DESIGN AND PURPOSE

Identification cards can be obtained from the Northwestern University Health Service offices on the Chicago and Evanston campuses.

Coverage is available for dependents of students on special application. A brochure describing coverage for dependents is available at the Health Service office on either campus.

BENEFITS

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 practitioners in the Chicago metropolitan area. The Plan functions like an HMO in that approval for outpatient service is provided by Health Service practitioners on the Evanston and Chicago campuses. The Plan is designed to provide coverage to students while in the Chicago area. This means that the Plan provides coverage for non-emergency services in the Chicago area only, upon referral from a Health Service practitioner to 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 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.

Eligible Inpatient 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 prescribed by a physician and incurred in an HFN Network hospital.

For inpatient medical expenses incurred at a non-HFN Network facility a deductible of $500 per confinement will apply. A10% patient co-payment with an annual maximum patient out-of-pocket of $500 will also apply. When emergency care is required in a life-threatening situation, the $500 deductible will be waived (however the 10% co-pay will still apply). The deductible is waived for hospital care received outside the United States.

The Plan will pay Hospital Room and Board charges (not to exceed the cost of a semi-private room) except where there are specific dollar limitations such as for Mental and Nervous Conditions and for Newborn Expenses that are specifically referred to elsewhere in this web page.

Eligible Outpatient Expenses: Outpatient expenses will be covered only if they result from a direct referral to an HFN facility by a Health Service practitioner and the referral is made prior to delivery of the outpatient service. Under these circumstances the student will incur a $20 co-payment per visit. If outpatient services are delivered by a non-HFN facility or without a Health Service Physician referral, a $500 deductible for each injury or illness will apply in addition to the $20 co-payment for each visit.

Outpatient services covered include but are not limited to: surgery performed on an outpatient basis, referral to a medical specialist for diagnosis or treatment, physical therapy and medically necessary laboratory or diagnostic tests including those performed at the Health Service. No co-payment is required for laboratory or diagnostic tests performed at the Health Service.

Outpatient surgery pursuant to a referral from Health Service is covered. Pre-operative lab tests are provided by the Health Service and are not covered if done elsewhere. Follow-up care after surgery is only covered when provided by the Health Service or if a referral for such care is made by the Health Service.

Outpatient services, including outpatient surgery, incurred when a covered individual is away from the University and the Health Service practitioner cannot be consulted for care, will be covered only for medical emergencies as listed under the following category of "Eligible Hospital Emergency Expenses." Expenses for any other outpatient services will not be paid under the Plan.

Eligible Hospital 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 a hospital emergency room for any "life threatening" occurrence or when referral to the emergency room is made by the Health Service. Health Service emergency room referrals must be obtained prior to treatment at the emergency room either by visiting the Health Service or by contacting the 24-hour emergency phone [847] 491-8100 for Evanston, [312] 695-8134 (business hours) or [312] 695-8161 (after hours) for Chicago. A $500 deductible will apply to medical charges that are incurred in a hospital emergency room for other than life threatening medical emergency care or without Health Service referral. Life threatening medical emergency means a severe condition whose symptoms occur suddenly and which requires 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 accident, broken bones or severe laceration, any of which are determined to be life-threatening medical emergencies by broadly accepted medical standards.

Prescription Drugs: Prescription drugs are covered under the Plan. Co-payments are $15 for a 30-day supply of a generic prescription drug, $30 for a 30-day supply of a non-generic prescription drug (even if a genetic drug is not available). 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.

Evanston Campus:
Students should fill prescriptions at the pharmacy located in the Health Service on the Evanston campus and pay the co-payment at the time of delivery. If the pharmacy is closed and a student must urgently fill a prescription elsewhere, the student must file a written claim for reimbursement, less the applicable co-payment, with the Insurance Office located in the Health Service facility on the Evanston Campus.

Chicago Campus:
Prescriptions costing up to $500 for a 30-day supply may be filled at any local pharmacy. Students must then file a written claim for reimbursement, less the applicable co-payment, with the Insurance Office located in the Health Service facility on the Evanston Campus. Prescriptions costing $500 or more for a 30-day supply must be filled at the Evanston campus Health Service Pharmacy where the student will pay the co-payment at the time of delivery.

The following conditions also apply to both campuses:

• All other specific conditions of the Plan including the listed exclusions apply to the prescription drug benefit.
  
• The maximum allowable supply of any prescription is for a period of one month per $15 co-payment for a generic prescription drug and $30 for a non-generic prescription drug.
  

Eligible Dental Expenses: This Plan is not designed to cover dental care; however, some accidental injury benefits are provided. In the event of accidental injury to sound natural teeth while coverage is in effect, the Plan will pay usual and customary expenses for necessary restoration, when prescribed by a doctor or dentist, of up to $200 per tooth.

Eligible Psychological Services Benefits: The Plan will cover usual and customary in-hospital expenses, up to a maximum of $25,000, for mental and nervous conditions first manifested during the Plan period (9/1/2003 - 8/31/2004). The Plan will also pay for up to twenty-four outpatient visits, when a referral for such care is made by Counseling and Psychological Services. 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. Upon satisfaction of the patient co-payment the Plan will pay 100% of usual and customary expenses, while hospital-confined in an HFN member facility. Coverage includes preferred provider physician's fees and fees for a certified nurse midwife whose services are under supervision of a physician. The initial visit that confirms conception is only covered by the Plan if conducted at the Health Service. The Plan will pay for all physician required laboratory tests and for one ultrasound test if required by the physician.

