 378-8885 or send an email through your Aetna Navigator Account or at http://www.aetnastudenthealth.com/customer-service/customer-service.aspx You will be able to obtain a copy of the full Master Policy as soon as it is available. WHEN COVERAGE BEGINS

WHEN COVERAGE ENDS

Insurance under the Master Policy will become effective at 12:01 a.m. on the later of:
ŒŒ The Master Policy effective date;
ŒŒ The beginning date of the term for which premium has been paid; ŒŒ The day after the Enrollment Form (if applicable) and premium payment are received by Wells Fargo Insurance, Authorized Agent or University; or ŒŒ The day after the date of postmark if the Enrollment Form is mailed. IMPORTANT NOTICE - Premiums will not be pro-rated if the Insured enrolls past the first date of coverage for which he or she is applying. Final decisions regarding coverage effective dates are made by Aetna Student Health.

Insurance of all Insured Persons terminates at 11:59 p.m. on the earlier of: ŒŒ Date the Master Policy terminates for all Insured Persons; or ŒŒ End of the period of coverage for which premium has been paid; or ŒŒ Date the Insured Person ceases to be eligible for the insurance; or ŒŒ Date the Insured Person enters military service.

ŒŒ In the event there is overlapping coverage under the same Master Policy number, the policy with the earliest effective date will stay in force through its termination date and the subsequent policy will go into effect immediately afterward with no gap in coverage.

The below enrollments will be allowed a 30 day grace period from the term start date to enroll whereby the effective date will be backdated a maximum of 30 days. No policy shall ever start prior to the term start date: 1. All hard-waiver and mandatory (insurance is required as a condition of enrollment on campus) insurance programs.

2. All re-enrollments into the same exact policy if re-enrollment occurs within 30 days of the prior policy termination date.

Dependent coverage will not be effective prior to that of the Insured Student or extend beyond that of the Insured Student.
COVERAGE IS NOT AUTOMATICALLY RENEWED. Eligible Persons must reenroll when coverage terminates to maintain coverage. NO notification of plan expiration or renewal will be sent.

PLAN COST
TERMS OF COVERAGE
Student only

ANNUAL
8/11/14 - 8/10/15
$1,507.47

NOTE: Costs below are in addition to the student premium. Dependents must be enrolled for the same term of coverage as student.

Spouse only

$4,347.11

Per Child (Age 0-25) only

$2,179.56

Rates include premium payable to Aetna Life Insurance Company, as well as administrative fees payable to CSU and Wells Fargo Insurance. Rates also include Medical Evacuation and Repatriation and Worldwide Emergency Travel Assistance benefits/services provided through On Call International and its contracted underwriting companies.

• 2 • San Francisco State University - International

WHO IS ELIGIBLE TO ENROLL?

PREMIUM REFUND/CANCELLATION

All international students, visiting faculty, scholars or other persons possessing and maintaining a current passport and valid visa status (F-1, J-1 or M-1, etc.), engaged in educational activities at San Francisco State University who are temporarily located outside their home country and have not been granted permanent residency status, are required to be insured under the Policy. Waiver may only be granted to people already insured under equivalent plans. Coverage is available for students engaged in “Practical Training”. Enrollment must be accompanied by confirmation of Practical Training from the insured student in the form of a copy of your EAD (OPT coverage is available for the first 12 months of OPT only). Contact Wells Fargo Insurance’s Customer Service for more details. (A person who is an immigrant or permanent resident alien is not eligible for coverage under the international plan.)

To be an Insured Person under the Policy, the student must have paid the required premium and his/her name, student number and date of birth must have been included in the declaration made by the School or the Administrative Agent to the Insurer. All students must actively attend classes on campus for 45 consecutive days following their effective date for the term purchased and/or pursuant to their visa requirements for the period for which coverage is purchased, except in the case of medical withdrawal or during school authorized breaks. ALIC and Wells Fargo Insurance maintains the right to investigate student status and attendance records to verify that the Policy eligibility requirements have been met. If and whenever ALIC and/or Wells Fargo Insurance discovers that the 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 the Student Health Insurance Plan within 30 days of loss of coverage. These students must provide Wells Fargo with proof that they have lost insurance through another group (certificate and letter of ineligibility) within 30 days of the qualifying event. The effective date would be the later of: a) term effective date, or b) the day after prior coverage ends if enrollment request is received by Wells Fargo within 30 days from loss of prior coverage.

Refund requests should be directed to Wells Fargo Insurance at (800) 853-5899 or via email at [email protected] A refund of premium will be granted for the reasons listed below only. No other refunds will be granted.

1. If you withdraw from school within the first 45 days of the coverage period, you and your insured dependents will receive a full refund of the insurance premium provided that you and your insured dependents did not file a medical claim during this period. Written proof of withdrawal from the school must be provided. If you withdraw after 45 days of the coverage period, your and your insured dependents coverage will remain in effect until the end of the term for which you have paid the premium. 2. If you or your insured dependents enter the armed forces of any country you and your insured dependents will not be covered under the Master Policy as of the date of such entry. If you enter the armed forces the policy will be cancelled. If your dependent enters the armed forces, a pro-rata refund of premium will be made for such person, upon written request received by Wells Fargo Insurance Services within 45 days of entry into service.

