Microsoft word - shbp -- plan document _2007-08 draft 1.5 10-3-07_.doc
PLAN DOCUMENT STUDENT HEALTH BENEFITS PLAN (SHBP) EFFECTIVE DATE: SEPTEMBER 1, 2007 For the most current information regarding the SHBP, notices, and general information, students should refer to the Student Health Program web site: www.ptsem.edu/current/healthresources/ TABLE OF CONTENTS Section Page(s) Schedule of Medical Benefits.1-5 Schedule of Prescription Drug Benefits . 6 Introduction . 7 Eligibility and Participation.7-9 Extension of Benefits Due to Total Disability. 10 Medical Benefits General
Princeton Area In-Network Benefits .10-11
Aggregate Plan Year Deductible (Out-of-Network Care Only) . 11
Copayments. 11 Coinsurance.11-12 Out-of-Pocket
Prescription Drug Benefits
Special Provisions .24-26 Coordination of Benefits .26-27 Subrogation .27-29 Other Important Plan Provisions .29-30 Claim Procedures .30-31 Appeals.31-32 Definitions .32-39 Name and Address of the Plan Administrator . 39 Name and Address of the Claims Administrator . 40
SCHEDULE OF SHBP MEDICAL BENEFITS This schedule applies to medical benefits only. There is a separate benefit schedule for prescrip- tion drugs. To locate In-Network Providers visit the Student Health Program web site at www.ptsem/current/healthresources/. Coinsurance Amount Benefit Description (What the SHBP Pays) In-Network Princeton Area Princeton Area
• Princeton HealthCare Trinity Counseling Beech Street Out-of-Network Comments Aggregate Plan Year Deductible There is no deductible for in-network care. If a Copayment is not specified for a specific service, the plan provides benefits at 80% of the Preferred Al-lowance.Plan Year Out-of- Pocket Maximum
maximums are combined for all categories of coverage. Medical Services Coinsurance Amount Benefit Description (What the SHBP Pays) In-Network Princeton Area Princeton Area
• Princeton HealthCare Trinity Counseling Beech Street Network* Comments
$100 Copayment per surgical procedures
charges, and ancillary services for labora-tory and X-ray.
Allowance for all other In-Network
Street providers may be cov-ered under the Medical Office
no greater reimbursement for urgent care services.
Coinsurance Amount Benefit Description (What the SHBP Pays) In-Network Princeton Area Princeton Area
• Princeton HealthCare Trinity Counseling Beech Street Network* Comments
$300 per hospital admission Copayment
for In-Network care (not subject to visit copayment)
nancy benefits are pro-vided on the same basis
as any other Sickness or temporary
$15 Copayment if the Pediatric Visit
for Adults -- Refer to Special Provisions
Deductible, the combined maximum benefit for Health
the Special Provisions of the Plan Document is $200 per Plan Year. Coinsurance Amount Benefit Description (What the SHBP Pays) In-Network Princeton Area Princeton Area
• Princeton HealthCare Trinity Counseling Beech Street Network* Comments Mental/Nervous and
Benefits are provided on the same basis as any other SicknessSubstance Abuse
for Biologically-Based Mental Sickness.
Treatment Services Inpatient – other
partial hospital and intensive outpatient programs of 3 to 6
$300 per hospital admission Copayment
treatment for eating disorders. Participation in intensive outpatient programs may follow or be in place of inpa-tient treatment and does not reduce the 24-visit annual counseling limit for Other Mental Health and Alcohol Substance Abuse care.
Outpatient– other
$100 Copayment for the first visit and
Princeton area include Trinity Counseling Service and the
$20 Copayment for each visit thereafter. .