Additional ultrasound tests will be covered only with the advance approval of a Health Service physician. A $500 deductible will apply if either a non-HFN physician or hospital is used. A list of preferred provider physicians and hospitals is available at the Health Service on either campus. Each required physician's office visit or laboratory test will be subject to a $20 co-payment by the covered student. The $500 deductible will be waived in the event of a medical emergency or where medical services are provided in a location outside of the preferred provider (HFN, Inc.) service area in the United States or elsewhere worldwide. Postpartum care is not covered under the Plan.

Eligible Newborn Expenses: To effect coverage from birth for a newborn under this Plan, a dependent coverage application must be completed at the Insurance Office of the Health Service on either campus within 30 days following birth. The maximum hospital expense benefit payable for a newborn is $100,000 during the plan period (9/1/2003 - 8/31/2004). Covered expenses include hospital charges, physician charges and necessary laboratory or diagnostic tests incurred during the hospital confinement immediately following birth. A $500 deductible per occurrence or confinement will apply where an HFN member hospital is not used.

EXCLUSIONS

1. Any treatment or service resulting from a sickness or accident which is covered by Workers' Compensation, Occupational Disease Law or similar legislation.
2. All dental care and treatment including surgical extraction of wisdom teeth, treatment of "TMJ" problems, treatment of the gums and tissues of the mouth and treatment of the supporting structures of the teeth, except as specified under Eligible Dental Expenses above.
3. Any treatment or service that is compensated for or furnished by the United States Government or any of its agencies.
4. Charges incurred as a result of war or any act of war, declared or undeclared, a riot or civil disorder or any other outpatient service, including diagnostic services.
5. Any treatment or service resulting from traveling as a passenger in any aircraft, except as a passenger on a scheduled commercial airline.
6. 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.
7. Expenses incurred as a result of the practice or play of intercollegiate athletics.
8. Charges incurred due to the use of illegal drugs, a self-inflicted injury, or resulting from participation in a felony.
9. Charges which exceed "Usual and Customary".
10. Charges for services that are not medically necessary.
11. Routine visits to the doctors office, including physical examinations.
12. Vision care, eyeglasses, contact lenses and the examination to determine the refractive state of the eye.
13. Treatment of flat foot conditions, prescription of supportive devices for such conditions, routine foot care or corrective shoes.
14. Treatment of infertility including therapeutic injections, fertility and other drugs, surgery, artificial insemination, in-vitro fertilization and all other forms of assisted reproductive technologies.
15. Elective surgery and medical treatment including all cosmetic procedures and elective sterilization.
16. Podiatric and chiropractic services.
17. Immunization, vaccines and titre tests

COORDINATION OF BENEFITS

ELIGIBILITY AND FEES

Students covered in the Plan who complete their studies or leave the University for other reasons may cancel coverage in the Plan by completing a request for cancellation form that is available at the Insurance Office at the Health Service on either campus. Refunds for cancellation are based on the number of quarters remaining in the Plan year after the quarter in which a refund is requested.

The cost and period covered for 2003 - 2004 Plan year are based on the quarter of entry as shown below. Students who register for classes anytime during a quarter will receive coverage retroactive to the first date of the entering quarter and must pay a fee for the entire quarter.

Part-time, half-time and School of Continuing Studies students, and students from Garrett-Evangelical Seminary and Seabury Western Seminary must also pay the Health Clinic use fee each quarter in order to be eligible for the Student Hospitalization Plan. The Clinic fee for the 2003/2004 Plan year is $104.00 per quarter. All full-time students enrolled in the plan and not registered for a quarter of classes must also pay the Health Clinic use fee that will enable the student to use the Health Service, including outpatient referrals.

The above-stated open enrollment dates are the only times that a student may enroll in the Plan unless the student can provide proof of expiration of coverage in another health plan. The annual cost for part-time students age 22 and under is $1,397.00. If the part-time student is over 22 years of age, the annual cost is $1,860.00. These costs are in addition to the required clinic use fee.

* Other students include students not registered for classes but who are completing dissertations and students on an authorized leave of absence. They can apply for this Plan only with a letter from their department verifying such status.

CLAIM FILING PROCEDURES

1. 1. As soon as an eligible medical expense is incurred for which this Plan provides benefits, it becomes the student's responsibility to make sure that the provider submits their bill to HFN. Each bill must show: (a) name of patient, (b) date and charge for each service rendered, and (c) the illness or injury for each item of expense.
   
   
2. Students must present their Student Insurance Identification Card to the hospital or to the provider to whom the student has been referred so that a copy of the card can be made to facilitate confirmation of coverage and billing.
   
   
3. Claims filed for prescription reimbursement must include the student's name, address and social security number, the name of the prescribing physician, the name of the medication prescribed and the cost of the prescription. THE CASH REGISTER RECEIPT ALONE IS NOT SUFFICIENT DOCUMENTATION FOR PRESCRIPTION REIMBURSEMENT.

TUITION CREDIT

MEDICAL EVACUATION AND REPATRIATION

Plan Number: 09012003
Administered By:
Office of Risk Management
2020 Ridge Avenue, Suite 240, Evanston, IL 60208-4335
For Coverage Period 9/1/2003 - 8/31/2004