This link will take you to Medical Insurance Waivers, Applications, Enrollment, and Claim Forms.
Please keep this brochure as a general summary of the insurance. The Master
onto 
http://www.kosterweb.com or
contact Koster Insurance Agency at Bcstudentinsurance@kosterins.com.
- Eligibility
- Effective and Termination Dates
- Premium Rates
- Waiver, Enrollment Procedures, and Additional Plan Information
- Intercollegiate Sports
- Privacy Policy
- Complaint Resolution
- Extension of Benefits After Termination
- Mandated Benefits
- Benefits for Bone Marrow Transplants for Treatment of Breast Cancer
- Benefits for Cardiac Rehabilitation
- Benefits for Cytological Screening and Mammography Examinations
- Benefits for Dependent Children Early Intervention Services
- Benefits for Dependent Children Preventive Care
- Benefits for Enteral Formula
- Benefits for Home Health Care Services
- Benefits for Hormone Replacement Therapy and Outpatient Contraceptive Services
- Benefits for Hospice Care
- Benefits for Human Leukocyte Antigen or Histacompatibility Locus Antigen Testing
- Benefits for Infertility Treatment
- Benefits for Initial Prosthetic Device and Reconstructive Surgery
- Benefits for Maternity, Childbirth, Well-Baby and Postpartum Care
- Benefits for Newborn or Adopted Children
- Benefits for Off-Label Drug Use
- Benefits for Qualified Clinical Trials for Treatment of Cancer
- Benefits for Scalp Hair Prostheses
- Benefits for Treatment of Alcoholism
- Benefits for Treatment of Diabetes
- Benefits for Treatment of Mental Disorders
- Benefits for Treatment of Speech, Hearing, and Language Disorders
- Excess Provision
- Preferred Provider Information
- Managed Care Information—Provisions
- Definitions
- Medical Emergency Treatment
- Benefits for Treatment of Drug Abuse
- Involuntary Disenrollment Rate
- Benefits Payable
- Prescription Drug Program
- Students Going Abroad
- Scholastic Emergency Services, Inc.
- Exclusions and Limitations
- Accidental Death and Dismemberment Benefits
- Resolution of Grievances
- Internal Inquiry Process
- Internal Grievance Review
- Grievance Decision Reconsideration
- Expedited Grievance Review
- Expedited Process for Insured with Terminal Illness
- Failure to Meet Time Limits
- Coverage or Treatment Pending Resolution of Internal Grievance
- External Review
- Utilization Review
- Utilization Review Program
- Quality Assurance
- Quality Management and Improvement Program
- Addendum to Quality Management
- Claims and Procedures
- Certificate of Coverage
- Questions
Students enrolled at least 75% of full-time and all students enrolled in a degree program, regardless of credit hours, are required by state law and Boston College to be covered under this plan, unless the student submits the required Waiver Information. Non-degree students registered at the credit levels listed below will be automatically enrolled in the plan and charged by Boston College. Failure to maintain these credit levels will result in the termination of the mandatory Boston College Student Injury and Sickness Insurance Plan. It is the student's responsibility to monitor their eligibility status.
- Graduate Woods College of Advancing Studies—7 or more
- Graduate Arts and Sciences—7 or more
- Graduate Education —7 or more
- Graduate Management—7 or more
- Graduate Nursing—7 or more
- Graduate Social Work—7 or more
- Woods College of Advancing Studies Undergraduate—9 or more
Post doctorate students are eligible to enroll on a voluntary basis. Students who are not citizens or permanent residents of the U.S. will automatically be enrolled in the Boston College plan regardless of the number of credit hours for which they are enrolled.
Students must actively attend classes for at least the first 31 days after the date for which coverage is purchased. Home study, correspondence, Internet, and television (TV) courses do not fulfill the Eligibility requirements that the student actively attend classes. The Company maintains its right to investigate student status and attendance records to verify that the policy Eligibility requirements have been met. If the Company discovers that the policy Eligibility requirements have not been met, its only obligation is refund of premium.
Eligible students who do enroll may also insure their Dependents. Eligible Dependents are the spouse (husband and wife) and unmarried children under 19 years of age, who are not self-supporting. Dependent eligibility expires concurrently with that of the insured student.
EFFECTIVE AND TERMINATION DATES
The Master Policy on file at the school becomes effective August 7, 2007. Coverage becomes effective on the first day of the period for which premium is paid or the date the enrollment form and full premium are received by the Company (or its authorized representative), whichever is later. The Master Policy terminates August 6, 2008. Coverage terminates on that date or at the end of the period through which premium is paid, whichever is earlier. Dependent coverage will not be effective prior to that of the Insured student or extend beyond that of the Insured student. Refunds of premiums are allowed only upon entry into the armed forces.
First Semester, August 7, 2007, to January 14, 2008
Student—$757
Spouse—$1,759
One Child—$921
All Children—$1,372
Second Semester, January 15, 2008, to August 6, 2008
Student—$ 964
Spouse—$2,248
One Child—$1,173
All Children—$1,751
You must meet the Eligibility requirements listed herein each time you pay a premium to continue insurance coverage. There is a Grace Period of 14 days to receive premium after the first premium. To avoid a lapse in coverage, your premium must be received within 14 days after the premium expiration date. It is the student's responsibility to make timely renewal payments to avoid a lapse in coverage.
The Policy is a Non-Renewable One Year Term Policy. It is the Insured's responsibility to obtain coverage the following year in order to maintain continuity of coverage. Insureds who have not received information regarding a subsequent plan prior to this policy's termination date should inquire regarding such coverage with the school or its agent.
WAIVER, ENROLLMENT PROCEDURES, AND ADDITIONAL PLAN INFORMATION
Waiver Enrollment: Students who do not want to be enrolled in the Student Injury and Sickness Insurance Plan, can waive the student insurance plan by providing proof of comparable coverage electronically through Agora. In order to show proof of comparable coverage, students need to log on to, http://agora.bc.edu/ and complete the online waiver form. Students may begin waiving the insurance for 2007-2008 on April 16, 2007. All waiver forms must be submitted by September 14, 2007 for the first semester and for newly enrolled students for the second semester by January 25, 2008. Students who do not complete a waiver form by the deadline will be billed the Student Only premium and enrolled in the Plan. If you waive the insurance at the beginning of the first semester it will be waived for the entire year. If you wish to obtain the Boston College Student Injury and Sickness Insurance Plan for the second semester, you must go to the Office of Student Services prior to the second semester waiver deadline and request to have the waiver removed by completing a Petition to Add form.
Please Note: If the student is under the age of 18, the student may not use the automated system. A written Waiver Form is required and must be signed by the parent or guardian and student. A written Waiver Form is available at http://www.bc.edu/studentservices/.
Dependent Enrollment: It is the student's responsibility to ensure timely enrollment of eligible Dependents each policy year. Previously insured Dependents must be re-enrolled by the deadlines in order to avoid a break in coverage. Dependents are not automatically reenrolled. Students can enroll their eligible Dependents by obtaining a Dependent Enrollment Form at the Boston College Health Services Primary Care Center (Cushing Hall 117) or by downloading a Dependent Enrollment Form on the Web at http://www.bc.edu/studentservices/ and submitting it and the applicable premium by the deadline to Koster Insurance Agency, or by submitting an online Dependent Enrollment Form. To submit Dependent information online, go to https://www.kosterweb.com/, select Boston College from the drop down box and then select the 2007-2008 Dependent Enrollment Form. Students can contact Koster Insurance Agency at 800-457-5599 or by email at Bcstudent@kosterins.com.
The deadlines for Dependent enrollment are September 14, 2007, for the first semester and January 25, 2008, for the second semester. Dependent coverage terminates concurrent with that of the Insured Student.
Coverage for Dependents begins on the later of the following: the beginning date of the semester policy term or the date payment is received at Koster Insurance Agency. Please be aware that Dependent Enrollment Forms and payments not received by the deadlines may result in a break in coverage and Dependents may be subject to the Pre-existing Condition Limitation.
Withdrawals: All premiums are payable in advance for each policy term in accordance with the Company's premium rates. The full premium must be paid even if the correct premium is received after the policy Effective Date. There is no pro-rata or reduced premium payment for late enrollees. If you withdraw from Boston College and receive a 100% refund of tuition, you will receive a full cancellation of this insurance premium. If you withdraw from Boston College, and receive a pro-rated refund of tuition, your coverage will remain in effect until the end of the period for which you have paid a premium. In this instance you will not receive a cancellation of the insurance premium. All full-time student premium cancellations will be generated by the Office of Student Services at Boston College. Dependent refunds will be generated by Koster Insurance Agency. There will be no pro-rated refunds to students who cancel coverage under the policy unless the Insured enters the armed forces.
EyeMed Vision Care: The discount vision plan is available through EyeMed Vision Care. EyeMed's provider network consists of over 20,000 independent providers and retail stores nationwide, including LensCrafters, Target and Pearle Vision. You will receive a separate EyeMed ID card. There is no waiting period; you can take advantage of the savings through EyeMed immediately upon receipt of your EyeMed ID card. You can purchase brand name prescription eyeglasses, conventional contact lenses or even non-prescription sunglasses at savings between 15% to 45% off regular retail pricing. In addition, you can receive discounts from 5% to 15% off laser correction surgery at some of the nation's most highly qualified laser correction surgeons. To locate a participating provider, you can call 1-866-8EYEMED or visit http://www.enrollwitheyemed.com/ (and select the Access Plan.) This plan is not underwritten by The MEGALife and Health Insurance Plan.