3. Refunds will be granted for insured dependents in case of a qualifying event such as legal separation, divorce or death within 31 days of the occurred event, provided that your insured dependents did not file a medical claim during the insured period. Written proof of such qualifying event must be submitted. Refunds will not be prorated.

INSURANCE PAYMENTS WITH PERSONAL CHECK
(Note: personal checks are not always a payment option. Please check your school’s enrollment form for available payment options.) If you make your or your dependents‘ insurance payment via personal check payable to Wells Fargo Insurance and we are unable to process the check (due to insufficient funds, closure of account, etc.), your and your dependents insurance coverage will be terminated retroactive to the effective date of the enrolled term.

COVERAGE FOR DEPENDENTS
Eligible Insured Students may also purchase Dependent coverage at the time of student’s enrollment in the plan; or within 31 days of one of the following qualified events: marriage, addition of domestic partner, birth, adoption or arrival in the U.S. Eligible dependents are the spouse or legally registered and valid domestic partner who resides with the Insured Student and the student’s, the spouse’s, or the domestic partner’s natural child, stepchild or legally adopted child under 26 years of age. Dependents of an Eligible International student or visiting faculty member must possess a valid passport and a proper visa (F-2, J-2, or M-2). A “Newborn” will automatically be covered for Injury or Sickness from birth until 31 days old, providing that the student is covered under this plan. Coverage may be continued for that child when Wells Fargo Insurance is notified in writing within 31 days from the date of birth and by payment of any additional premium. Dependents must be enrolled for the same term of coverage for which the Insured Student enrolls. Dependent coverage expires concurrently with that of the Insured Student, and Dependents must re-enroll when coverage terminates to maintain coverage.

San Francisco State University - International • 3 •

WHERE DO I GO FOR SERVICE?

ID CARDS

When you need care, consider Student Health Services (SHS) on your campus as your first stop. They can provide many of the routine health services you need. Services obtained at the SHS are reimbursed at the Preferred Care rate. A SHS referral is not required, and it does not guarantee services received will be considered eligible expenses under the plan, nor is it a guarantee of payment. You may visit any licensed health care provider directly for covered services, except for specific Plan restrictions on certain services. However, when you visit a Preferred Care Provider, you’ll generally have less out of pocket expense for your care. To learn more about Preferred Care Providers, visit www.aetnastudenthealth.com.

Insured dependents are not eligible to use the SHS. The benefits listed in the Schedule of Benefits are available to the insured dependents. *Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services.

Medical ID cards may be shipped before or within 3 weeks of your policy effective date. Providers need your Member ID# from your ID card to identify you, verify your coverage and bill Aetna Life Insurance Company. You do not need an ID card to be eligible to receive benefits, if you need medical attention before receiving your ID card, benefits will be payable according to the Policy. Once you have received your ID card, present it to the provider to facilitate prompt payment of your claim. You can also print your ID cards at www.aetnastudenthealth.com.

PREFERRED CARE PROVIDER NETWORK
Aetna Student Health has arranged for you to access the Aetna Preferred Care Provider network. It is to your advantage to utilize a Preferred Care Provider because savings can be achieved from the Negotiated Charges these providers have agreed to accept as payment for their services. Students are responsible for informing their Physicians of potential out-of-pocket expenses for a referral to both a Preferred Care Provider and a Non-Preferred Care Provider. Preferred Care Providers are independent contractors and are neither employees nor agents of the California State University system nor Aetna Student Health. To find a Preferred Care Provider, you can use Aetna’s online DocFind® service located at www.aetnastudenthealth.com. Click on “Find Your School” and enter your school name. You can use DocFind® to find out whether a specific provider belongs to Aetna’s network or to find Preferred Care Providers practicing in your area.

PRESCRIPTION DRUG
CLAIM PROCEDURE
When obtaining a covered prescription, please present your ID card to a Preferred Pharmacy, along with your applicable copay. The pharmacy will bill Aetna for the cost of the drug, plus a dispensing fee, less the copay amount. When you need to fill a prescription, and do not have your ID card with you, you may obtain your prescription from an Aetna Preferred Pharmacy, and be reimbursed by submitting a completed Aetna Prescription Drug claim form. You will be reimbursed for covered medications, less your copay. For an Aetna Prescription claim form go to www.aetnastudenthealth.com. Find your school, then click “Prescription” to obtain an RX claim form. Or call (866) 378-8885.

Prescriptions from a Non-Preferred Pharmacy, or a health center pharmacy incapable of billing, must be paid for in full at the time of service and submitted for reimbursement.