rection are $10 per visit for services at the
Provider’s Office and $15 per visit if
Spiritual Direction
not reduce the 24 visit maxi-mum for Outpatient services
Group benefits are adminis-tered internally by Princeton
Coinsurance Amount Benefit Description (What the SHBP Pays) In-Network Princeton Area Princeton Area
• Princeton HealthCare Trinity Counseling Beech Street Network* Comments
$200 Copayment for scans and imaging
up to six visits for Bereave-ment Counseling
Benefit Maximums
*In-Network benefits are reduced by the amount of any Out-of-Network benefits that are utilized. Student Health Benefits Plan (SHBP)
SCHEDULE OF PRESCRIPTION DRUG BENEFITS Copayments Benefit Description (What You Pay) In-Network MEDCO Participating Phar- Pharmacies that do not participate with Comments
ments The Prescription Drug Copayments do not apply to the Out-of-Pocket Maximum or the Deducti- ble under the Schedule of Medical Benefits. For more information about your prescription drug benefits, refer to the Section entitled Prescrip- tion Drug Benefitsin thisPlan Document. INTRODUCTION Princeton Theological Seminary has prepared this document to help you understand your medical and prescription drug benefits. Please read it carefully. Your benefits are affected by certain limitations and conditions designed to encourage you to be a wise consumer of health services and to use only those ser- vices you need. Also, benefits are not provided for certain kinds of treatments or services, even if such services are Medically Necessary and your Physician or other Health Care Provider recommends them. As used in this document, the word year refers to the Plan Year, which is the 12-month period beginning September 1 and ending August 31. Maximums and deductibles accumulate during the Plan Year. The word Lifetime as used in this document refers to the period of time you or your eligible dependents par- ticipate in the SHBP or any other plan sponsored by Princeton Theological Seminary for its students and/or their eligible dependents. The benefits described in this document are effective September 1, 2007. Terms printed in italics are de- fined in the Section of this Plan Document entitled Definitions. ELIGIBILITY AND PARTICIPATION Student Eligibility
You are eligible to participate in the SHBP if you qualify as one of the following: • A full-time or part-time student enrolled at Princeton Theological Seminary if enrollment occurs pur-
suant to the Annual Open Enrollment Period requirements for the SHBP.
• Doctoral Teaching Fellows at Princeton Theological Seminary. • An international student, regardless of degree seeking status or credit hour enrollment, enrolled at
Dependent Eligibility
Your eligible dependents may participate in the SHBP, provided you are also currently enrolled. Eligible dependents include: • Your lawful spouse as defined by applicable state law; • An unmarried children younger than age 19 (or an unmarried child who is a full-time student, through
age 23, and is attending an accredited college or university).
• A Physically or Mentally Disabled Child of any age, provided the disability began before he or she
reached age 19 and while covered under the SHBP. Coverage may continue for as long as the child remains disabled, unmarried and wholly dependent upon you for financial support (in accordance with Internal Revenue Service dependent guidelines). The SHBP may require you at any time to submit a Physician’s statement certifying the child’s Physical or Mental Disability.
For purposes of the SHBP, child means: • A child who, before reaching the age of 18, was either adopted by you or placed in your home for
• A stepchild living in your home; • A foster child if he or she lives with you and is dependent upon you for support and maintenance. • Your natural child, including any child for whom you are required to provide coverage under a court
If you and your spouse are both students, only one of you may cover a dependent child. In addition you may not participate in the SHBP as both a student and as a dependent at the same time. Student Enrollment
You will be billed for the SHBP unless you submit an approved waiver of coverage within the time pre- scribed by Princeton Theological Seminary. To activate your coverage you must complete an enrollment form for the SHBP. Your coverage will become effective as described in the Section of this Plan Docu- ment entitled When Coverage Begins. Dependent Enrollment
You must enroll your eligible dependents within 31 days of when you enroll at Princeton Theological Seminary. If you do not have any eligible dependents at the time of initial enrollment, but acquire eligible dependents at a later date, you must enroll the dependent(s) within 31 days of the date you acquire them. You may also enroll your eligible dependents during the Annual Open Enrollment Period in September of each year. Your coverage will become effective as described in the Section of this Plan Document entitled When Coverage Begins. Your newborn child is automatically covered at birth for 31 days. For coverage to continue beyond 31 days, you must notify the Plan Administrator (i.e., Office of Admissions and Financial Aid at Princeton Theological Seminary) of the birth and pay any required contribution during the 31-day period following the birth. If you fail to do so, coverage will terminate at the end of 31 days following your child’s birth. Submission of claims for maternity expenses do not qualify as notification to the Plan Administrator. The 31 day automatic coverage provision also applies to the adoption of a child. Coverage begins when the adoption process is finalized and the adoption is effective. Late Enrollments
If you waived coverage under the SHBP for yourself or your dependents because you or they had cover- age under an employer-sponsored group health plan, and that coverage ends for any reason other than non-payment of premium, you may enroll yourself and/or your dependents for coverage, provided you do so within 31 days of the date coverage under the other plan ends. If you do not enroll within the 31-day period, you will not be allowed to enroll in this plan until the next Annual Open Enrollment Period.