Dental Savings Program: The Dental Savings Program is an exclusive plan for students enrolled in the Student Injury and Sickness Insurance Plan. The program is operated by Basix, LLC to provide students access to general and specialty dental care from a select network of local dentists. The network of providers have met strict credentialing and quality assurance requirements. The network of participating dental providers have agreed to accept negotiated prices for the services they provide. Students will be responsible for paying for services they receive at the time of the visit. Students will generally save from 20% to 50% of charges for a wide range of dental services—from routine cleaning to root canals. Because the Dental Savings Program is not insurance, there are no claim forms, annual maximums, benefit limitations and conditions or other plan provisions. Students can log onto http://www.basixstudent.com/ to locate participating dental providers, download the fee schedule and learn more about the Program. This plan is not underwritten by The MEGA Life and Health Insurance Plan.
If an Insured Person sustains an accidental injury while participating in the play or practice of an intercollegiate sport sponsored by Boston College, the Company will pay up to a maximum of $1,000 for medical or surgical treatment or hospitalization, except that injury to sound natural teeth is limited to $500 for any one Injury. This plan also provides up to $1,000 for Accidental Death and Dismemberment and Loss of Sight Benefit as a result of injury sustained while participating in the play or practice of an intercollegiate sport sponsored by Boston College. All varsity athletic injuries must be reported immediately to the Boston College Athletic Trainer. The benefits and the maximum amounts are specified in the Schedule of Benefits and endorsement attached hereto, if so noted in the Schedule of Benefits.
We (MEGA) know that your privacy is important to you and we strive to protect the confidentiality of your nonpublic personal information. We do not disclose any nonpublic personal information about our customers or former customers to anyone, except as permitted or required by law. We believe we maintain appropriate physical, electronic and procedural safeguards to ensure the security of your nonpublic personal information. You may obtain a detailed copy of our privacy practices by calling us toll-free at 1-800-767-0700 or by visiting us at https://www.uhcsr.com/.
Insured Persons, Preferred Providers, Out-of-Network Providers or their representatives with questions or complaints may call the Customer Service Department at 1-800-331-1096. If the question or complaint is not resolved to the satisfaction of the complainant, the complainant may submit a written request to the Claims Review Committee, which will make a thorough investigation and respond to the complainant in a timely manner. The Company will not retaliate against the complainant because of the complaint.
EXTENSION OF BENEFITS AFTER TERMINATION
The coverage provided under this policy ceases on the Termination Date. However, if an Insured incurs medical expenses within 60 days of the Termination Date form a covered Injury or Sickness for which benefits were paid before the Termination Date, Covered Medical Expenses for such Injury or Sickness will continue to be paid as long as the condition continues:
- 1. When not Hospital Confined on the Termination Date, not to exceed 90 days after the Termination Date; or
- 2. When Hospital Confined .on the Termination Date, not to exceed 90 days after the Termination Date.
After this Extension of Benefits provision has been exhausted, all benefits cease to exist, and under no circumstances will further payment be made. The total payments made in respect of the Insured for such condition both before and after the Termination Date will never exceed the Maximum Benefit. If the Insured is also an Insured under the succeeding policy issued to the Policyholder; this Extension of Benefits provision will not apply.
Benefits for Bone Marrow Transplants for Treatment
of Breast Cancer
Benefits will be paid the same as any other Sickness for a bone marrow transplant or transplants for Insureds who have been diagnosed with breast cancer that has progressed to metastatic disease. Insureds must meet the criteria established by the Department of Public Health and which are consistent with medical research protocols reviewed and approved by the National Cancer Institute. Benefits shall be subject to all Deductible, copayment, coinsurance, limitations or any other provisions of the policy.
Benefits for Cardiac Rehabilitation
Benefits will be paid the same as any other Sickness for Cardiac Rehabilitation. Cardiac Rehabilitation shall mean multidisciplinary, Medically Necessary treatment of persons with documented cardiovascular disease, which shall be provided in either a Hospital or other setting and which shall meet standards promulgated by the commissioner of public health. Benefits shall include, but not be limited to, outpatient treatment which is to be initiated within twenty six (26) weeks after diagnosis of such disease. Benefits shall be subject to all Deductible, copayment, coinsurance, limitations or any other provisions of the policy.
Benefits for Cytological Screening and Mammographic
Examinations
Benefits will be paid the same as any other Sickness for: 1) an annual cytological
screening for women eighteen (18) years of age or older; and 2) a baseline mammogram
for women between the ages thirty-five (35) and forty (40) and for an annual
mammogram for women forty (40) years of age and older. Benefits shall be subject
to all Deductible, copayment, coinsurance, limitations or any other provisions
of the policy.
Benefits for Dependent Children Early Intervention Services
Benefits will be paid the same as any other Sickness for early intervention services for Dependent children from birth to their third birthday. Certified early intervention specialists in accordance with an early intervention program approved by the Department of Public Health and in accordance with applicable certification requirements shall provide early intervention services. Maximum benefit per policy year for such services shall not exceed $5,200 for each Dependent child and a Maximum Lifetime Benefit of $15,600 per child. Benefits shall be subject to all Deductible, copayment, coinsurance, limitations or any other provisions of the policy.
Benefits for Dependent Children Preventive Care
Benefits will be paid for the Usual and Customary Charges for those preventive
and primary services delivered or supervised by a Physician that are rendered
to a Dependent child of an Insured from the date of birth through the attainment
of six years of age. Benefits include physical examination, history, measurements,
sensory screening, neuropsychiatric evaluation and development screening, and
assessment at the following intervals: six times during the child's first year
after birth, three times during the next year, annually until age six. Benefits
shall also include hereditary and metabolic screening at birth, appropriate
immunizations, and tuberculin tests, hematocrit, hemoglobin or other appropriate
blood tests, and urinalysis as recommended by the Physician. Benefits shall
include those special medical formulas which are approved by the commissioner
of the Department of Public Health, prescribed by a Physician, and are Medically
Necessary for treatment of phenylketonuria, tyrosinemia, homocystinuria, maple
syrup urine disease, propionic acidemia, or methylmalonic acidemia in infants
and children.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations or any other provisions of the policy.
Benefits for Enteral Formula
Benefits will be paid the same as any other Sickness for nonprescription enteral
formulas for home use when a Physician has issued a written order for such formula
and when Medically Necessary for the treatment of malabsorption caused by Crohn's
disease, ulcerative colitis, gastroesophageal reflux, gastrointestinal motility,
chronic intestinal pseudo-obstruction, and inherited diseases of amino acids
and organic acids. Benefits for inherited diseases of amino acids and organic
acids shall include food products modified to be low protein limited to $2,500
annually for any Insured Person. Benefits are provided for formulas that are
taken orally as well as those that are administered by tube. Benefits shall
be subject to a copayment for a 30-day supply of enteral formula that is equal
to the copayment required for outpatient Physician Visits.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations or any other provisions of the policy.
Benefits for Home Health Care Services
Benefits will be paid the same as any other Sickness for Home Health Care Services.
Additional services such as occupational therapy, speech therapy, medical social
work, nutritional consultation, the services of a home health aid and the use
of durable medical equipment and supplies shall be provided to the extent such
services are determined to be a Medically Necessary component of said nursing
and physical therapy. Benefits for Home Health Care Services are payable only
when such services are Medically Necessary and provided in conjunction with
a Physician approved Home Health Care Services plan. Durable medical equipment
and supplies provided as part of an approved Home Health Care Services plan
will not be subject to any policy limitations regarding durable medical equipment
and supplies.
"Home health care services" means health care services for an Insured Person by a public or private home health agency which meets the standards of service of the purchaser of service, provided in a patient's residence; provided, however, that such residence is neither a hospital nor an institution primarily engaged in providing skilled nursing or rehabilitation services. Said services shall include, but not be limited to, nursing and physical therapy.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations or any other provisions of the policy.
Benefits for Hormone Replacement Therapy and Outpatient
Contraceptive Services
Benefits will be paid the same as any other Sickness for outpatient hormone
replacement therapy services for peri and post menopausal women and outpatient
contraceptive services. Outpatient contraceptive services include consultations,
examinations, procedures and medical services for all United States Food and
Drug Administration (FDA) approved contraceptive methods to prevent pregnancy.
If the policy provides benefits for Prescription Drugs, benefits will be paid the same as any other Sickness for FDA approved hormone replacement therapy and outpatient prescription contraceptive drugs or devices.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations or any other provisions of the policy.
Benefits for Hospice Care
When an Insured Person is diagnosed with a covered Injury or Sickness, and therapeutic
intervention directed toward the cure of the Injury or Sickness is no longer
appropriate, and the Insured's medical prognosis is one in which there is a
life expectancy of six months or less as a direct result of such Injury or Sickness,
benefits will be payable for the Usual and Customary Charges for services and
supplies for hospice care prescribed by a Physician and provided by a licensed
hospice agency, organization or unit. This benefit does not cover non-terminally
ill patients who may be confined in: a convalescent home, rest or nursing facility;
a skilled nursing facility; a rehabilitation unit or a facility that provides
treatment for persons suffering from mental disease or disorders, or care for
the aged, drug addicts, or alcoholics. For this benefit to be payable, a written
statement from the attending Physician that the Insured is terminally ill within
the terms of this benefit and a written statement from the hospice certifying
the days on which services were provided must be furnished to the Company.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations or any other provisions of the policy.
Benefits for Human Leukocyte Antigen or Histacompatibility
Locus Antigen Testing
Benefits will be paid the same as any other Sickness for human leukocyte antigen
testing or Histacompatibility locus antigen testing that is necessary to establish
bone marrow transplant donor suitability for potential donors for Insured Persons.
Benefits shall include the costs of testing for A, B or DR antigens, or any
combination thereof, consistent with rules, regulations and criteria established
by the Department of Public Health.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations or any other provisions of the policy.
