2009-2010 Insurance Overview Information

2009-2010 Health Insurance

Benefit Plan Information

Student Medical Plan

The Plan will always pay benefits in accordance with any applicable Missouri Insurance Law(s), including: bone marrow antigen testing, cancer clinical trials, cancer- second opinion diagnosis, colorectal cancer screening, dental care anesthesia & hospitalization, diabetes expenses, early intervention services, immunizations for children, newborn child expenses, newborn hearing screening, prostate screening and reconstruction surgery as a result of mastectomy.

Plan Maximum	$500,000 per Policy Year
Plan Deductible	Preferred Care $350 per Policy Year Non-Preferred Care $700 per Policy Year
Annual Out-of-Pocket Maximum	$10,000 per Policy Year
Student Health Center Coverage	80% for Covered Medical Expenses Deductible waived Referral Required The Insured Student or insured dependent spouse/domestic partner must first seek treatment from the Washington University Student Health Services (SHS) to determine if a referral can be issued before receiving any medical care outside the SHS in order for benefits to be payable for that care. A SHS referral is not necessary under the following conditions only: 1. Treatment of an Emergency Medical Condition. The insured student or insured dependent spouse/domestic partner must return to the SHS for necessary follow-up care and referrals the next business day. 2. When the SHS is closed. 3. Medical care received when the insured student or insured dependent spouse/domestic partner is more than 50 miles from campus. Upon return to the St. Louis area, the insured student or insured dependent spouse/domestic partner must return to the SHS for necessary follow-up care. 4. OB/GYN and maternity care. 5. For care of an insured dependent child.
Inpatient Hospitalization Benefits
	Preferred Care		Non-Preferred Care
Hospital Room and Board Expense	80% of the Negotiated Charge for the semi-private room rate for an overnight stay.		50% of the Reasonable Charge for the semi-private room rate for an overnight stay.
Intensive Care Unit Expense	80% of the Negotiated Charge for an overnight stay.		50% of the Reasonable Charge for an overnight stay.
Miscellaneous Hospital Expense Covered Medical Expenses include, but are not limited to: laboratory tests, x-rays, anesthesia, use of special equipment, medicines (excluding take home drugs) and use of operating room.	80% of the Negotiated Charge.		50% of the Reasonable Charge.
Physician Hospital Visit Expenses (non-surgical services of the Physician or a consulting Physician)	80% of the Negotiated Charge.		50% of the Reasonable Charge.
Surgical Benefits (Inpatient and Outpatient)
	Preferred Care		Non-Preferred Care
Surgical Expense	80% of the Negotiated Charge.		50% of the Reasonable Charge.
Anesthetist Expense & Assistant Surgeon Expense	80% of the Negotiated Charge.		50% of the Reasonable Charge.
Ambulatory Surgical Expense	80% of the Negotiated Charge.		50% of the Reasonable Charge.
Outpatient Benefits
Covered Medical Expenses include, but are not limited to: Physician’s office visits, hospital or out-patient department or emergency room visits, durable medical equipment, physical therapy, clinical lab, radiological facility or other similar facility licensed by the state.
	Preferred Care		Non-Preferred Care
Physician’s Office Visits	80% of the Negotiated Charge.		50% of the Reasonable Charge.
Specialist Expenses	80% of the Negotiated Charge.		50% of the Reasonable Charge.
Emergency Care	80% of the Negotiated Charge.		80% of the Reasonable Charge.
Urgent Care Expense	80% of the Negotiated Charge.		50% of the Reasonable Charge.
X-ray and Laboratory Expense	80% of the Negotiated Charge.		80% of the Reasonable Charge.
Therapy Expense Includes Occupational and Speech Therapy Covered Medical Expenses are payable up to a maximum of $1,000 per Policy Year.	80% of the Negotiated Charge.		50% of the Reasonable Charge.
Chiropractic Expense Covered Medical Expenses are payable up to a maximum of 26 visits per Policy Year.	80% of the Negotiated Charge.		50% of the Reasonable Charge.
Mental Health and Substance Abuse Benefits
	Preferred Care		Non-Preferred Care
Inpatient Expense—Mental Health Includes the charges made for treatment received during partial hospitalization or intensive outpatient in a hospital or treatment facility. Prior review and approval must be obtained on a case-by-case basis. When approved, benefits will be payable in place of an inpatient admission, whereby 2 days of partial hospitalization or intensive outpatient treatment may be exchanged for 1 day of full hospitalization	80% of the Negotiated Charge		50% of the Reasonable Charge.
Outpatient Expense—Mental Health	80% of the Negotiated Charge.		50% of the Reasonable Charge.
Inpatient Expense—Substance Abuse Limited to a maximum of 30 days per Policy Year per condition for any one or related substance abuse condition. Includes the charges made for treatment received during partial hospitalization or intensive outpatient in a hospital or treatment facility. Prior review and approval must be obtained on a case-by-case basis. When approved, benefits will be payable in place of an inpatient admission, whereby 2 days of partial hospitalization or intensive outpatient treatment may be exchanged for 1 day of full hospitalization.	80% of the Negotiated Charge		50% of the Reasonable Charge.
Outpatient Expense—Substance Abuse Maximum of 30 visits per Policy Year for outpatient treatment.	80% of the Negotiated Charge.		50% of the Reasonable Charge.
Maternity Benefits
	Preferred Care		Non-Preferred Care
Maternity Expense	80% of the Negotiated Charge.		50% of the Reasonable Charge.
Additional Benefits
		Preferred Care	Non-Preferred Care
Women’s Health Benefit		Covered Medical Expenses will include one baseline mammogram for women between the ages of 35 and 40. Women age 40 and older have coverage for an annual mammogram per Policy Year. Covered Medical Expenses are payable on the same basis as any X-ray expense. Covered Medical Expenses include an annual Pap Smear screening for women age 18 and older. Covered Medical Expenses are payable on the same basis as any outpatient expense. If follow-up diagnostic Pap Smears are medically necessary, they will be covered on the same basis as any outpatient expense.
Dental Expense		80% of the Negotiated Charge to a maximum of $100 per tooth per Accident for the treatment of an Injury to sound, natural teeth or for the removal of impacted wisdom teeth.	50% of the Reasonable Charge to a maximum of $100 per tooth per Accident for the treatment of an Injury to sound, natural teeth or for the removal of impacted wisdom teeth.
Ambulance Expense Covered Medical Expenses are for the services of a professional ambulance to or from a hospital when required due to the emergency nature of a covered Accident or Sickness		80% of the Reasonable Charge.