There is a pro-rated fee schedule for late enrollments. Late enrollments are subject to all limitations, pro- visions and requirements of the SHBP. When Coverage Begins
Your coverage begins on the earlier of September 1 or the date you are required to be at Princeton Theo- logical Seminary for a Seminary-sponsored activity. In no event will your coverage begin prior to August 1. Coverage for your dependents begins the later of the date your coverage begins or the first day a de- pendent is legally acquired, if the dependent is properly enrolled. In the case of a late enrollment, cover- age begins on the date coverage under the other health plan ends. The effective date for Doctoral Teaching Fellows will be the date designated by PTS. The date may be set to provide coverage not more than 60 days prior to the date the Doctoral Teaching Fellow will arrive at PTS. For students and their dependents who first enroll at the Seminary for the summer session, that typically begins on or about July 1, these students and their dependents will be eligible for the SHBP for the re- maining two months of coverage under the Plan Year then effect, subject to payment of the appropriate SHBP costs. When Coverage Ends
Your coverage will end on the earliest of the following dates: • August 31st, if you waive coverage for the next Plan Year or you or your dependents are no longer
• The date your Extension of Benefits Due to Disability expires.
• The first date of class for the spring semester for students who complete their degree requirements or
otherwise withdraw from the Seminary during the fall semester or at the end of the fall semester.
• You may apply for cancellation of your student coverage for the spring semester (prior to the end of
the fall semester coverage period) if you provide evidence that you have attained coverage under an employer-sponsored group health insurance plan that meets all of the Seminary’s requirements for health insurance coverage.
• The date you enter into the armed services of any country. A pro-rated refund of the SHBP cost will
be provided. NO OTHER SHBP COST REFUNDS WILL BE ISSUED.
Coverage for your dependents ends on the earliest of the following dates:
• The date your coverage ends. • The date you cancel your dependent’s coverage. Dependent coverage may be canceled for the spring
semester if the student waives the right for payment of future claims for the dependent.
EXTENSION OF BENEFITS DUE TO TOTAL DISABILITY
If you or your dependent is Totally Disabled on the date coverage ends for the SHBP, SHBP coverage will continue for such Injury or Sickness that is the underlying cause of the Total Disability as long as the disability continues but not to exceed 90 days after the SHBP coverage terminates for you or your de- pendent. The total payments made under the Extension of Benefits Due to Disability will not exceed the Lifetime Maximum Benefit. After the Extension of Benefits Due to Total Disability provision has been exhausted, all benefits under the SHBP will cease, and under no circumstance will further benefits be provided by the SHBP. Extension of Eligibility or Conversion Privilege
Except as specifically provided for the 2005-06 Plan Year, there is no Extension of Eligibility or Conver- sion Privilege under the Student Health Benefits Plan provided by Princeton Theological Seminary. MEDICAL BENEFITS General Requirements
The SHBP imposes some conditions on benefits that are common to many health benefit plans. You will get the most out of the benefit program by understanding the following requirements. • The SHBP provides benefits only for Covered Expenses/Services that are Medically Necessary for the
treatment of a covered Sickness or Injury. Not all Medically Necessary services are covered. For ex-ample, Experimental/Investigational treatments are not covered.
• The SHBP provides benefits only for Covered Expenses/Services that are equal to or less than the
Usual and Customary Charge in the geographic area where services or supplies are provided. Any amounts that exceed the Usual and Customary Charge are not recognized by the SHBP for any pur-pose. In-Network Providers charge for their services to the SHBP at negotiated rates which are con-sidered to be the Usual and Customary Charge for those services. If you use an Out-of-Network pro-vider, you will be responsible for any amounts in excess of the Usual and Customary Charge.
• The SHBP provides benefits only for Covered Expenses/Services rendered by a Physician or other Princeton Area In-Network Benefits
Physicians and other Health Care Providers in the Princeton Area who have contracted with the SHBP to provide specific medical services at negotiated prices or a Preferred Allowance are referred to collectively as In-Network Providers. Outside of the Princeton Area, the SHBP has contracted with the managed care network identified in the Schedule of Medical Benefits to provide In-Network services. In-NetworkProviders accept the Preferred Allowance as full payment for Covered Expenses/Services. You identify your eligibility for Preferred Allowance charges by showing your Identification Card to the Provider when you register.