Benefits for Infertility Treatment
Benefits will be paid the same as any other Sickness for the diagnosis and treatment of Infertility for persons residing within the Commonwealth of Massachusetts to the same extent that benefits are provided for other pregnancy-related procedures. Benefits will include, but not be limited to, the following Non-experimental
Infertility Procedures:
- 1. Artificial Insemination (AI);
- 2. In Vitro Fertilization and Embryo Placement (IVF-EP);
- 3. Gamete Intra-Fallopian Transfer (GIFT);
- 4. Sperm, egg and/or inseminated egg procurement, processing and banking, to the extent such costs are not covered by the donor's insurer, if any;
- 5. Intracytoplasmic Sperm Injection (ICSI) for the treatment of male factor infertility; and
- 6. Zygote Intrafallopian Transfer (ZIFT).
Benefits are not provided for the following Experimental Infertility Procedures:
- 1. Any Experimental Infertility Procedure, until the procedure becomes recognized as non-experimental and is so recognized by the Commissioner;
- 2. Surrogacy;
- 3. Reversal of Voluntary Sterilization; and
- 4. Cryopreservation of eggs.
"Infertility" means the condition of a presumably healthy individual who is unable to conceive or produce conception during a period of one (1) year. "Non-experimental Infertility Procedures" means a procedure which is: 1) recognized as such by the American Fertility Society (AFS) or the American College of Obstetrics and Gynecology (ACOG) or another infertility expert recognized as such by the Commission; and 2) incorporated as such in this provision by the Commissioner after a public hearing pursuant to M.G.L. c. 30A.
"Experimental Infertility Procedures" means a procedure not yet recognized as non-experimental.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations or any other provisions of the policy, except that any Pre-Existing Condition exclusion or waiting period shall not apply to benefits for Infertility treatment.
Benefits for Initial Prosthetic Device and Reconstructive
Surgery
Benefits will be paid the same as any other Sickness for a Mastectomy and the
initial prosthetic device or reconstructive surgery incident to the Mastectomy.
Benefits shall be provided for reconstructive surgery on a nondiseased breast
to produce a symmetrical appearance. Reconstructive surgery includes, but is
not limited to, augmentation mammoplasty, reduction mammoplasty and mastopexy.
When a Mastectomy is performed and there is no evidence of malignancy, benefits
will be limited to the cost of the prosthesis or reconstructive surgery to within
2 years after the date of the Mastectomy. "Mastectomy" means the removal of
all or part of the breast for Medically Necessary reasons as determined by a
licensed Physician.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations or any other provisions of the policy.
Benefits for Maternity, Childbirth, Well-Baby and
Postpartum Care
Benefits will be paid the same as any other Sickness for the expense of prenatal
care, childbirth and postpartum care. Benefits will be provided for a minimum
of forty-eight hours of in-patient care following a vaginal delivery and a minimum
of ninety-six hours of inpatient care following a caesarean section for a mother
and her newly born child including routine well-baby care. Any decision to shorten
such minimum stay shall be made by the attending Physician in consultation with
the mother. Any such decision shall be made in accordance with rules and regulations
promulgated by the Department of Public Health. Said regulations shall be relative
to early discharge, defined as less than forty-eight hours for a vaginal delivery
and ninety-six hours for a caesarean delivery. Post-delivery care shall include,
but not be limited to, home visits, parent education, assistance and training
in breast or bottle feeding and the performance of any necessary and appropriate
clinical tests; provided, however, that the first home visit shall be conducted
by a Physician. Additional Medically Necessary home visits shall be provided
upon recommendation by a Physician.
Benefits will be paid the same as any other Sickness for Medically Necessary special medical formulas which are approved by the commissioner of the Department of Public Health, when prescribed by a Physician to protect the unborn fetuses of pregnant women with phenylketonuria.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations or any other provisions of the policy.
Benefits for Newborn or Adopted Children
Benefits will be paid for Newborn Infants, including Newborn Infants of a Dependent,
from the moment of birth the same as any other Insured Dependent. Benefits shall
also be provided for adopted or adoptive children of the Insured Person immediately
from the date of the filing of a petition to adopt under chapter two hundred
and ten and thereafter if the child has been residing in the home of the Insured
Person as a foster child for whom the Insured Person has been receiving foster
care payments, or, in all other cases, immediately from the date of placement
by a licensed placement agency of the child for purposes of adoption in the
home of the Insured Person. Benefits for Newborn infants and adoptive children
shall include treatment of Injury and Sickness including the necessary care
and treatment of medically diagnosed congenital defects and birth abnormalities,
or premature birth.
Benefits shall include those special medical formulas which are approved by the commissioner of the Department of Public Health, prescribed by a Physician, and are Medically Necessary for treatment of phenylketonuria, tyrosinemia, homocystinuria, maple syrup urine disease, propionic acidemia, or methylmalonic acidemia in infants and children.
Benefits shall include screening for lead poisoning on the basis required by the Department of Public Health.
Benefit shall include a newborn hearing screening test to be performed before the Newborn Infant is discharged from the hospital or birthing center to the care of the parent or guardian or as provided by regulations of the Department of Public Health.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations or any other provisions of the policy.
Benefits for Off-Label Drug Use
If benefits are payable for Prescription Drugs under this policy (see Schedule
of Benefits), then benefits will be paid the same as any other Prescription
Drug for any drug prescribed to treat an Insured Person for cancer or HIV/AIDS
if the drug is recognized treatment for that indication in one of the standard
reference compendia or in the medical literature, or in the Association of Community
Cancer Centers' Compendia-Based Drug Bulletin.
"Standard reference compendia" means (a) the United States Pharmacopoeia Drug Information; (b) the American Medical Association Drug Evaluations; or (c) the American Hospital Formulary Service Drug Information.
"Medical literature" means scientific studies published in any peer-reviewed national professional journal.
For such Prescription Drugs that are payable due to establishment by the commissioner as payable after a review of the panel of medical experts as outlined in Massachusetts Insurance Code, 175:47L, benefits will be paid for such drugs that are not included in any of the standard reference compendia or in the medical literature for the treatment of cancer.
Benefits shall include Medically Necessary services associated with the administration of such drugs.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations or any other provisions of the policy
Benefits for Qualified Clinical Trials for Treatment of Cancer
Benefits will be paid the same as any other Sickness for Patient Care Service furnished pursuant to a Qualified Clinical Trial. Patient Care Service means a health care item or service that is furnished to an individual enrolled in a Qualified Clinical Trial which is consistent with the Usual and Customary standard of care for someone with the patient's diagnosis, is consistent with the study protocol for the clinical trial, and would be covered if the patient did not participate in the clinical trial. Qualified clinical trial means a clinical trial that meets the following conditions:
- 1. the clinical trial is to treat cancer;
- 2. the clinical trial has been peer reviewed and approved by one of the following;
- a. United States National Institutes of Health;
- b. A cooperative group or center of the National Institutes of Health;
- c. A qualified nongovernmental research entity identified in guidelines issued by the National Institutes of Health for center support grants;
- d. The United States Food and Drug Administration pursuant to an investigational new drug exemption;
- e. The United States Departments of Defense or Veterans Affairs; or
- f. With respect to Phase II, III and IV clinical trials only, a qualified institutional review board.
- 3. the facility and personnel conducting the clinical trial are capable of doing so by virtue of their experience and training and treat a sufficient volume of patients to maintain that experience;
- 4. with respect to Phase I clinical trials, the facility shall be an academic medical center or an affiliated facility and the clinicians conducting the trial shall have staff privileges at said academic medical center;
- 5. the patient meets the patient selection criteria defined in the study protocol for participation in the clinical trial;
- 6. the patient has provided informed consent for participation in the clinical trial in a manner that is consistent with current legal and ethical standards;
- 7. the available clinical or pre-clinical data provide a reasonable expectation that the patient's participation in the clinical trial will provide a medical benefit that is commensurate with the risks of participation in the clinical trial;
- 8. the clinical trial does not unjustifiably duplicate existing studies; and
- 9. the clinical trial must have a therapeutic intent and must, to some extent, assume the effect of the intervention on the patient.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations or any other provisions of the policy.
Benefits for Scalp Hair Prostheses
Benefits will be paid for expenses for scalp hair prostheses worn for hair loss
suffered as a result of the treatment of any form of cancer or leukemia when
a written statement by a Physician is furnished stating that the scalp hair
prosthesis is Medically Necessary.
Benefits are limited to $350 per Policy Year. Benefits shall be subject to all Deductible, copayment, coinsurance, limitations or any other provisions of the policy.
Benefits for Treatment of Alcoholism
Benefits will be paid the same as any other Sickness for the treatment of Alcoholism subject to the following:
- 1. Inpatient benefits will be limited to a maximum of 30 days in any policy year when an Insured is confined in an accredited or licensed Hospital or in any other public or private facility thereof providing services especially for the detoxification or rehabilitation of intoxicated persons or alcoholics and which is licensed by the Department of Public Health for those services, or in a residential alcohol treatment program as referred to in section 24 of chapter 90 of the Massachusetts Insurance Laws.
- 2. Outpatient benefits will be limited to a maximum of $500 over a 12-month period for services furnished by: 1) an accredited or licensed Hospital; or 2) by any public or private facility or portion thereof providing services especially for the rehabilitation of intoxicated persons or alcoholics and which is licensed by the Department of Public Health for those purposes. Consultants or treatment sessions furnished by a facility in this clause shall be rendered by a Physician or psychotherapist fully licensed under the provisions of Chapter 112 of the Massachusetts Insurance Laws who devotes a substantial portion of his time treating intoxicated persons or alcoholics.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations or any other provisions of the policy.