Alternate Student Medical Plan

Plan Maximum	$500,000 per Policy Year
Plan Deductible	Preferred Care $250 per Policy Year Non-Preferred Care $500 per Policy Year
Annual Out-of-Pocket Maximum	$5,000 per Policy Year
Student Health Center Coverage	80% for Covered Medical Expenses Deductible waived Referral Required The Insured Student or insured dependent spouse/domestic partner must first seek treatment from the Washington University Student Health Services (SHS) to determine if a referral can be issued before receiving any medical care outside the SHS in order for benefits to be payable for that care. A SHS referral is not necessary under the following conditions only: 1. Treatment of an Emergency Medical Condition. The insured student or insured dependent spouse/domestic partner must return to the SHS for necessary follow-up care and referrals the next business day. 2. When the SHS is closed. 3. Medical care received when the insured student or insured dependent spouse/domestic partner is more than 50 miles from campus. Upon return to the St. Louis area, the insured student or insured dependent spouse/domestic partner must return to the SHS for necessary follow-up care. 4. OB/GYN and maternity care. 5. For care of an insured dependent child.
Inpatient Hospitalization Benefits
	Preferred Care		Non-Preferred Care
Hospital Room and Board Expense	80% of the Negotiated Charge for the semi-private room rate for an overnight stay.		50% of the Reasonable Charge for the semi-private room rate for an overnight stay.
Intensive Care Unit Expense	80% of the Negotiated Charge for an overnight stay.		50% of the Reasonable Charge for an overnight stay.
Miscellaneous Hospital Expense Covered Medical Expenses include, but are not limited to: laboratory tests, x-rays, anesthesia, use of special equipment, medicines (excluding take home drugs) and use of operating room.	80% of the Negotiated Charge.		50% of the Reasonable Charge.
Physician Hospital Visit Expenses (non-surgical services of the Physician or a consulting Physician)	80% of the Negotiated Charge.		50% of the Reasonable Charge.
Surgical Benefits (Inpatient and Outpatient)
	Preferred Care		Non-Preferred Care
Surgical Expense	80% of the Negotiated Charge.		50% of the Reasonable Charge.
Anesthetist Expense & Assistant Surgeon Expense	80% of the Negotiated Charge.		50% of the Reasonable Charge.
Ambulatory Surgical Expense	80% of the Negotiated Charge.		50% of the Reasonable Charge.
Outpatient Benefits
Covered Medical Expenses include, but are not limited to: Physician’s office visits, hospital or out-patient department or emergency room visits, durable medical equipment, physical therapy, clinical lab, radiological facility or other similar facility licensed by the state.
	Preferred Care		Non-Preferred Care
Physician’s Office Visits	80% of the Negotiated Charge.		50% of the Reasonable Charge.
Specialist Expenses	80% of the Negotiated Charge.		50% of the Reasonable Charge.
Emergency Care	80% of the Negotiated Charge.		80% of the Reasonable Charge.
Urgent Care Expense	80% of the Negotiated Charge.		50% of the Reasonable Charge.
X-ray and Laboratory Expense	80% of the Negotiated Charge.		80% of the Reasonable Charge.
Therapy Expense Includes Occupational and Speech Therapy Covered Medical Expenses are payable up to a maximum of $1,000 per Policy Year.	80% of the Negotiated Charge.		50% of the Reasonable Charge.
Chiropractic Expense Covered Medical Expenses are payable up to a maximum of 26 visits per Policy Year.	80% of the Negotiated Charge.		50% of the Reasonable Charge.
Mental Health and Substance Abuse Benefits
	Preferred Care		Non-Preferred Care
Inpatient Expense—Mental Health Includes the charges made for treatment received during partial hospitalization or intensive outpatient in a hospital or treatment facility. Prior review and approval must be obtained on a case-by-case basis. When approved, benefits will be payable in place of an inpatient admission, whereby 2 days of partial hospitalization or intensive outpatient treatment may be exchanged for 1 day of full hospitalization	80% of the Negotiated Charge		50% of the Reasonable Charge.