• 4 • San Francisco State University - International

INFORMED HEALTH® LINE
The Informed Health Line is a 24-hours-a-day, 7-days-a-week toll-free line for insured students and dependents to access confidential medical advice, or get assistance with locating nearby preferred network providers. Just call (800) 556-1555 to talk to a registered nurse who can provide information on a range of topics. Callers must be enrolled in the Student Health Insurance Plan in order to be eligible to utilize the Informed Health Line. MEMBER WEB: AETNA NAVIGATOR®

Got Questions? Get Answers with Aetna Navigator®
As an Aetna Student Health insurance member, you have access to Aetna Navigator®, your secure member website, packed with personalized benefits and health information. You can take full advantage of our interactive website to complete a variety of self-service transactions online.

By logging into Aetna Navigator®, you can:
ŒŒ Review who is covered under your plan.
ŒŒ Request member ID cards.
ŒŒ View Claim Explanation of Benefits (EOB) statements.
ŒŒ Estimate the cost of common healthcare services and procedures to better plan your expenses.
ŒŒ Research the price of a drug and learn if there are alternatives. ŒŒ Find healthcare professionals and facilities that participate in your plan. ŒŒ Send an e-mail to Aetna Student Health Customer Service at your convenience.

ŒŒ View the latest health information and news, and more!
How do I register?
ŒŒ Go to www.aetnastudenthealth.com
ŒŒ Click on “Find Your School.”
ŒŒ Enter your school name and then click on “Search.”
ŒŒ Click on Aetna Navigator® and then the “Access Navigator” link. ŒŒ Follow the instructions for First Time User by clicking on the “Register Now” link.
ŒŒ Select a user name, password and security phrase.
Need help with registering onto Aetna Navigator®
Technical assistance is available toll free, Monday through Friday, from 7 a.m. to 9 p.m. Eastern Time at (800) 225-3375.

IMPORTANT NOTICE

This is just a brief description of your benefits. For information regarding the full Master Policy (which includes plan benefits, exclusions and limitations, and information about refund requests, how to file a claim, mandated benefits and other important information) please call Aetna Student Health at (866) 378-8885 or send an email through your Aetna Navigator Account or at http://www.aetnastudenthealth.com/customer-service/customer-service.aspx You will be able to obtain a copy of the full Master Policy as soon as it is available.

The Plan will pay benefits in accordance with any applicable California State Insurance Law(s). WAIVER OF ANNUAL DEDUCTIBLE
In compliance with Federal Health Care Reform legislation, the Annual Deductible is waived for Preferred Care Covered Medical Expenses rendered as part of the following benefit types: Routine Physical Exam Expense (Office Visits), Pap Smear Screening Expense, Mammogram Expense, Routine Screening for Sexually Transmitted Disease Expense, Routine Colorectal Cancer Screening, Routine Prostate Cancer Screening Expense, Preventive Care Immunizations (Facility or Office Visits), Well Woman Preventive Visits (Office Visits), Screening & Counseling Services (Office Visits) as illustrated under the Routine Physical Exam benefit type, Routine Cancer Screenings (Outpatient), Prenatal Care (Office Visits), Comprehensive Lactation Support and Counseling Services (Facility or Office Visits), Breast Pumps & Supplies, Family Contraceptive Counseling Services (Office Visits), Female Voluntary Sterilization (Inpatient and Outpatient), Pediatric Preventive Vision and Dental Service, Female Contraceptives Generic Prescription Drugs, Brand Prescription Drugs if no Generic equivalent. FDA-Approved Female Generic Emergency Contraceptives.

SCHEDULE OF BENEFITS
Coinsurance
Covered Medical Expenses are payable at the coinsurance percentage specified below, after any applicable deductible, up to an Unlimited maximum benefit. Out of Pocket Maximums
Preferred Care Individual Out-of-Pocket: $2,500 per Insured per Policy Year; Preferred Care Family Out-of-Pocket: $5,000 per Policy Year Once the Individual or Family Out-of-Pocket Limit for Preferred Care has been satisfied, Covered Medical Expenses will be payable at 100% for the remainder of the Policy Year, up to any benefit maximum that may apply. Coinsurance, Deductibles, Copays and Prescription Drug expenses apply to the Out-of-Pocket Limit. Services that do not apply towards satisfying the Out-Of-Pocket Limit: expenses that are not Covered Medical Expenses; expenses for Designated Care or Non-Preferred care; penalties,and other expenses not covered by this Plan.

INPATIENT HOSPITALIZATION EXPENSES

PREFERRED CARE

NON-PREFERRED CARE

Room and Board Expense, semi-private room.

100% of the Negotiated Charge

75% of the Recognized Charge

Intensive Care Room and Board Expense, overnight stay.

100% of the Negotiated Charge

75% of the Recognized Charge

Miscellaneous Hospital Expense, includes; among others; expenses incurred during a hospital confinement for: anesthesia and operating room; laboratory tests and x rays; oxygen tent; and drugs; medicines; and dressings.

100% of the Negotiated Charge

75% of the Recognized Charge

PREFERRED CARE

NON-PREFERRED CARE

Surgical Expense

100% of the Negotiated Charge

75% of the Recognized Charge

Anesthesia Expense

100% of the Negotiated Charge

75% of the Recognized Charge

OUTPATIENT BENEFITS

PREFERRED CARE

NON-PREFERRED CARE

Walk-In Clinic E...

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