You should be aware that In-NetworkHospitals may be staffed with Physicians and other professional staff who are not in In-Network Providers. Unless specified otherwise, the charges of the providers who are out-of-network will not be paid at the In-NetworkProvider level of benefits. To locate In-NetworkProviders refer to the contacts information on the Table of Contents for this Plan Document or the Student Health Program web site at www.ptsem/current/healthresources/.
In-Network Benefits Outside of the Princeton Area
The SHBP provides coverage when you receive medical care outside of the Princeton Area from an In- Network Provider. Generally, the percentage of charges that the SHBP pays is the same as for Princeton Area In-Network benefits. The SHBP does not provide all of the benefits specified in the Schedule for SHBP Medical Benefits for In-Network Providers in the Princeton Area when you receive these same services away from the Princeton Area, regardless of your use of an In-Network Provider.
Out-of-Network Benefits
You may choose to use a Physician or other Health Care Provider that is not an In-Network Provider. This decision may increase your out-of-pocket costs because of lower coverage levels or charges that ex- ceed the Usual and Customary Charge allowance. The lack of available In-Network Provider in a specific geographic may not be used as the basis for an appeal of a claim under the SHBP. Aggregate Plan Year Deductible (Out-of-Network Care Only)
Except as specifically provided for coverage that is subject to In-Network services, the Aggregate Plan Year Deductible is the amount of Out-of-Network Covered Expenses/Services you must pay during each Plan Year before the SHBP will consider expenses for reimbursement. The individual deductible applies separately to each SHBP-Covered Person. The family deductible applies collectively to all SHBP- Covered Persons in the same family. When the family deductible is satisfied, no further deductible will be applied for any covered Family Member during the remainder of that Plan Year. The Plan Year individual and family deductible amounts are shown on the Schedule of Medical Benefits. Expenses from separate Sicknesses or Injuries may be used to satisfy the Aggregate Plan Year Deducti- ble.
Copayments
Dollar Copayments specified on the Schedule of Medical Benefits represent amounts paid by the Covered Person before the SHBP pays benefits at the percentage stated in the Schedule of Medical Benefits or in the Schedule of Prescription Drug Benefits. Coinsurance After satisfaction of any applicable Aggregate Plan Year Deductible or Copayment, the SHBP will pay the percentage of charges indicated in the Schedule of Medical Benefits or in the Schedule of Prescription Drug Benefits, subject to the specified maximums. The SHBP encourages you to use In-Network providers whenever possible. In the Princeton Area you will receive a higher benefit level for services from In-Network providers. The Coinsurance for In- and Out-of-Network providers is specified in the Schedule of Medical Benefits at the front of this document. Student Health Benefits Plan (SHBP) In-Network providers will not balance-bill you if their charges exceed the In-Network fee schedule. You may be balance-billed when charges made by an Out-of-Network Provider exceed the Usual and Custom- ary (U&C) amount for such services. Out-Of-Pocket Maximums
The out-of-pocket maximum is the maximum amount of charges for Covered Expenses/Services an SHBP-Covered Person must pay during a Plan Year. The individual out-of-pocket maximum applies separately to each SHBP-Covered Person. When an SHBP-Covered Person reaches the Plan Year out-of- pocket maximum, the SHBP will pay 100% of additional Covered Expenses/Services incurred by that in- dividual during the remainder of the Plan Year. The family out-of-pocket maximum applies collectively to all SHBP-Covered Persons in the same family. When the Plan Year family out-of-pocket maximum is reached, the SHBP will pay 100% of Covered Expenses/Services for any covered Family Member in- curred during the remainder of the Plan Year. The Plan Year individual and family out-of-pocket maximum amounts are shown on the Schedule of Medical Benefits. Any amount applied toward the In-Network out-of-pocket maximum will be applied toward the Out-of-Network out-of-pocket maximum and vice versa. The out-of-pocket maximum does not apply to the following: • Any expenses not covered or excluded by the SHBP, including expenses which exceed Usual and
• Charges in excess of Benefit Maximums.
Benefit Maximums
Total plan payments for each SHBP-Covered Person are limited to certain maximum benefit amounts. A benefit maximum can apply to specific benefit categories or to all benefits. A benefit maximum amount also applies to a specific time period, such as Plan Year or Lifetime. The benefit maximums applicable to the SHBP are shown on the Benefit Schedules. Unless otherwise specified, maximums apply to combined In- and Out-of-Network benefits. The Lifetime maximum applies to combined Medical Benefits and Prescription Drug Benefits. Medical Case Management Medical case management is designed to help manage the care of patients who have special or extended care Sicknesses or injuries. The primary objective of medical case management is to identify and coordi- nate cost-effective medical care alternatives meeting accepted standards of medical practice. Medical case management also monitors the care of the patient, offers emotional support to the family, and coordinates communications among Health Care Providers, patients, and others. Benefits may be modified by the SHBP ClaimsAdministrator to permit a method of treatment not ex- pressly provided for, but not prohibited by law, rules or public policy, if the SHBP Claims Administrator determines that such modification is Medically Necessary and is more cost-effective than continuing a benefit to which you or your eligible dependents may otherwise be entitled. The SHBP Claims Adminis- trator also reserves the right to limit payment for services to those amounts which would have been
charged had the service been provided in the most cost-effective setting in which the service could safely have been provided. Examples of Sicknesses or Injuries that may be appropriate for medical case management include, but are not limited to: • Chronic or Terminal Sicknesses such as AIDS, cancer, multiple sclerosis, renal failure, chronic ob-
structive pulmonary disease and cardiac conditions.
• Post-accident long-term rehabilitative therapy. • Newborns with high risk complications or multiple birth defects. • Diagnosis involving long-term IV therapy. • Sicknesses not responding to medical care. • Child and adolescent Mental/Nervous Disorders. Covered Expenses/Services
When all of the provisions of the SHBP are satisfied, the SHBP will provide benefits as outlined on the Schedule of Medical Benefits for the services and supplies listed in this Section. Treatment or services rendered outside the United States of America or its territories are covered on the same basis as treatment or services rendered within the United States. For international students and their SHBP-Covered dependents, such SHBP benefits are only provided to the extent they are not covered by any other insurance plan, insurance program, or system of socialized medicine. Medical Services • Physician home and office visits, as specified in the specified in the Schedule of Medical Benefits. • Inpatient visits by the attending Physician. • Treatment of complications arising from any non-covered Surgery or procedure. • Second Surgical Opinions. • Third Surgical Opinions. • Pregnancy-related care. • Involuntary termination of pregnancy. • Treatment of diabetes. • Dialysis.
• Dental services received after an accidental Injury to teeth, excluding biting or chewing Injuries. This
includes replacement of teeth and any related X-rays.
• Chiropractic Services. • Acupuncture.• Radiation therapy, including but not limited to high-dose radiotherapy in connection with autologous
bone marrow transplantation, stem cell rescue or other hematopoietic support procedures for treat-ment of acute leukemia in remission, resistant non-Hodgkin’s lymphoma, Hodgkin’s disease, neuro-blastoma, Ewing’s sarcoma, multiple myeloma (after induction therapy) and non-inflammatory stage II breast cancer with 10 or more positive nodes and negative bone marrow, but only when the indi-vidual qualifies as a candidate for the procedure under the health and age standards generally ac-cepted by the national medical professional community.
Other courses of treatment involving high-dose radiotherapy and autologous bone marrow transplan-tation, stem cell rescue or other hematopoietic support procedures for any symptom, disease or condi-tion are not covered.
• Chemotherapy, including but not limited to high-dose chemotherapy in connection with autologous
bone marrow transplantation, stem cell rescue or other hematopoietic support procedures for treat-ment of acute leukemia in remission, resistant non-Hodgkin’s lymphoma, Hodgkin’s disease, neuro-blastoma, Ewing’s sarcoma, multiple myeloma (after induction therapy) and non-inflammatory stage II breast cancer with 10 or more positive nodes and negative bone marrow, but only when the indi-vidual qualifies as a candidate for the procedure under the health and age standards generally ac-cepted by the national medical professional community.
Other courses of treatment involving high-dose chemotherapy and autologous bone marrow trans-plantation, stem cell rescue or other hematopoietic support procedures for any symptom, disease or condition are not covered.
• Physical therapy as specified in the Schedule of Medical Benefits from a qualified Health Care Pro-
• Non-custodial services of a Health Care Provider which are not billed by a Home Health Care
• Home health care provided by a Home Health Care Agency, as specified in the Schedule of Medical
• Hospice care, as specified in the Schedule of Medical Benefits. • Speech therapy as specified in the Schedule of Medical Benefits from a qualified Health Care Pro-vider to restore speech loss due to an Sickness, Injury or surgical procedure.
• Occupational therapy as specified in the Schedule of Medical Benefits from a qualified Health Care Provider to restore a physical function.
• Medically Necessary treatment of the feet, including treatment of metabolic or peripheralvascular dis-
• Allergy testing and treatment. • Titer when Medically Necessary and not for routine testing. Emergency Services • Ground transportation provided by a professional ambulance service to an emergency care facility
equipped to treat a condition that can be classified as a Medical Emergency.
• Treatment of an Accident in a Hospital or other emergency care facility.
• Treatment in a Hospital emergency room or other emergency care facility for a condition that can be
Hospital Services • Semi-private room and board. • Private room and board, not to exceed the cost of a semi-private room (if available). • Intensive Care Unit and coronary care unit charges. • Miscellaneous Hospital services and supplies required for treatment during a Hospital confinement. • Well-baby nursery, Physician and initial exam expenses during the initial Hospital confinement of a
newborn. Charges for the newborn will be considered as part of the mother’s expenses.
• Outpatient Hospital services.
Surgical Services • Surgeon’s expenses for the performance of a surgical procedure. • Assistant surgeon’s expenses. • Two or more surgical procedures performed during the same session through the same or different
incisions, natural body orifice or operative field. The amount eligible for consideration is the sum of Usual and Customary Chargesfor each procedure performed.
• Reconstructive Surgery when needed to correct damage caused by an accidental Injury or a birth de-
fect resulting in the malformation or absence of a body part.
• Anesthetic services, when performed by a licensed anesthesiologist or certified registered Nurse anes-
thetist in connection with a surgical procedure.
• Circumcision for newborn children. Student Health Benefits Plan (SHBP)
• OutpatientSurgery. • Podiatric Surgery. • Human organ and tissue transplants, including courses of treatment involving high-dose chemother-
apy or radiotherapy and autologous bone marrow transplantation, stem cell rescue or other hemato-poietic support procedures for acute leukemia in remission, resistant non-Hodgkin’s lymphoma, Hodgkin’s disease, neuroblastoma, Ewing’s sarcoma, multiple myeloma (after induction therapy) and non-inflammatory stage II breast cancer with 10 or more positive nodes and negative bone marrow but only when the individual qualifies as a candidate for the procedure under the health and age stan-dards generally accepted by the national medical professional community: Eligible expenses for the donor will also be covered by the SHBP.
Other courses of treatment involving high-dose chemotherapy or radiotherapy and autologous bone marrow transplantation, stem cell rescue or other hematopoietic support procedures are not covered as organ and tissue transplants.
Mental/Nervous and Substance Abuse Services • Biologically-Based Mental Illness
Benefits will be paid on the same basis as any other Sickness for Biologically-Based Mental Illness. Benefits are subject to the Deductible, Copayment, Coinsurance, and all other provisions of this Plan Document.
• Non-Biologically-Based Mental Illness or Substance Abuse Care
Inpatient treatment of substance abuse and/or a Mental/Nervous Disorder are provided for confine-ment in a Hospital, Mental/Nervous Treatment Facility, Residential Treatment Facility, or Substance Abuse Treatment Facility.Benefits will be limited to 30 days of Hospital confinement or 60 partial days of confinement in Psychiatric Date Treatment Facility per Plan Year or other Specialized Treatment Facility. Inpatient benefits include treatment for eating disorders.
Outpatient treatment of substance abuse and/or a mental/nervous disorder. Benefits will be limited to 24 visits per Plan Year, not including any visits that are pre-funded by Princeton Theological Semi-nary at Trinity Counseling Services. Outpatient benefits include, but are not limited to: treatment re-lating to an eating disorder; marital, couples and family counseling; and treatment of or related to an overdose of drug or medication.
Diagnostic X-Ray and Laboratory Services • Diagnostic Charges for X-rays. • Diagnostic Charges for laboratory services. • Mammography screening (refer to the Section of this Plan Document entitled Special Provisions). • Pre-admission tests (PAT) for a Hospital admission. Student Health Benefits Plan (SHBP)
• Amniocentesis. • Ultrasound. • Magnetic Resonance Imaging (MRI). • Positron Emission Tomography (PET Scan). • Computerized Axial Tomography (CAT Scan). • Dual Energy X-ray Absorptiometry, when Medically Necessary (DEXA Scan). Medical Equipment and Supplies • Durable Medical Equipment, including expenses related to necessary repairs and maintenance. A
statement is required from the prescribing Physician describing how long the equipment is expected to be necessary. This statement will determine whether the equipment will be rented or purchased.
• Artificial limbs and eyes and replacement of artificial eyes and limbs if required due to a change in
the patient’s physical condition; or replacement, if replacement is less expensive than repair of exist-ing equipment.
• Original fitting, adjustment and placement of orthopedic braces, casts, splints, crutches, cervical col-
lars, head halters, traction apparatus or prosthetic appliances to replace lost body parts or to aid in their function when impaired. Replacement of such devices only will be covered if the replacement is necessary due to a change in the physical condition of the SHBP-Covered Person.
• Oxygen and rental of equipment required for its use, not to exceed the purchase price of such equip-
• Blood and/or plasma and the equipment for its administration. • Insulin infusion pumps. • Initial prescription contact lenses or eyeglasses, including the examination and fitting of the lenses, to
replace the human lens lost through intraocular Surgery.
• Wigs and artificial hairpieces, only after chemotherapy or radiation therapy or when it is disease- or
Injury-related and not due to the normal aging process or premature baldness.
• Occupational therapy supplies. • Sterile surgical supplies after Surgery. • Jobst garments.
Specialized Treatment Facilities • A Skilled Nursing Facility as specifically provided in the Schedule of Medical Benefits.
• A Mental/Nervous Treatment Facility.
• A Substance Abuse Treatment Facility.
• An Ambulatory Surgical Facility.
• A Hospice Facility, including bereavement counseling as specified in the Schedule of Medical Bene-
• A chemical dependency/substance abuse day treatment facility.
• A Psychiatric Day Treatment Facility. Medical Benefit Exclusions
The SHBP will not provide medical benefits for any of the items listed below, regardless of Medical Ne- cessity or recommendations of a Physician or Health Care Provider. • Any treatment of a condition that is not a covered Sickness or Injury or any service or supply that is
not specifically listed in the Covered Expenses/Services Section of this Plan Document.
• Expenses exceeding the Usual and Customary Charge for the geographic area in which services are
• Treatment not prescribed or recommended by a Physician or Health Care Provider. • Services, supplies or treatment not Medically Necessary. • Orthotics, orthopedic or corrective shoes and other supportive appliances for the feet, except as spe-
cifically provided for treatment of diabetes.
• Congenital conditions, except as specifically provided for newborn children or adopted infants. • Cosmetic Surgery, treatment, procedures, services or supplies, except Surgery required to correct an
Injury for which benefits are otherwise payable, care for newborn or adopted children, and Cosmetic Surgery following treatment for breast cancer as provided in Special Provisions.
• Services or supplies for which there is no legal obligation to pay for expenses, or charges which
would not be made except for the availability of benefits under the SHBP. This includes any expense incurred by an international student or dependent that would also be covered by under another insur-ance plan, program, or system of socialized medicine in the absence of SHBP coverage.
• Experimental/Investigational equipment, services or supplies. • Services furnished by or for the United States government or any other government, unless payment
• Any condition, disability or expense sustained as a result of being engaged in an illegal occupation;
commission or attempted commission of an assault or other illegal act (regardless of whether charges are filed by a law enforcement agency).
• Intentional or accidental atomic explosion or other release of nuclear energy, whether in peacetime or
wartime; participation in a civil revolution or a riot or a war; or act of war which is declared or unde-clared.
• Any condition or disability sustained as a result of being engaged in an activity primarily for wage,
profit or gain, and that could entitle the SHBP-Covered Person to a benefit under a Worker’s Com-pensation Act or similar legislation.
• Educational, vocational, or training services and supplies. • Expenses for preparing medical reports, itemized bills, or claim forms. Mailing and/or shipping and
• Expenses for broken appointments, telephone call consultations, or electronic mail, Web, or Internet-
• Services or supplies furnished, paid for or for which benefits are provided or required by reason of
past or present service of any SHBP-Covered Person in the armed forces of a government.
• Travel expenses of a Physician.• Travel expenses of an SHBP-Covered Person other than local ambulance services to nearest medical
facility equipped to treat the illness or injury, expect as specified in the Schedule of Medical Benefits.
• Custodial Care. • Expenses used to satisfy plan Deductibles, Copayments, or Coinsurance amounts. • Except as specifically provided under the Extension of Benefits Due to Total Disability provision,
expenses incurred for services rendered prior to the effective date of coverage under the SHBP or af-ter coverage terminates, even though illness or injury started while coverage was in force.
• Sales tax. • Personal comfort or service items while confined in a Hospital, such as, but not limited to, radio, tele-
• Any inpatient or residential treatment facility that is not included in the Section of this Plan Docu-
• Sex change Surgery. • Penile prosthetic implants. • Non-Surgical or Surgical testing or treatment for the correction of infertility or any surgical impreg-
• Reproductive sterilization or reversal of any reproductive sterilization procedure. • Services related to Dental or Oral surgery (including diagnosis or treatment of temporomandibular
joint dysfunction or related conditions).• Services for or related to Reconstructive Surgery or Cosmetic Surgery, except as specifically provided
• Orthognathic Surgery or mandibular retrognathia Surgery. • Massage therapy or rolfing. • Sex counseling. • Eye examinations for diagnosis or treatment of a refractive error, including the fitting of eyeglasses or
lenses, orthoptics, vision therapy or supplies. Any refractive eye Surgery or procedure designedto improve nearsightedness, farsightedness, and/or astigmatism by changing the shape of the cornea, in-cluding, but not limited to, LASIK, radial keratotomy and keratomileusis Surgery.
• Hearing examinations, hearing aids or related supplies. • Adoption expenses. • Surrogate expenses. • Biofeedback. • Hypnosis. • Genetic counseling or genetic testing. • Routine PAP tests, routine physical exams, vaccinations, inoculations or immunizations, except as
specifically provided in the Section entitled Special Provisions.
• Expenses incurred for non-surgical treatment of the feet, including treatment of corns, calluses and
toenails, or other routine foot care, except as specified in Covered Medical Expenses.
• Expenses for Outpatient prescription drugs or medicines. (See next Section entitled Prescription Drug
Benefits). Expenses for supplies that do not require a Physician’s prescription (i.e., over-the-counter medications).
• Services or supplies that are primarily and customarily used for a non-medical purpose, or used for
environmental control or enhancement (whether or not they are Medically Necessary or prescribed by a Physician or other Health Care Provider), including but not limited to: equipment such as air condi-tioners, air purifiers, dehumidifiers, heating pads, hot water bottles, water beds, swimming pools, hot tubs and any other clothing or equipment which could be used in the absence of an Sickness or Injury.
• Expenses for services and supplies in excess of Benefit Maximums. • Services for or related to smoking cessation program fees and/or related program supplies. • Weight reduction Surgery, treatment, procedures, services or supplies, regardless of a condition of
• Services for treatment of non-biologically based behavioral disorders, mental retardation, or Attention
Deficit Disorder (ADD), Attention Deficit Hyperactivity Disorder (ADHD), or any other learning disability.
• Voluntary termination of pregnancy. • Circumcision, except as specifically provided for newborn children. • Claims originally submitted more than one year after the date on which the service or supply was in-
PRESCRIPTION DRUG BENEFITS General Requirements
Prescription Drug benefits are payable in connection with covered prescriptions and refills dispensed by licensed pharmacists. Although a Physician's prescription is required, such prescription does not guaran- tee that a particular drug will be covered by the SHBP. The SHBP has selected MEDCO as the prescription benefit program manager. When you fill a covered prescription at a MEDCO participating pharmacy and show your SHBP Identification Card with the MEDCO logo, the pharmacy will submit the claim on your behalf and accept the Maximum Allowable Cost as full payment. You pay only your Copayment specified in the Prescription Drug Schedule of Bene- fits. When you fill a covered prescription at a pharmacy outside the MEDCO Network, you must pay for the full cost of the purchase and then submit a claim for benefits to MEDCO to be reimbursed. A pharmacy that does not participate with MEDCO may charge you either more than the Maximum Allowable Cost or an amount in excess of the SHBP’s Usual and Customary Charge allowance. Charges in excess of the Maximum Allowable Cost or the SHBP’s Usual and Customary Charge allowance are not covered by the SHBP.
Covered Drugs
Expenses for the following items are eligible for benefits unless listed as an exclusion below: • Federal Legend Drugs and State Restricted Drugs.
• Compounded medications of which at least one ingredient is a Legend drug.
• Insulin (including insulin needles and diabetic supplies).
• Oral contraceptives. Emergency contraceptives are only covered when there is a suspected act of rape
• