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2011-2012
COMMUNITY COLLEGE COLLEGE OF DENVER CONVERSION PLAN
SCHEDULE OF MEDICAL EXPENSE BENEFITS – INJURY AND SICKNESS
UP TO $10,000 MAXIMUM BENEFIT PAID AS SPECIFIED BELOW (FOR EACH INJURY OR SICKNESS)
DEDUCTIBLE $250 (FOR EACH INJURY OR SICKNESS)
The Policy provides benefits for 80% of the Usual and Customary Charges (U&C) incurred by an Insured Person for loss due to a covered injury or Sickness up to the Maximum Benefit of $10,000. Benefits wil be paid up to the Maximum Benefit for each service as scheduled below.
Policy Exception: The age limit for the mandated Cervical Cancer Vaccine is 26.
COVERED MEDICAL EXPENSES INCLUDE:
INPATIENT
Room and Board/Hospital Miscel aneous Expense, daily semi private room rate: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Usual and Customary Charges/
and general nursing care provided by the Hospital. Hospital miscel aneous expenses such as the cost of the operating room, laboratory tests, x-ray examinations, anesthesia drugs (excluding take home drugs) or medicines, therapeutic services, and supplies. In computing the number of days payable under this benefit, the date of admission wil be counted, but not the date of discharge.
Physiotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Paid under Room & Board/Hospital Misc.
Surgeon’s Fees, in accordance with data provided by FAIR Health, Inc. No more than one . . . . . . . . . . . . . . . . . . . . . . . . .Usual and Customary Charges/
surgical procedure wil be covered when multiple procedures are performed through the the same incision or in immediate succession.
(The aggregate maximum payable for Inpatient and Outpatient Surgery is $2,000 Per Policy Year).
Anesthetist, professional services in connection with inpatient surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Paid under Room & Board/Hospital Misc.
Assistant Surgeon’s Fees, payable only when required by the Hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paid under Room & Board/Hospital Misc.
Registered Nurses’ Services, private duty nursing care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paid under Room & Board/Hospital Misc.
Physician’s Visits, benefits are limited to one visit per day and do not apply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Paid under Room & Board/Hospital Misc.
Pre-Admission Testing, payable within 72 hours prior to admission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Paid under Room & Board/Hospital Misc.
Psychotherapy, as mandated by the State of Colorado . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paid as any other Sickness/45 days
Biological y Based Mental Il ness, as mandated by the State of Colorado . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paid as any other Sickness
OUTPATIENT
Surgeon’s Fees, in accordance with data provided by FAIR Health, Inc. No more than one . . . . . . . . . . . . . . . . . . . . . . . . .Usual and Customary Charges/
surgical procedure wil be covered when multiple procedures are performed through the the same incision or in immediate succession.
(The aggregate maximum payable for Inpatient and Outpatient Surgery is $2,000 Per Policy Year).
Day Surgery Miscel aneous, related to scheduled surgery performed in a Hospital, including . . . . . . . . . . . . . . . . . . . . . . Paid under Surgery Benefit
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 Miscel aneous are based on the Outpatient Surgical Facility Charge Index.
Anesthetist, professional services in connection with outpatient surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Paid under Surgery Benefit
Assistant Surgeon’s Fees, payable only when required by the Hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Usual and Customary Charges
Outpatient Miscel aneous Benefit, including benefits designated as Paid under Outpatient Miscel aneous . . . . . . . . . . . . Usual and Customary Charges/
Physician’s Visits, benefits are limited to one visit per day. Benefits for Physician’s Visits . . . . . . . . . . . . . . . . . . . . . . . . . .Paid under Outpatient Miscel aneous
do not apply when related to surgery or physiotherapy.
Physiotherapy, benefits are limited to one visit per day. See exclusion number 18 for . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paid under Outpatient Miscel aneous
Medical Emergency Expenses, use of the emergency room and supplies. Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Paid under Outpatient Miscel aneous
must be rendered within 72 hours from time of injury or first onset of sickness.
Diagnostic X-Ray Services/Laboratory Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paid under Outpatient Miscel aneous
Tests & Procedures, diagnostic services and medical procedures performed by a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paid under Outpatient Miscel aneous
Physician, other than Physician’s visits. Physiotherapy, X-rays and lab procedures.
Prescription Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Usual & Customary Charges/
Biological y Based Mental Il ness, as mandated by the State of Colorado . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paid as any other Sickness
Injections, Chemotherapy, Radiation Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No Benefits
Psychotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .No Benefits
Alcoholism/Drug Abuse, as mandated by the State of Colorado . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paid as any other Sickness
Ambulance Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Paid under Outpatient Miscel aneous
Durable Medical Equipment, a writ en prescription must accompany the claim when . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Paid under Outpatient Miscel aneous
submit ed. Replacement equipment is covered if required because of a change in the insured’s physical condition. (Exception; as mandated for Prosthetic Devices) Maternity/Complications of Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paid as any other Sickness
Consultant Physician’s Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No Benefits
Pre-existing Condition – means any condition for which an Insured Person: 1) incurred charges: 2) received medical treatment: 3) consulted with a health care professional or; 4) took Prescription Drugs within 6 months immediately prior to the Insured’s Effective Date under this policy. “Pre-existing condition” does not include pregnancy.
ELIGIBILITY
All Insured Persons who were insured at least 3 consecutive months under the school’s blanket student insurance plan underwritten by UnitedHealthcare Insurance Company whose coverage has terminated because of loss of eligibility are eligible to enroll in the Plan in accordance with the provisions of the Conversion Privilege endorsement.
Eligible students may also insure their Dependents who have been continuously insured for at least 3 consecutive months. Eligible Dependents are the spouse or domestic partners and unmarried children under 24 years of age, if a full-time dependent student at an accredited institution of higher learning, who are non self-supporting. Dependent Eligibility expires concurrently with that of the insured student.
EFFECTIVE AND TERMINATION DATES
The Master Policy on file becomes effective on August 22, 2011. Coverage becomes effective on that date or the date the enrol ment form and premium are received by the Company (or its authorized representative), whichever is later. The Master Policy terminates on August 19, 2012. Coverage terminates on that date or at the end of the period through which premium is paid, whichever is earlier. Dependent coverage wil not be effective prior to that of the Insured student or extend beyond that of the Inured student. Refunds of premiums are al owed only upon entry into the armed forces. The Policy is a Non-Renewable One Year Term Policy. You must enrol within 14 days of your expiration date under the school’s regular student plan.
ADDITIONAL MANDATED BENEFITS
Benefits are provided a mandated by the State of Colorado such as Benefits for Therapies for Congenital Defects & Birth Abnormalities, Cleft Lip or Cleft Palate, Telemedicine Services, Mammography, Psychotherapy, Hearing Aids for Minor Children, Colorectal Cancer Screenings, Biologically Based Mental Illness, Cervical Cancer Vaccines, Child Health Supervision Services, Prostate Cancer Screening, Hospitalization and General Anesthesia for Dental Procedures for Dependent Children, Treatment of Autism Spectrum Disorder, Diabetes, Prosthetic Devices and Medical Foods. A detail of these benefits may be found in the Master Policy on file at the College.
EXCLUSIONS AND LIMITATIONS
EXCLUSIONS AND LIMITATIONS, Cont’d
No benefits wil be paid for: a) loss or expense caused by, contributed to, or resulting 24. Residential treatment of eating disorders, such as anorexia or bulimia;
from; or b) treatment, services or supplies for, at, or related to: 25. Routine Newborn Infant Care, wel -baby nursery and related Physician charges
1. Acne; Acupuncture;
in excess of 48 hours for vaginal delivery or 96 hours for cesarean delivery. If forty- 2. Addiction, such as nicotine addiction and caffeine addiction; non-chemical addic-
eight hours fol owing a vaginal delivery fal s after 8 p.m., coverage shal continue tion, such as: gambling sexual, spending, shopping, working and religious; code- until 8 a.m. the fol owing morning. If ninety-six hours fol owing the cesarean sec- tion fal s after 8 p.m., coverage shal continue until 8 a.m., the fol owing morning, 3. Autistic disease of childhood, except as specifical y provided in the Benefits for the
26. Routine physical examinations and routine testing; preventive testing or treat-
Treatment of Autism Spectrum Disorders, hyperkinetic syndromes, milieu therapy, ment; screening exams or testing in the absence of Injury or Sickness, except as learning disabilities, behavioral problems, parent-child problems, conceptual hand- icap, developmental delay or disorder or mental retardation,except as specifical y 27. Services provided normal y without charge by the Health Service of the
4. Biofeedback;
Policyholder; or services covered or provided by the student health fee; 5. Circumcision;
28. Skeletal irregularities of one or both jaws, including orthognathia and mandibular
6. Congenital conditions, except as specifical y provided in the policy;
retrognathia; temporomandibular joint dysfunction; nasal and sinus surgery; except 7. Cosmetic procedures, except cosmetic surgery required to correct an Injury for
for treatment of chronic purulent sinusitis; which benefits are otherwise payable under this policy; removal of warts, non- 29. Skydiving, parachuting, hang gliding, glider flying, parasailing, sail planing, bun-
gee jumping, or flight in any kind of aircraft, except while riding as a passenger on 8. Dental treatment;
a regularly scheduled flight of a commercial airline; 9. Elective Surgery or Elective Treatment;
30. Supplies, except a specifical y provided in the policy;
10. Elective abortion;
31. Surgical breast reduction, breast augmentation, breast implants or breast pros-
11. Eye examinations, eye refractions, eyeglasses, contact lenses, prescriptions or fit-
thetic devices, or gynecomastia; except as specifical y provided in the policy; ting or eyeglasses or contact lenses, vision correction surgery, or other treatment for 32. Treatment in a Government hospital, unless there is a legal obligation for the
visual defects and problems; except when due to a disease process; Insured Person to pay for such treatment; 12. Foot care including: flat foot conditions, supportive devices for the foot, subluxa-
33. War or any act of war, declared or undeclared; or while in the armed forces of any
tions of the foot, care of corns, bunions (except capsular or bone surgery), cal uses, country other than the United States (a pro-rate premium wil be refunded upon toenails, fal en arches, weak feet, chronic foot strain, and symptomatic complaints request for such period not covered); and 34. Weight management, weight reduction, nutrition programs, treatment for obesity,
13. Hearing examinations or hearing aids, except as specifical y provided in this poli-
surgery for removal of excess skin or fat, except as specifical y provided in the cy; or other treatment for hearing defects and problems. “Hearing defects” means any physical defect of the ear which does or can impair normal hearing, apart from 14. Hirsutism; alopecia;
15. Immunizations; preventive medicines or vaccines, except where required for treat-
COORDINATION OF BENEFITS:
ment of a covered injury, (accidental exposure is a covered injury); Benefits wil be coordinated with any other group medical, surgical or hospital plan so 16. Injury or Sickness for which benefits are paid or payable under any Workers’
that combined payments under al programs wil not exceed 100% of charges incurred Compensation or Occupational Disease Law or Act. Or similar legislation; 17. Injury sustained while a) participating in any interscholastic, club intercol egiate,
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 CLAIM PROCEDURE:
conditioning program for such sport, contest or competition; In the event of Injury or Sickness, the student should: 18. Organ transplants, including organ donation;
1) Mail to the address below al medical and hospital bil along with the 19. Outpatient Physiotherapy, except as specifical y provided in the policy; or except
patient’s name and insured student’s name, address, Social Security or School ID for a condition that required surgery or Hospital Confinement: 1) within the 30 days number and name of the col ege under which the student is insured. A Company immediately preceding such Physiotherapy; or 2) within the 30 days immediately claim form is not required for filing a claim.
fol owing the at ending Physician’s release for rehabilitation; 2) File claim within 30 days of Injury or first treatment for a Sickness. Bil s should be 20. Participation in a riot or civil disorder; commission of or at empt to commit
received by the company within 90 days of service. Bil s submit ed after one year wil not be considered for payment except in the absence of legal capacity.
21. Pre-existing Conditions, except for: 1) individuals who have been continuously
insured for at least 6 consecutive months under the school’s student insurance policy; or 2) a child that is adopted or placed for adoption before at aining eighteen years of age. The Pre-existing Condition exclusionary period wil be reduced by the total THE PLAN IS UNDERWRITTEN BY:
number of months that the Insured provides documentation of continuous coverage UnitedHealthcare
under prior Creditable Coverage if such Creditable Coverage was continuous to a Insurance Company
date not more than 90 days prior to the Insured’s Effective Date under this policy; 22. Prescription Drugs, services or supplies as fol ows;
a) Therapeutic devices or appliances, including: hypodermic needles, syringes, SUBMIT ALL CLAIMS OR INQUIRIES TO:
support garments and other non-medical substances, regardless of intended use; except as provided under Benefits for Diabetes; AmeriBen
b) Birth control and/or contraceptives, oral or other, whether medication or device, c) Immunization agents, biological sera, blood or blood products administered on d) Drugs Labeled, “Caution – limited by federal law to investigational use” or MASTER POLICY:
f) Drugs used to treat or cure baldness; anabolic steroids used for body building; Please keep this as a general summary of the insurance. The Master Policy on file at the g) Anorectics – drugs used for the purpose of weight control; Col ege contains al of the Provisions, Limitations, Exclusions and Qualifications of your h) Fertility agents or sexual enhancement drugs, such as Parlodel, Pergonal, Clomid, insurance benefits, some of which may not be included in this Brochure. The Master Pol- icy is the contract and wil govern and control payment of benefits.
j) Refil s in excess of the number specified or dispensed after one (1) year of date 23. Reproductive/infertility services including but not limited to: family planning; fer-
tility test; infertility (male or female), including any services or supplies rendered for the purpose or with the intent of inducing conception; premarital examinations; impotence, organic or otherwise; tubal ligation; vasectomy; sexual reassignment surgery; reversal of sterilization procedures; Policy # 2011-200282-5

Source: https://eligibility.eciservices.com/pdf/CCD/CCD_conversion_brochure.pdf

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