Outpatient Expense—Mental Health	80% of the Negotiated Charge.		50% of the Reasonable Charge.
Inpatient Expense—Substance Abuse Limited to a maximum of 30 days per Policy Year per condition for any one or related substance abuse condition. Includes the charges made for treatment received during partial hospitalization or intensive outpatient in a hospital or treatment facility. Prior review and approval must be obtained on a case-by-case basis. When approved, benefits will be payable in place of an inpatient admission, whereby 2 days of partial hospitalization or intensive outpatient treatment may be exchanged for 1 day of full hospitalization.	80% of the Negotiated Charge		50% of the Reasonable Charge.
Outpatient Expense—Substance Abuse Maximum of 30 visits per Policy Year for outpatient treatment.	80% of the Negotiated Charge.		50% of the Reasonable Charge.
Maternity Benefits
	Preferred Care		Non-Preferred Care
Maternity Expense	80% of the Negotiated Charge.		50% of the Reasonable Charge.
Additional Benefits
		Preferred Care	Non-Preferred Care
Women’s Health Benefit		Covered Medical Expenses will include one baseline mammogram for women between the ages of 35 and 40. Women age 40 and older have coverage for an annual mammogram per Policy Year. Covered Medical Expenses are payable on the same basis as any X-ray expense. Covered Medical Expenses include an annual Pap Smear screening for women age 18 and older. Covered Medical Expenses are payable on the same basis as any outpatient expense. If follow-up diagnostic Pap Smears are medically necessary, they will be covered on the same basis as any outpatient expense.
Dental Expense		80% of the Negotiated Charge to a maximum of $100 per tooth per Accident for the treatment of an Injury to sound, natural teeth or for the removal of impacted wisdom teeth.	50% of the Reasonable Charge to a maximum of $100 per tooth per Accident for the treatment of an Injury to sound, natural teeth or for the removal of impacted wisdom teeth.
Ambulance Expense Covered Medical Expenses are for the services of a professional ambulance to or from a hospital when required due to the emergency nature of a covered Accident or Sickness		80% of the Reasonable Charge.

Exclusions: Please review the information at shs.wustl.edu or aetnastudenthealth.com for a complete list of exclusions on the plan.

Vital Savings by Aetna ® :

The Vital Savings Discount program is included for those enrolled in the medical plan.

The availability of the Vital Savings Discount plan will be included in the pamphlet that is mailed to students, and will be included on the Aetna Student Health/Washington University in St. Louis web page.

The Vital Savings by Aetna ® program (the “Program”) is not insurance. The Program provides Members with access to discounted fees pursuant to schedules negotiated by Aetna Life Insurance Company for the Vital Savings by Aetna ® discount program. The Program does not make payments directly to the providers participating in the Program. Each Member is obligated to pay for all services or products but will receive a discount from the providers who have contracted with the Discount Medical Plan Organization to participate in the Program. Aetna Life Insurance Company, 151 Farmington Avenue, Hartford, CT 06156, 1-877-698-4825, is the Discount Medical Plan Organization .

***Advantage TM Dental* - Insured Dental Plan*** :

Washington University in St. Louis will offer Advantage Dental plan as an option for students to purchase on a voluntary basis.

The availability of the Aetna Advantage Dental plan will be included in the pamphlet that is mailed to students, and will be included on the Aetna Student Health/ Washington University in St. Louis web page. This plan can be purchased only during the open enrollment period.

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