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This
web page summarizes the important features of the Student Hospitalization
Dependent Plan. We suggest you read it carefully so that you will be acquainted
with the benefits should illness or injury occur. A more detailed description
of the benefits is contained in the Plan Document, which will govern the
operation of the Plan and which is available at the Office of Risk Management
for inspection. Identification cards will be mailed to the enrolled dependent
upon completion of the application process.
The
Plan will pay up to a maximum of $250,000 in expenses associated with
any illness or accidental injury occurring during the term of coverage
(9/1/2003 - 8/31/2004). Included in this coverage limit are expenses arising
from any illness or accidental injury having its inception within the
term of coverage but which are incurred during the twelve months immediately
following expiration of the policy term.
The
Student Hospitalization Plan utilizes hospital and physician discounts
that have been negotiated by HFN, Inc., a preferred provider organization
(PPO). Both Evanston Northwestern Healthcare and Northwestern Memorial
Hospital are members of the HFN network as are other hospitals and physicians
in the Chicago metropolitan area. The Plan is designed to provide coverage
to dependents while in the Chicago area. This means that the Plan provides
coverage for non-emergency services in the Chicago area only at an HFN
member physician or hospital. Services obtained from non-HFN providers
will be subject to a $500 deductible for each illness or injury plus a
$20 co-payment per visit (A complete listing of HFN member physicians
and hospitals is located at www.hfninc.com).
Non-emergency care provided outside the Chicago area will also be subject
to a $500 deductible for each illness or injury. Emergency medical care
is covered by the Plan at 100% no matter where the emergency occurs. This
program of hospital benefits is intended to provide assistance to enrolled
students and their dependents at Northwestern University. It is intended
to provide protection worldwide, 24 hours per day.
The
Plan term starts September 1, 2003 and expires on August 31, 2004. Dependents
may be enrolled in the Plan at the beginning of the Plan term or at open
enrollment periods at the beginning of each academic quarter. For details
as to the dates of open enrollment for dependents, please contact the
Health Service in Chicago or Evanston. Please note that, unlike enrolled
students who elect coverage and who then will be automatically billed
for coverage throughout their academic career at Northwestern University,
dependent coverage must be applied for at the beginning of each
academic year in order for coverage to be continuous from year to year.
If a student elects to pay for dependent coverage on a quarterly basis,
payment must be made by the last day of open enrollment for the quarter.
Except for newborns, no dependent may be enrolled
in the Plan after the open enrollment period. Also, in order
to be eligible for dependent coverage, it is required that all dependents
reside with the student covered in the Plan.
Dependent coverage may be canceled at any time during the term of the
Plan, however, refunds for cancellation are based on the number of quarters
remaining in the plan term after the quarter in which cancellation of
coverage is requested. Refunds can only be made on a quarterly basis.
The costs of coverage for each dependent for the 2003 - 2004 Plan year
are as follows:
|
Quarter
of Enrollment
|
Cost
for Partner / Each Child
|
Dates
of Open Enrollment
|
|
Fall
|
$4,260
|
9/1/2003 - 10/1/2003
|
|
Winter
|
$3,195
|
12/15/2003 - 1/30/2004
|
|
Spring
|
$2,130
|
3/15/2004 - 4/9/2004
|
|
Summer
|
$1,065
|
6/7/2004 - 7/2/2004
|
Because
the sole purpose of health coverage is to help meet actual hospital and
medical expenses, nearly all group health plans contain a "coordination
of benefits" provision. This means that any two group plans in force
will be coordinated to pay no more than 100% of the covered expenses. This
plan is secondary to all other group plans. In the interest of controlling
costs, no one can be permitted to actually profit from an illness or accident.
Subrogation: Claims filed under this Plan for medical expenses resulting
from an injury or sickness due to the act of a third party, Northwestern
University will be subrogated to any legal claim the injured insured may
have against the third party. "Subrogation" means Northwestern
University has the right to act in place of the insured or the insured's
dependent to make a lawful claim or demand against the third party. If subrogation
conflicts with the laws of the State or governing jurisdiction, it shall
not be enforced, and the Right of Reimbursement shall not apply.
Right of Reimbursement: If you have received benefit payments from
this Plan for injury or sickness, and subsequently obtain a settlement from
or a judgment against a third party payor who, because of circumstances,
is liable for your health care costs, you are liable to reimburse the Plan.
The amount of reimbursement shall be equal to the benefit payment received
under this Plan or the amount recovered, whichever is less.
Eligible In-Patient Hospital Expenses: Inpatient hospital expenses
are subject to a 10% patient co-payment with an annual maximum patient
out-of-pocket of $500. Upon satisfaction of the patient co-payment, the
Plan will pay 100% of the usual and customary in-hospital expenses when
incurred in an HFN Network hospital. The Plan will pay up to $250,000
in expenses associated with any illness or accidental injury. Covered
expenses include: hospital room and board, ancillary hospital expenses,
including diagnostic tests and operating room and intensive care services
while confined in a preferred provider hospital; fees for preferred provider
physician's in-hospital visits; consultant's charges when prescribed by
the attending physician; and surgery and anesthesia; if these expenses
are incurred in an HFN Network hospital. For medical expenses (hospital,
physician, etc.) not incurred at an HFN Network facility a deductible
of $500 per confinement will apply. The deductible will be waived
if a preferred provider (physician or hospital) is not readily available
in a medical emergency or if the services are provided in a location outside
of the HFN Network area. A current listing of preferred provider physicians
and hospitals is available at the HFN
Website.
- Hospital
Hospital Room and Board charges (not to exceed the cost of a semi-private room) except for
specific dollar limitations. Benefits payable for Mental and Nervous Conditions and Newborn
Expenses are specifically referred to elsewhere in this web page.
-
Ancillary hospital expenses, including diagnostic tests and the operating
room while confined to the hospital.
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Intensive care services while confined to the hospital.
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Doctor's visits to you in the hospital.
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Consultant's charges when required by the attending physician.
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Surgery and Anesthesia.
Eligible Out-Patient Expenses: Outpatient expenses will be covered
only if they are provided by an HFN facility. Under these circumstances
the patient will incur a $20 co-payment per visit. If outpatient services
are delivered by a non-HFN facility a $500 deductible for each injury or
illness will apply in addition to the $20 co-payment for each visit. Outpatient
services covered include: surgery performed on an outpatient basis, referral
to a medical specialist for diagnosis or treatment, physical therapy and
medically necessary laboratory or diagnostic tests.
Surgical and orthopedic follow-up care including physical therapy: For
these services a $20 co-payment will be required for each visit
Eligible Emergency Expenses: Emergency expenses are subject to a
10% patient co-payment with an annual maximum patient out-of-pocket of $500.
Upon satisfaction of the co-payment the Plan will pay 100% of the expenses
incurred at the hospital emergency room for any "life threatening"
occurrence, including the cost of emergency ambulance service. Medical
charges that are incurred in a hospital emergency room for other than life
threatening medical emergency care will not be covered. Life threatening
medical emergency means a severe condition whose symptoms occur suddenly
and which require immediate medical care to prevent death or serious impairment
to health at the most accessible facility equipped to furnish such
care. Examples of medical emergencies include, but are not limited to: suspected
poisoning, acute appendicitis, heat prostration, convulsions, physical trauma
resulting from vehicular or other accident, broken bones or severe laceration,
any of which are determined to be life threatening medical emergencies by
broadly accepted medical standards.
Eligible Dental Expenses: This Plan was not designed to cover routine
dental care; however, some benefits are provided. In the event of accidental
injury to sound, natural teeth while covered under this program, this Plan
will pay expenses when prescribed by a doctor or a dentist up to $200 per
tooth.
Eligible Mental and Nervous Conditions Expenses: The Plan will pay a
maximum of $25,000 in the Plan period for expenses, not to exceed usual
and customary in-hospital expenses, for mental and nervous conditions. The
Plan will also pay for up to twenty-four outpatient visits. Outpatient visits
will be subject to a $20 co-payment by the covered student for each such
visit.
Eligible Maternity Expenses: Inpatient maternity hospital expenses are
subject to a 10% patient co-payment with an annual maximum patient out-of-pocket
of $500. The Plan will pay for medical expenses incurred, while hospital-confined
(subject to conditions under Eligible In-Patient Hospital Expenses)
with respect to maternity, provided conception occurs after the covered
individual's effective date of coverage under the Plan. Coverage is also
afforded after 180 days to individuals who are pregnant when enrolling in
the Plan. This includes the preferred provider physician's fees for antepartum
care. Physicians' fees include the fees for a certified nurse midwife whose
services are under the supervision of the preferred provider physician.
The Plan will pay for one ultra sound test. The Plan will pay for any other
laboratory tests that may be required by the physician. Any required
physician's office visits for which a separate charge is made will be subject
to a $20 per visit co-payment by the covered person. The $500 deductible
will be waived in the event of a medical emergency or where medical services
are furnished in any location outside the preferred provider (HFN) service
area.
Eligible Newborn Expenses: Prescription drugs are covered under the
Plan. Co-payments are 50% for a 30-day supply of a prescription drug. The
Plan pays only the cost of drugs prescribed to treat illnesses and medical
conditions covered under the terms of the policy. Examples of conditions
whose drugs are not covered include but are not limited to: travel, birth
control, immunizations, nail fungal infection, cosmetics, fertility, smoking
cessation and sexual dysfunction.
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Any treatment or service resulting from a sickness or accident which
is covered by Workers' Compensation, Occupational Disease Law or similar
legislation.
- Routine
dental care, treatment to the teeth or gums or the supporting structures
of the teeth.
-
Any treatment or service that is compensated for or furnished by the
United States Government or any of its agencies.
- Charges
incurred as a result of war or any act of war, declared or undeclared,
a riot or civil disorder.
- Any
treatment or service resulting from flying, except as a passenger on
a scheduled commercial airline.
- Routine
health examinations, eye examinations or the fitting of glasses or lenses.
- Cosmetic
or any other optional surgery or medical treatment unless required in
connection with an accidental injury occurring after the effective date
of coverage in the Plan.
- Expenses
incurred as a result of the practice or play of intercollegiate athletics.
- Charges
incurred due to the use of illegal drugs, a self-inflicted injury, or
resulting from participation in a felony.
- Charges
that exceed "Usual and Customary".
- Charges
for services that are not medically necessary.
- Routine
visits to the doctor's office, including physical examinations, premarital
or pre-employment examinations.
- Treatment
or services provided by a member of the immediate family.
- Treatment
of infertility including therapeutic injections, fertility and other
drugs, surgery, artificial insemination, in-vitro fertilization and
all other forms of assisted reproductive technologies.
- Elective
surgery and medical treatment including all cosmetic procedures and
elective sterilization.
- Podiatric
and chiropractic services.
- Immunization,
vaccines and titre tests.
- Vitamins,
and nutritional supplements.
Have
the treating physician or hospital submit their standard insurance billing
to:
Insurance
Office
Health Service
633 Emerson Street
Evanston, IL 60208
NOTE: To assist in coordination of benefits with other applicable
coverages, claim forms should be obtained, completed, and filed for other
group coverage. A copy of the "Explanation of Benefits" from the
other insurance coverage together with a copy of all itemized bills and
a completed Northwestern University Student Hospitalization claim form should
be submitted to the Insurance Office of the Health Service. This will enable
bills to be paid promptly and thus avoid repeat billings from health care
providers.
The
Plan will cover up to $15,000 in expenses when, as a direct result of a
covered illness or accident, a covered dependent requires evacuation to
the nearest appropriate medical facility, subject to the prior approval
of the Director of the Health Service.
REPATRIATION
In the event of the death of a covered dependent while traveling outside
of their home country, the Plan will pay up to $15,000 in actual expenses
incurred for the transportation of the remains back to their home country.
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