Benefits for Treatment of Diabetes
Benefits will be paid the same as any other Sickness for Insured Persons for Medically Necessary services and supplies for the diagnosis or treatment of insulin-dependent, insulin-using, gestational and non-insulin-dependent diabetes when prescribed by a Physician. Benefits will be paid for the following, subject to any applicable Deductibles, co-payments and coinsurance shown on the Schedule of Benefits:
- 1. Prescription Drugs: blood glucose monitoring strips for home use; urine glucose strips; ketone strips; lancets; insulin; insulin syringes; insulin pumps and insulin pump supplies; insulin pens and prescribed oral diabetes medications that influence blood sugar levels;
- 2. Durable medical equipment: blood glucose monitors; voice synthesizers for blood glucose monitors for use by the legally blind; visual magnifying aids for use by the legally blind;
- 3. Laboratory/radiological services: including glycosylated hemoglobin, or HbAlc tests; urinary protein/microalbumin and lipid profiles;
- 4. Prosthetics: therapeutic/molded shoes and shoe inserts prescribed by a Physician and approved by the Federal Drug Administration for the purposes for which they were prescribed for Insureds who have severe diabetic foot disease; and
- 5. Outpatient services: diabetes outpatient self-management training and education, including medical nutrition therapy, when provided by a Physician certified in diabetes health care As used in this section, a "Physician certified in diabetes health care" means a licensed health care professional with expertise in diabetes, a registered dietician or a health care provider certified by the National Certification Board of Diabetes Educators as a certified diabetes educator.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations or any other provisions of the policy.
Benefits for Treatment of Mental Disorders
Benefits will be paid the same as any other Sickness for the diagnosis and treatment of the following biologically-based mental disorders, as described in the most recent edition of the Diagnostic and Statistical Manual of the American Psychiatric Association, referred to in this benefit as the "DSM":
- 1. schizophrenia,
- 2. schizoaffective disorder,
- 3. major depressive disorder,
- 4. bipolar disorder,
- 5. paranoia and other psychotic disorders,
- 6. obsessive-compulsive disorder,
- 7. panic disorder,
- 8. delirium and dementia,
- 9. affective disorders; and
- 10. any biologically-based mental disorders appearing in the DSM that are scientifically recognized and approved by the commissioner of the Department of Mental Health in consultation with the commissioner of the Division of Insurance.
Benefits will be paid the same as any other Sickness for the diagnosis and treatment of rape-related mental or emotional disorders to victims of a rape or victims of an assault with intent to commit rape, as defined by sections 22 and 24 of chapter 265, whenever the costs of such diagnosis and treatment exceed the maximum compensation awarded to such victims pursuant to subparagraph (C) of paragraph (2) of subsection (b) of section 3 of chapter 258C. Benefits will be paid the same as any other Sickness for Dependent children under the age of 19 for the diagnosis and treatment of non-biologically-based mental, behavioral or emotional disorders, as described in the most recent edition of the DSM, which substantially interfere with or substantially limit the functioning and social interactions of such a child provided, that said interference or limitation is documented by and the referral for said diagnosis and treatment is made by a Physician, or is evidenced by conduct, including, but not limited to:
- 1. an inability to attend school as a result of such disorder,
- 2. the need to hospitalize such child as a result of such disorder, or
- 3. a pattern of conduct or behavior caused by such disorder which poses a serious danger to self or others. Such benefits to a Dependent child who is engaged in an ongoing course of treatment shall continue beyond the Dependent's nineteenth birthday until said course of treatment, as specified in such child's treatment plan, is completed and while the policy under which such benefits first became available remains in effect, or subject to a subsequent policy which is in effect.
Benefits will be paid the same as any other Sickness for the diagnosis and treatment of all other mental disorders not otherwise provided for in this benefit section and which are described in the most recent edition of DSM during each 12 month period on the following basis:
- 1. Up to 60 days of inpatient treatment; and
- 2. Up to 24 outpatient visits.
Benefits will be paid the same as any other Sickness for treatment of alcoholism or chemical dependency when said treatment is rendered in conjunction with treatment for mental disorders pursuant to this benefit section. Benefits shall include inpatient, intermediate, and outpatient services that are Medically Necessary and provided in the least restrictive clinically appropriate setting. Inpatient services may be provided in a general Hospital licensed to provide such services, in a facility under the direction and supervision of the Department of Mental Health, in a private mental Hospital licensed by the Department of Mental Health, or in a substance abuse facility licensed by the Department of Public Health. Intermediate services shall include, but not be limited to, Level III community-based detoxification, acute residential treatment, partial hospitalization, day treatment and crisis stabilization licensed or approved by the Department of Public Health or the Department of Mental Health. Outpatient services may be provided in a licensed Hospital, a mental health or substance abuse clinic licensed by the Department of public health, a public community mental health center, a professional office, or home-based services, provided, however, services delivered in such offices or settings are rendered by a licensed mental health professional acting within the scope of his license. Benefits will be paid the same as any other Sickness for psychopharmacological services and neuropsychological assessment services. When necessary for administration of claims under this benefit section, consent to the disclosure of information regarding services for mental disorders will be required on the same basis as disclosure of information for other Sickness or Injury.
Benefits will not be payable for mental health benefits or services: which are provided to a person who is incarcerated, confined or committed to a jail, house of correction or prison, or custodial facility in the department of youth services within the commonwealth or one of its political subdivisions; which constitute educational services required to be provided by a school committee pursuant to section 5 of chapter 71B; or which constitute services provided by the Department of Mental Health. "Licensed mental health professional" means a Physician who specializes in the practice of psychiatry, a licensed psychologist, a licensed independent clinical social worker, a licensed mental health counselor, or a licensed nurse mental health clinical specialist.
Benefits shall be subject to all Deductible, co-payment, coinsurance, limitations or any other provisions of the policy.
Benefits for Treatment of Speech, Hearing and Language
Disorders
Benefits will be paid the same as any other Sickness for Insured Persons for
Medically Necessary diagnosis and treatment of speech, hearing and language
disorders by individuals licensed as speech language pathologists or audiologists
if such services are rendered within the lawful scope of practice for such speech-language
pathologists or audiologists. Benefits will be paid for services provided in
a Hospital, clinic or private office. Benefits will not be provided for the
diagnosis or treatment of speech, hearing and language disorders for services
provided in a school-based setting.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations or any other provisions of the policy.
No benefits are payable for any expense incurred for Injury or Sickness which has been paid or is payable by other valid and collectible insurance or under an automobile insurance policy.
However, this Excess Provision will not be applied to the first $100 of Covered Medical Expenses incurred.
Covered Medical Expenses excludes amounts not covered by the primary carrier due to penalties imposed as a result of the Insured's failure to comply with policy provisions or requirements.
Important: The Excess Provision has no practical application if you do not have other medical insurance or if your other insurance does not cover the loss.
PREFERRED PROVIDER INFORMATION
HealthCare Value Management, Inc. ("HCVM") is a network (locally in New England: MA, CT, RI, ME, VT, NY) of Physicians, Hospitals, and other health care providers who have contracted to provide specific medical care at negotiated prices.
First Health is a network of Physicians, Hospitals, and other health care providers who have contracted to provide specific medical care at negotiated prices. This network is available only outside of New England: MA, CT, RI, ME, VT, NY.
"Preferred Providers" are the Physicians, Hospitals and other health care providers who participate in HCVM and First Health.
"Preferred Allowance" means the amount a Preferred Provider will accept as payment in full for Covered Medical Expenses.
"Network Area" means the geographic service area approved by the Massachusetts Division of Insurance.
"Out-of-Network" providers have not agreed to any prearranged fee schedules. You may incur significant out-of-pocket expenses with these providers. Charges in excess of the insurance payment are your responsibility.
Regardless of the provider, you are responsible for the payment of your Deductible. You must satisfy your Deductible before benefits are paid. We will pay according to the benefit limits in the Schedule of Benefits.
Inpatient Hospital Expenses
Preferred Hospitals Eligible inpatient Hospital expenses at a Preferred Hospital will be covered at 100% up to the limits specified in the Schedule of Benefits. Call (888) 685-7774 or visit http://www.ccnusa.com/ for information about Preferred Hospitals.
Out-of-Network Hospitals If care is provided at a Hospital that is not a Preferred Provider, your eligible inpatient hospital expenses will be paid according to the benefit limits in the Schedule of Medical Expense Benefits.
Outpatient Hospital Expenses Preferred Providers may discount your bills for outpatient hospital expenses. Benefits are paid according to the Schedule of Benefits. You pay any amount that exceeds the benefits shown on the Schedule of Benefits, up to the Preferred Allowance.
MANAGED CARE INFORMATION—PROVISIONS
Provider Directories
Provider Directories for the HCVM Network may be obtained:
- a. by calling Student Insurance at 1-800-767-0700; or
- b. log onto https://www.studentresources.com/ for information.
In addition, HCVM directories may be obtained by:
- a. logging on to the HCVM website at http://www.HCVM.com/;
- b. or calling HCVM directly at 1-800-922-4286.
Service Area Description
The following counties in Massachusetts are included in the HCVM networks:
- Barnstable
- Berkshire
- Bristol
- Dukes
- Essex
- Franklin
- Hampden
- Hampshire
- Middlesex
- Nantucket
- Norfolk
- Plymouth
- Suffolk
- Worcester
Continuity of Coverage
- 1. If an Insured female is in her second or third trimester of pregnancy and her Physician providing care for her pregnancy is involuntarily disenrolled (other than disenrollment for quality related reasons or for fraud), the Insured female may continue treatment with such Physician, consistent with the terms of this Certificate, for the period up to and including the Insured's first postpartum visit.
- 2. If an Insured is terminally ill and their Physician providing care in connection with said illness is involuntarily disenrolled (other than disenrollment for quality related reasons or for fraud) the Insured may continue treatment with such Physician consistent with the terms of this Certificate, until the Insured's death.
- 3. If a newly enrolled Insured is in an ongoing course of treatment and the Insured's Physician is not a participating provider in the Preferred Provider Network, benefits will be provided for such course of treatment for up to 30 days from the Effective Date of coverage, subject to the Pre-Existing Condition Limitation, consistent with the terms of this Certificate.
Such continuity of coverage will only apply if such Physician agrees to the following: (a) to accept reimbursement from the Company at the rates applicable prior to notice of disenrollment as payment in full and not to impose cost sharing with respect to the Insured in an amount that would exceed the cost sharing that could have been imposed if the Physician had not been disenrolled; (b) to adhere to the quality assurance standards of the Company or Network and to provide the Company with necessary medical information related to the care provided; and (c) to adhere to the Company's policies and procedures. This section does not require coverage of benefits that would not have been covered if the Physician involved had remained a Preferred Provider.
Adopted or Adoptive Child means:
- 1. a child from the date of the filing of a petition to adopt, who has been residing in the home of the Insured as a foster child and the Insured has been receiving foster care payments; provided the person adopting the child is insured under the policy on the date the petition is filed; or
- 2. a child from the date of placement by a licensed placement agency for purposes of adoption in the home of the Insured provided the person adopting the child is insured under this policy on the date the child is placed with the Insured.
Such child will be covered under the policy for the first 31 days after:
- 1. date of the filing of a petition to adopt a foster child; or
- 2. date of placement of a child for purposes of adoption.
The Insured will have the right to continue such coverage for the child beyond the first 31 days. To continue the coverage the Insured must, a) apply to the Company, and b) pay the required additional premium (if any) for the continued coverage within 31 days after:
- 1. filing of a petition to adopt; or
- 2. date of placement for purposes of adoption.
If the Insured does not use this right as stated here, all coverage as to that child will terminate at the end of the first 31 days after the date of:
- 1. filing of a petition to adopt; or
- 2. date of placement of a child for purposes of adoption.
Covered Medical Expenses means reasonable charges which are:
- 1. not in excess of Usual and Customary Charges;
- 2. not in excess of the maximum benefit amount payable per service as specified in the Schedule of Benefits;
- 3. made for services and supplies not excluded under the policy;
- 4. made for services and supplies which are a Medical Necessity;
- 5. made for services included in the Schedule of Benefits; and
- 6. in excess of the amount stated as a Deductible, if any.
Covered Medical Expenses will be deemed "incurred" only:
- 1. when the covered services are provided; and
- 2. when a charge is made to the Insured Person for such services.
Deductible means if an amount is stated in the Schedule of Benefits or any endorsement to this policy as a deductible, it shall mean an amount to be subtracted from the amount or amounts otherwise payable as Covered Medical Expenses before payment of any benefit is made. The deductible will apply per policy year or per occurrence (for each Injury or Sickness) as specified in the Schedule of Benefits.
Dependent means the spouse (husband or wife) of the Named Insured and their dependent, unmarried children and any Newborn Infant of a dependent of the Named Insured. Children shall cease to be dependent on the first to occur of:
- 1. The end of the month in which they marry; or,
- 2. The end of the month in which they attain the age of nineteen (19) years.
The attainment of the limiting age will not operate to terminate the coverage of such child while the child is and continues to be both:
- 1. Incapable of self-sustaining employment by reason of mental retardation or physical handicap; and
- 2. Chiefly dependent upon the Insured Person for support and maintenance.
Proof of such incapacity and dependency shall be furnished to the Company:
- 1. by the Named Insured; and
- 2. within 31 days of the child's attainment of the limiting age.
Subsequently, such proof must be given to the Company annually following the child's attainment of the limiting age. If a claim is denied under the policy because the child has attained the limiting age for dependent children, the burden is on the Insured Person to establish that the child is and continues to be handicapped as defined by subsections (1) and (2).
Elective Surgery or Elective Treatment means those health care services or supplies that do not meet the health care need for a Sickness or Injury. Elective surgery or elective treatment includes any service, treatment or supplies that: 1) are deemed by the Company to be research or experimental; or 2) are not recognized and generally accepted medical practices in the United States.
Experimental or Investigative Treatment means a service, supply, procedure, device or medication that meets any of the following:
- 1. a drug or device that cannot be lawfully marketed without the 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 or to be furnished; or
- 2. a treatment, or the "informed consent" form used with a treatment, that was reviewed and approved by the treating facility's institutional review board or other body servicing a similar function, or federal law requires such review or approval; or
- 3. reliable evidence shows that the treatment is the subject of ongoing Phase I or Phase II clinical trials; is the research, experimental, study or investigative arm of ongoing Phase III clinical trials; or is otherwise under study to determine its safety, efficacy, toxicity, maximum tolerated dose, or its efficacy as compared with a standard means of treatment or diagnosis; or
- 4. reliable evidence shows that prevailing opinion amount experts regarding the treatment is that more studies or clinical trials are necessary to determine its safety, efficacy, toxicity, maximum tolerated dose, or its efficacy as compared with a standard means of treatment or diagnosis.
Reliable evidence, as used in this definition, means only published reports and articles in the authoritative peer-reviewed medical and scientific literature; the written protocol or protocols used by the treating facility or the protocol(s) of another facility studying substantially the same treatment; or the written informed consent form used by the treating facility or by another facility studying substantially the same treatment.
Hospital means a licensed or properly accredited general hospital which:
- 1. is open at all times;
- 2. is operated primarily and continuously for the treatment of and surgery for sick and injured persons as inpatients;
- 3. is under the supervision of a staff of one or more legally qualified Physicians available at all times;
- 4. continuously provides on the premises 24 hour nursing service by Registered Nurses;
- 5. provides organized facilities for diagnosis on the premises; and
- 6. is not primarily a clinic, nursing, rest or convalescent home.
Hospital Confined/Hospital Confinement means confined in a Hospital for at least 18 hours by reason of an Injury or Sickness for which benefits are payable.
Injury means bodily injury which is:
- 1. directly and independently caused by specific accidental contact with another body or object;
- 2. unrelated to any pathological, functional, or structural disorder;
- 3. a source of loss;
- 4. treated by a Physician within 30 days after the date of accident; and
- 5. sustained while the Insured Person is covered under this policy. All injuries sustained in one accident, including all related conditions and recurrent symptoms of these injuries will be considered one injury.
Injury does not include loss which results wholly or in part, directly or indirectly, from disease or other bodily infirmity. Covered Medical Expenses incurred as a result of an injury that occurred prior to this policy's Effective Date will be considered a Sickness under this policy.
Insured Person means:
- 1. the Named Insured; and,
- 2. Dependents of the Named Insured, if:
- a. the Dependent is properly enrolled in the program, and
- b. the appropriate Dependent premium has been paid. The term "Insured" also means Insured Person.
Intensive Care means:
- 1. a specifically designated facility of the Hospital that provides the highest level of medical care; and
- 2. which is restricted to those patients who are critically ill or injured. Such facility must be separate and apart from the surgical recovery room and from rooms, beds and wards customarily used for patient confinement. They must be:
- a. permanently equipped with special life-saving equipment for the care of the critically ill or injured; and
- b. under constant and continuous observation by nursing staff assigned on a full-time basis, exclusively to the intensive care unit. Intensive care does not mean any of these step-down units:
- Progressive care;
- Sub-acute intensive care;
- Intermediate care units;
- Private monitored rooms;
- Observation units; or
- Other facilities which do not meet the standards for intensive care
Medical Emergency means a medical condition, whether physical or mental, manifesting itself by symptoms of sufficient severity, including severe pain, that the absence of prompt medical attention could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine, to result in:
- 1. placing the health of the Insured Person in serious jeopardy;
- 2. serious impairment to body function, or serious dysfunction of any body organ or part; or
- 3. with respect to a pregnant woman, the health of the woman or her unborn child.
Medical Necessity or Medically Necessary means those services or supplies provided or prescribed by a Hospital or Physician which are:
- 1. Essential for the symptoms and diagnosis or treatment of the Sickness or Injury;
- 2. Provided for the diagnosis, or the direct care and treatment of the Sickness or Injury;
- 3. In accordance with the standards of good medical practice;
- 4. Not primarily for the convenience of the Insured, or the Insured's Physician; and
- 5. The most appropriate supply or level of service which can safely be provided to the Insured.
The Medical Necessity of being Hospital Confined means that:
- 1. the Insured requires acute care as a bed patient; and
- 2. the Insured cannot receive safe and adequate care as an outpatient.
This policy only provides payment for services, procedures and supplies which are a Medical Necessity. No benefits will be paid for expenses which are determined not to be a Medical Necessity, including any or all days of Hospital Confinement.
Mental and Nervous Disorder means a Sickness that is a mental, emotional or behavioral disorder. If not excluded or defined elsewhere in the policy, all diagnoses classified as a "Mental Disorder" according to the (International Classification of Diseases) are considered one Sickness.
Named Insured means an eligible, registered student of the Policyholder, if: 1) the student is properly enrolled in the program; and 2) the appropriate premium for coverage has been paid.
Newborn Infant means any child born of an Insured or of the Insured's Dependent while that person is insured under this policy. Newborn Infants will be covered under the policy for the first 31 days after birth. Coverage for such a child will be for Injury or Sickness, including medically diagnosed congenital defects, birth abnormalities, prematurity and nursery care; benefits will be the same as for the Insured Person who is the child's parent.
The Insured will have the right to continue such coverage for the child beyond the first 31 days. To continue the coverage the Insured must, within the 31 days after the child's birth:
- 1. apply to the Company; and
- 2. pay the required additional premium, if any, for the continued coverage.
If the Insured does not use this right as stated here, all coverage as to that child will terminate at the end of the first 31 days after the child's birth.
Physician means a legally qualified licensed practitioner of the healing arts who provides care within the scope of his/her license, other than a member of the Insured Person's immediate family. This includes but is not limited to certified registered nurse anesthetists, nurse practitioners, certified nurse midwives, podiatrists, chiropractors, optometrists or any other legally licensed practitioner of the healing arts who is practicing within the scope of his/her license." Physician's eligible for reimbursement under the terms of this policy shall include pediatric specialty care Physicians, including mental health care, by Physicians with recognized expertise in specialty pediatrics to Insureds requiring such services.
The term "member of the immediate family" means any person related to an Insured Person within the third degree by the laws of consanguinity or affinity.
Physiotherapy means any form of the following: physical or mechanical therapy; diathermy; ultra-sonic therapy; heat treatment in any form; manipulation or massage administered by a Physician.
Pre-existing Condition means any condition:
- 1. which manifested itself during the 6 months immediately preceding the Insured's Effective Date of coverage under this policy and would cause an ordinarily prudent person to seek medical advice, diagnosis, care or treatment or for which medical advice, diagnosis, care or treatment was recommended or received; or
- 2. a pregnancy existing on the Insured's Effective Date of coverage under this policy.
Prescription Drugs means:
- 1. prescription legend drugs;
- 2. compound medications of which at least one ingredient is a prescription legend drug;
- 3. any other drugs which under the applicable state or federal law may be dispensed only upon written prescription of a Physician; and
- 4. injectable insulin.
Registered Nurse means a professional nurse (R.N.) who is not a member of the Insured Person's immediate family.
Sickness means sickness or disease of the Insured Person which causes loss while the Insured Person is covered under this policy. All related conditions and recurrent symptoms of the same or a similar condition will be considered one sickness. Covered Medical Expenses incurred as a result of an Injury that occurred prior to this policy's Effective Date will be considered a sickness under this policy.
Sound, Natural Teeth means natural teeth, the major portion of the individual tooth is present, regardless of fillings or caps; and is not carious, abscessed, or defective.
Usual and Customary Charges means a reasonable charge which is:
- 1. usual and customary when compared with the charges made for similar services and supplies; and
- 2. made to persons having similar medical conditions in the locality of the Policyholder.
No payment will be made under this policy for any expenses incurred which in the judgment of the Company are in excess of Usual and Customary Charges.
In the event of Injury or Sickness, the student should contact their Physician or report to the Student Health Service if such services are available to the Insured. Should the Insured have a condition that a prudent layperson would consider a Medical Emergency, the Insured should go to the nearest Physician or Hospital or call the local pre-hospital emergency medical service system by dialing the emergency telephone access number 911, or its local equivalent. An Insured is not required to contact the Company prior to treatment.
After 72 hours of Inpatient care and if an Insured has been stabilized, the Company has the right to require an Insured to be transferred to a Preferred Provider Hospital in order to continue benefit levels at the Preferred Provider rate. Any such transfer must be approved by the attending Physician. If the Insured is not considered stabilized at that time, the Company has the right to require transfer to a Preferred Provider Hospital when the Insured is deemed stabilized by the attending Physician. If the Insured does not accept transfer, benefits will be payable at the Out-of-Network rate following the day in which such transfer was possible. See the Pre-Notification Section for instructions on informing the Company of your expected Hospitalization or following emergency admission.
BENEFITS FOR TREATMENT OF DRUG ABUSE
Benefits will be paid for the treatment of Drug Abuse, subject to all terms and conditions of the policy and the provisions of this benefit.
- a. Benefits will be paid for confinement as an inpatient in an accredited or licensed Hospital, a residential treatment program, or in any other public or private facility thereof providing services especially for the treatment of Drug Abuse and which is licensed by the Department of Public Health for those services. Benefits will not exceed a maximum of 30 days in any policy year.
- b. Outpatient benefits for treatment of Drug Abuse shall not exceed a maximum of $500 over a 12-month period. Services must be furnished by an accredited or licensed Hospital, any public or private facility or portion thereof providing services especially for the treatment of Drug Abuse and which is licensed by the Department of Public Health for those purposes. Consultants or treatment sessions furnished by such a facility in this provision shall be rendered by a Physician who devotes a substantial portion of his/her time treating Drug Abuse.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations or any other provisions of the policy.
INVOLUNTARY DISENROLLMENT RATE
The involuntary disenrollment rate for insureds in Massachusetts for The MEGA Life and Health Insurance Company for 2006 was 0%.
All benefits are payable without discrimination for all Insured Persons under this plan. Benefits currently mandated by state and federal law are contained within these benefit provisions.
Schedule of Benefits, Medical Expense Benefits, and Injury and Sickness Benefits
This policy provides benefits as shown below for loss incurred by an Insured due to a covered Injury of Sickness. If you receive care from a Preferred Provider, any Covered Medical Expenses will be paid at the applicable Preferred Provider level of benefits. If a Preferred Provider is not available in your Network Area, benefits will be paid at the level of benefits as shown as Preferred Provider benefits. If the Covered Medical Expense is incurred due to a Medical Emergency treatment, benefits will be paid at the level of benefits shown as Preferred Provider level of benefits. (See Medical Emergency Treatment on page 18 for additional information). In all other situations, reduced, or lower benefits will be provided when an Out-of-Network provider is used. The Benefits payable are as defined in and subject to all provisions of the Maximum Benefit identified for each service scheduled bellows. After the Deductible has been satisfied, benefits will be paid as listed for the provider selected.
NOTE: Although the Maximum Benefit per Injury or Sickness is $100,000, there are some specific benefit limitations as identified in the Schedule.
These benefits may be subject to a Pre-Existing Condition limitation.
PA = Preferred Allowance
U&C = Usual and Customary
Max = Maximum
Per Injury or Sickness Maximum Benefit: $100,000
Deductible, does not apply to visits, or lab work ordered at the Boston College Student Health Center, or Prescription Drugs: $150 Per Insured Person per Policy Year
| Preferred Providers |
Out-of-Network Providers |
|
| OUTPATIENT BENEFITS | ||
| Surgeon's Fees In accordance with data provided by Ingenix, Inc. If two or more procedures are performed through the same incision or in immediate succession at the same operative session, the maximum amount paid will not exceed the benefits for the one of such procedures for which the largest benefit is payable, unless medically necessary. | 100% of PA up to a combined maximum of $5,000 |
80% of U&C up to a combined maximum of $5,000 |
| Assistant Surgeon | 30% of the Surgery Allowance |
30% of the Surgery Allowance |
| Anesthetist Professional services administered in connection with outpatient surgery. | 30% of the Surgery Allowance |
30% of the Surgery Allowance |
| Day Surgery Miscellaneous Related to scheduled surgery performed in a Hospital including the cost of the operating room, laboratory tests and x-ray examinations, including professional fees, anesthesia, drugs or medicines, and supplies. Usual and Customary Charges for Day Surgery Miscellaneous are based on the Outpatient Surgical Facility Charge Index. | 100% of PA— $5,000 maximum per procedure |
80% of U&C—$5,000 maximum per procedure |
| Outpatient Miscellaneous Benefits Includes benefits designated as Paid under Outpatient Miscellaneous including physician office visits, hospital, outpatient miscellaneous, emergency room and supplies, diagnostic tests and procedures, consultant physician fees, injections, Durable Medical Equipment | 100% of PA— $2,000 maximum |
80% of U&C—$2,000 maximum |
| Hospital Outpatient Department | Paid under Outpatient Misc. Benefit—$35 copay
per visit |
Paid under Outpatient Misc. Benefit—$35 copay
per visit |
| Physician Visits Benefits for Physician Visits do not apply when related to surgery or physiotherapy. | Paid under Outpatient Misc. Benefit—$20 copay
per visit |
Paid under Outpatient Misc. Benefit—$20 copay
per visit |
| Physiotherapy (Physical Therapy). Benefits limited to one visit per day. | 100% of PA—$500 combined maximum |
80% of U&C—$500 combined maximum |
| Medical Emergency Expenses Attending Physician chart, x-ray, laboratory procedures, injection, and the use of the emergency room supply. Copay waived if admitted | Paid under Outpatient Misc. Benefit—$100 copay
per visit |
Paid under Outpatient Misc. Benefit—$100 copay
per visit |
| Diagnostic X-rays and Laboratory | Paid under Outpatient Misc. Benefit |
Paid under Outpatient Misc. Benefit |
| Test and Procedures Diagnostic services and medical procedures performed by a Physician, other than Physician's visits, physiotherapy, x-rays, and laboratory procedures. | Paid under Outpatient Misc. Benefit |
Paid under Outpatient Misc. Benefit |
| Chemotherapy and Radiation Therapy | Paid under High Cost Procedure |
Paid under High Cost Procedure |
| Injections when administered in the Physician's office and charged on Physician's statement (Does not include immunizations or allergy injections. Refer to Other Coverages: Wellness Program.) | Paid under Outpatient Misc. Benefit |
Paid under Outpatient Misc. Benefit |
| Prescription Drugs $1,000 maximum per policy year. Prescription must be filled at participating MEDCO pharmacy. Drugs and medicines lawfully obtainable only upon written prescription of a Physician based on a 30-day supply per prescription. Contact http://www.medco.com/ for participating pharmacies. Deductible does not apply. | $10 copay per prescription for generic drugs. |
No Benefits |
| Medical Disorders including all related and ancillary charges incurred as a result of a Mental and Nervous Disorder. Benefits are limited to one visit per day. | See Benefits for Treatment of Mental Disorders. |
See Benefits for Treatment of Mental Disorders. |
The outpatient prescription drug benefit is available through the MEDCO Pharmacy Network and includes national pharmacy chains such as CVS, Walgreens, and Brooks, and local independent pharmacies, and is based on their national preferred drug formulary as well as a 3-tier co-payment structure. After a per prescription copayment of $10 for a 30-day supply of a generic drug or a $25 copayment for a 30-day supply of a preferred brand name drug, or a $45 co-payment for a 30-day supply of a non-preferred brand drug, the Expenses incurred for the cost of prescription drugs will be reimbursed at 100% up to the maximum of $1,000 per policy year. In order to maximize your benefits under this prescription plan, we encourage you to ask your physician to consult the drug formulary. Insured Students will be given an ID Card to show to the pharmacy as proof of coverage. If a prescription needs to be filled prior to receiving the ID card, reimbursement will be made upon submitting a completed Rx claim form (claims forms can be obtained from Koster Insurance Agency or online at http://www.bc.edu/studentservices/. Within the first 90 days of the policy year, students seeking reimbursement without having their ID card, will be reimbursed for the full amount paid for the prescription less the copayment. After the first 90 days, students not using their ID card will be reimbursed at the retail price less both the copayment amount and the MEDCO discounted amount that would have been applied had the ID card been used. MEDCO Pharmacies can be located by calling 1-800-711-0917 or by visiting http://www.medco.com/.
Mail Service Prescription Drug Program: Medications that are taken for a chronic condition can be filled for up to a 90-day supply using Medco's Mail Service Prescription Program. Using the Mail Service program, a 90-day supply of a generic can be filled with a one copayment equivalent to 2X the 30-day supply copayment.
When you use the Mail Service Prescription Drug Program you will need to complete a Medco By Mail Order Form and include that and your doctor's signed prescription form and mail directly to Medco. A brochure describing the Mail Service Program, Medco By Mail Order Forms and accompanying mailing envelope are available at the Student Health Center or by contacting Koster Insurance Agency.
In accordance with the Massachusetts State Mandate, Outpatient hormone replacement therapy for premenopausal and postmenopausal women and outpatient contraceptive drugs and devices are covered. Please refer to Exclusions and Limitations for medications not covered.
Whether studying or traveling abroad, the Student Injury and Sickness Insurance Plan provides the same benefits as if you were on campus at Boston College. When outside of the United States, you will likely be asked to pay for your medical care first and then will need to seek reimbursement. Covered Medical Expenses will be reimbursed on an out-of-network basis. When you submit claims for reimbursement, you will need to have the itemized bill(s) translated into English and include a letter informing the claims administrator that you are seeking reimbursement for charges previously paid. Please insure that your name, ID number, address (to receive your reimbursement check), and the College's name are on the bill.
SCHOLASTIC EMERGENCY SERVICES, INC.
If you are a student insured with this insurance plan, you and your insured spouse and minor child(ren) are eligible for Scholastic Emergency Services, Inc. (SES) services. The requirements to receive these services are as follows:
International Students, insured spouse and insured minor child(ren): You are eligible to receive SES services worldwide, except in your home country.
Domestic Students, insured spouse and insured minor child(ren): You are eligible for SES services when 100 miles or more away from your campus address or 100 miles or more away from your permanent home address or while participating in a Study Abroad program.
SES services include Emergency Medical Evacuation and Return of Mortal Remains. The Emergency Medical Evacuation services are not meant to be used in lieu of or replace local emergency services such as an ambulance requested through emergency 911 telephone assistance. All SES services must be arranged and provided by SES prior to receiving services in order for these services to be covered.
Key Services include:
- Medical Consultation, Evaluation and Referrals
- Foreign Hospital Admission Guarantee (outside of the U.S.)
- Emergency Medical Evacuation
- Critical Care Monitoring
- Medically Supervised Repatriation
- Prescription Assistance
- Transportation to Join Patient
- Care for Minor Children Left Unattended Due to a Medical Incident
- Return of Mortal Remains
- Emergency Counseling Services
- Lost Luggage or Document Assistance
- Interpreter and Legal Referrals
Please visit your school's insurance coverage page at http://www.uhcsr.com/ for the SES Global Emergency Assistance Services brochure which includes service descriptions and program exclusions and limitations.
To access services please call (877) 488-9833 toll-free within the United States or (609) 452-8570 Collect outside the United States. Services are also accessible via e-mail at medservices@assistamerica.com.
When calling the SES Operations Center, please be prepared to provide:
- 1. Caller's name, telephone and (if possible) fax number, and relationship to the patient
- 2. Patient's name, age, sex, and Reference Number (found on student's ID card)
- 3. Description of the patient's condition 4.Name, location, and telephone number of hospital, if applicable
- 5. Name and telephone number of the attending physician
- 6. Information of where the physician can be immediately reached
SES is not travel or medical insurance but a service provider for emergency medical assistance services. All medical costs incurred should be submitted to your health plan and are subject to the policy limits of your health coverage. All SES services must be arranged and provided by SES. Claims for reimbursement of services not provided by SES will not be accepted. Please refer to your SES brochure for Program Guidelines as well as limitations and exclusions pertaining to the SES program.
No benefits will be paid for:
- a. loss or expense caused by, contributed to, or resulting from; or
- b. treatment, services or supplies for, at, or related to:
- 1. Acupuncture, allergy, except as specifically provided in the policy;
- 2. Cosmetic procedures, except cosmetic surgery required to correct an Injury for which benefits are otherwise payable under this policy or for Newborn or Adopted children;
- 3. Dental treatment, except as specifically provided in the Schedule of benefits;
- 4. Elective Surgery or Elective Treatment;
- 5. Elective abortion;
- 6. Eye examinations, eyeglasses, contact lenses, prescriptions or fitting of eyeglasses or contact lenses;
- 7. Hearing examinations or hearing aids; or other treatment for hearing defects and problems, except as specifically provided in the policy. "Hearing defects" means any physical defect of the ear which does or can impair normal hearing, apart from the disease process;
- 8. Immunizations; except as specifically provided in the policy; preventive medicines or vaccines, except where required for treatment of a covered Injury or as specifically provided in the policy;
- 9. Injury or Sickness for which benefits are paid or payable under any Workers' Compensation or Occupational Disease Law or Act, or similar legislation;
- 10. Injury sustained while:
- a. participating in any intercollegiate or professional sport, contest or competition;
- b. traveling to or from such sport, contest or competition as a participant; or
- c. while participating in any practice or conditioning program for such sport, contest or competition
- 11. Participation in a riot or civil disorder; commission of or attempt to commit a felony;
- 12. Pre-existing Conditions in excess of $2,500, except for individuals who have been continuously insured under the school's student insurance policy for at least 6 consecutive months; or under a previous qualifying health plan, provided such coverage was in force within 30 days prior to the Insured's Effective Date under this policy;
- 13. Prescription Drugs, services or supplies as follows:
- a. Drugs labeled, "Caution - limited by federal law to investigational use" or experimental drugs, except as specifically provided in the policy;
- b. Products used for cosmetic purposes;
- c. Drugs used to treat or cure baldness; anabolic steroids used for body building;
- d. Anorectics, drugs used for the purpose of weight control;
- e. Sexual enhancement drugs, such as Viagra.
- 14. Family planning; impotence, organic or otherwise; tubal ligation; vasectomy; sexual reassignment surgery;
- 15. Skeletal irregularities of one or both jaws, including orthognathia and mandibular retrognathia; temporomandibular joint dysfunction;
- 16. Skydiving, parachuting, hang gliding, glider flying, parasailing, sail planing, bungee jumping, or flight in any kind of aircraft, except while riding as a passenger on a regularly scheduled flight of a commercial airline;
- 17. Speech Therapy, except as specifically provided in policy; and
- 18. Surgical breast reduction, breast augmentation, breast implants or breast prosthetic devices; except as specifically provided in the policy.
ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS
Loss of Life, Limb or Sight
If such Injury shall independently of all other causes and within 180 days from the date of Injury solely result in any one of the following specific losses, the Insured Person or beneficiary may request the Company to pay the applicable amount below in addition to payment under the Medical Expense Benefits (and under Major Medical, if coverage is afforded under Major Medical) provision.
For Loss Of:
- Life$5,000
- Two or More Members$5,000
- One Member$2,500
- Intercollegiate Sports Participants
- For Loss Of:
- Life$1,000
- Two or More Members$1,000
- One Member$500
Member means hand, arm, foot, leg, or eye. Loss shall mean with regard to hands or arms and feet or legs, dismemberment by severance at or above the wrist or ankle joint; with regard to eyes, entire and irrecoverable loss of sight. Only one specific loss the greater resulting from any one Injury will be paid.
You, the Insured, will be notified in writing by us, The MEGA Life and Health Insurance Company, if a claim or any part of your claim is denied. The notice will include the specific reason or reasons for the denial and the reference to the pertinent plan provision(s) on which the denial was based.
If you have a complaint about your claim denial, you may call our Member Services telephone number 1-800-767-0700 for further explanation to informally resolve your complaint or contact the consumer assistance toll-free number maintained by the Office of Patient Protection at 1-800-436-7757. If you are not satisfied with our explanation of why the claim was denied, you, your authorized representative or provider may request an internal review of the claim denial. The following is our internal inquiry process:
- 1. You, the Insured, must request in writing a benefit review within 60 days after the date that you receive the notice denying your claim. This will be an informal reconsideration review process of your claim by a Claims Supervisor. The Insured may not attend this review.
- 2. A decision will be made by the Claims Supervisor, within 3 days after the receipt of your request for review or the date all information required from the Insured is received.
- 3. We will provide written notice to an Insured whose inquiry has not been explained or resolved to the Insured's satisfaction within three business days of the inquiry of the right to have the inquiry processed as an internal grievance under 105 CMR 128.300 through 128.313 at his/her option, including reduction of an oral inquiry to writing by the carrier, written acknowledgment and written resolution of the grievance as set forth in 105 CMR 128.300 through 128.313. The Insured is not required to attend the grievance review.
- 4. The MEGALife and Health Insurance Company has a system for maintaining records for a period of two years of each inquiry communicated by an Insured or on his behalf and response thereto. These records shall be subject to inspection by the Commissioner of Insurance and the Office of Patient Protection.
- 1. The internal grievance material must be submitted in writing, by electronic means at info@StudentResources.com or by calling our Member Services telephone number 1-800-767-0700 by the Insured or his/her provider for consideration by the grievance reviewer. An oral grievance made by the Insured or the authorized representative shall be reduced to writing by us and a copy thereof forwarded to the Insured by us within 48 hours of receipt, except where this time limit is waived or extended by mutual written agreement of the Insured or the Insured's authorized representative and us.
- 2. Within 15 business days after we receive your request for an internal grievance review, we must provide you with the name, address and telephone number of the grievance coordinator and information on how to submit written material, except where an oral grievance has been reduced to writing by us or this time period is waived or extended by mutual written agreement of the Insured or the Insured's authorized representative and us.
- 3. Any grievance that requires the review of medical records, shall include the signature of the Insured, or the Insured's authorized representative on a form provided promptly by us authorizing the release of medical and treatment information relevant to the grievance to us, in a manner consistent with state and federal law. The Insured and the authorized representative shall have access to any medical information and records relevant to the grievance relating to the Insured which is in the possession of us and under our control. We shall request said authorization from the Insured when necessary for requests reduced to writing by us and for any written requests lacking said authorization.
- 4. The Insured may or may not attend this review but is not required to do so.
- 5. An internal grievance review written decision will be issued to the Insured and, if applicable, the Insured's provider, within 30 days of the receipt of the grievance. When a grievance requires the review of medical records, the 30 business day period will not begin to run until the Insured or the Insured's authorized representative submits a signed authorization for release of medical records and treatment information as required in 105 CMR 128.302(B). In the event that the signed authorization is not provided by the Insured or the Insured's authorized representative, if any, within 30 business days of the receipt of the grievance, we may, in our discretion, issue a resolution of the grievance without review of some or all of the medical records. The 30 business day time period for written resolution of a grievance that does not require the review of medical records, begins on the day immediately following the three business day time period for processing inquiries pursuant to 105 CMR 128.200, if the inquiry has not been addressed within that period of time; or on the day the Insured or the Insured's authorized representative, if any, notifies the carrier that s/he is not satisfied with the response to any inquiry under 105 CMR 128.200 if earlier than the three business day time period. The time limits in 105 CMR 128.305 may be waived or extended by mutual written agreement of the Insured or the Insured's authorized representative and us. The person or persons reviewing the grievance shall not be the same person or persons who initially handled the matter that is the subject of the grievance and, if the issue is a clinical one, at least one of whom shall be an actively practicing Physician in the same or similar specialty who typically treat the medical condition, perform or provide the treatment that is the subject of the grievance to evaluate the matter. The written decision issued in a grievance review shall contain:
- a. The professional qualifications and licensure of the person or persons reviewing the grievance.
- b. A statement of the reviewer's understanding of the grievance.
- c. The reviewers' decision in clear terms and the contractual basis or medical rationale in sufficient detail for the Insured to respond further to the Insurer's position. In the case of a grievance that involves an adverse determination, the written resolution shall include a substantive clinical justification therefore that is consistent with generally accepted principles of professional medical practice, and shall at a minimum:
- i. identify the specific information upon which the adverse determination was based;
- ii. discuss the Insured's presenting symptoms or condition, diagnosis and treatment interventions and the specific reasons such medical evidence fails to meet the relevant medical review criteria;
- iii. specify alternative treatment options covered by the carrier, if any; iv. reference and include applicable clinical practice guidelines and review criteria; and
- v. notify the Insured or the Insured's authorized representative of the procedures for requesting external review.
- d. A reference to the evidence or documentation used as the basis for the decision.
- e. A statement advising the Insured of his or her right to request a reconsideration of the grievance decision and a description of the procedure for submitting a request for a reconsideration of the grievance decision.
Grievance Decision Reconsideration
- 1. A grievance decision reconsideration is available to the Insured dissatisfied with the grievance review decision.
- 2. We may offer to the Insured or the Insured's authorized representative, if any, the opportunity for reconsideration of our final adverse determination where relevant medical information:
- a. was received too late to review within the 30 business day time limit; or
- b. was not received but is expected to become available within a reasonable time period following the written resolution.
- 3. When an Insured or the Insured's authorized representative, if any, chooses to request reconsideration, we must agree in writing to a new time period for review, but in no event greater than 30 business days from the agreement to reconsider the grievance. The time period for requesting external review shall begin to run on the date of the resolution of the reconsidered grievance.
We shall provide for an expedited resolution concerning our coverage or provision of immediate and urgently needed services, which shall include, but not be limited to:
- 1. A written resolution pursuant to 105 CMR 128.307 before an Insured's discharge from a hospital if the grievance is submitted by an Insured or the Insured's authorized representative while the Insured is an inpatient in a hospital.
- 2. Provisions for the automatic reversal of decisions denying coverage for services or durable medical equipment, pending the outcome of the internal grievance process, within 48 hours (or earlier for durable medical equipment at the option of a Physician responsible for treatment or proposed treatment of the covered patient) of receipt of certification by said Physician that, in the Physician's opinion:
- a. the service or use of durable medical equipment at issue in grievance is Medically Necessary;
- b. a denial of coverage for such services or durable medical equipment would create a substantial risk of serious harm to the Insured; and
- c. such risk of serious harm is so immediate that the provision of such services of durable medical equipment should not await the outcome of the normal grievance process.
- 3. Provisions that require that, in the event a Physician exercises the option of automatic reversal earlier than 48 hours for durable medical equipment, the Physician must further certify as to the specific, immediate and severe harm that will result to the Insured absent action within the 48 hour time period.
Expedited Process for Insured with Terminal Illness
- 1. When a grievance is submitted by an Insured with a terminal illness, or by the Insured's authorized representative on behalf of said Insured, a resolution shall be provided to the Insured or said authorized representative within five business days from the receipt of such grievance.
- 2. If the expedited review process affirms the denial of coverage or treatment to an Insured with a terminal illness, we shall provide the Insured or the Insured's authorized representative, if any, within five business days of the decision:
- a. a statement setting forth the specific medical and scientific reasons for denying coverage or treatment.
- b. a description of alternative treatment, services or supplies covered or provided by the carrier, if any.
- 3. If the expedited review process affirms the denial of coverage or treatment to an Insured with a terminal illness, we shall allow the Insured or the Insured's authorized representative, if any, to request a conference.
- a. The conference shall be scheduled within ten days of receiving a request from an Insured; provided however that the conference shall be held within five business days of the request if the treating Physician determines, after consultation with our medical consultant or his designee, and based on standard medical practice, that the effectiveness of either the proposed treatment, services or supplies or any alternative treatment, services or supplies covered by us, would be materially reduced if not provided at the earliest possible date.
- b. At the conference, we shall permit attendance of the Insured, the authorized representatives of the Insured, if any, or both.
- c. At the conference, the Insured and/or the Insured's authorized representative, if any, and our representative who has authority to determine the disposition of the grievance shall review the information provided to the Insured under 105 CMR 128.310(B).
A grievance not properly acted on by us within the time limits required by 105 CMR 128.300 through 128.310 shall be deemed resolved in favor of the Insured. Time limits include any extensions made by mutual written agreement of the Insured or the Insured's authorized representative, if any, and us.
Coverage or Treatment Pending Resolution of Internal Grievance
If a grievance is filed concerning the termination of ongoing coverage or treatment, the disputed coverage or treatment shall remain in effect at our expense through completion of the internal grievance process regardless of the final internal grievance decision. For the purposes of 105 CMR128.312, ongoing coverage or treatment includes only that medical care that, at the time it was initiated, was authorized by us, unless such care is provided pursuant to 105 CMR 128.309 (2) and does not include medical care that was terminated pursuant to a specific time or episode-related exclusion from the Insured's contract for benefits.
Any Insured or authorized representative of an Insured who is aggrieved by a final adverse determination issued by us may request an external review by filing a request in writing with the Office of Patient Protection within 45 days of the Insured's receipt of written notice of the final adverse determination.
If the external review involves the termination of ongoing services, the Insured may apply to the external review panel to seek the continuation of coverage for the terminated service during the period the review is pending. Any such request must be made before the end of the second business day following receipt of the final adverse determination. The review panel may order the continuation of coverage or treatment where it determines that substantial harm to the Insured's health may result absent such continuation or for such other good cause, as the review panel shall determine. Any such continuation of coverage shall be at The MEGA Life and Health Insurance Company's expense regardless of the final external review determination.
The Department of Public Health, Office of Patient Protection, is available to assist consumers with insurance related problems and questions. An Insured seeking a review is responsible to pay a fee of $25 to the Office of Patient Protection which shall accompany the request for a review. The fee may be waived by the Office of Patient Protection if it determines that the payment of the fee would result in an extreme financial hardship to the Insured.
An Insured or the Insured's authorized representative, if any, may request to have his or her request for review processed as an expedited external review. Any request for an expedited external review shall contain a certification, in writing, from a Physician, that delay in the providing or continuation of health care services that are the subject of a final adverse determination, would pose a serious and immediate threat to the health of the Insured. Upon a finding that a serious and immediate threat to the Insured exists, the Office of Patient Protection shall qualify such request as eligible for an expedited external review.
Requests for review submitted by the Insured or the Insured's authorized representative shall: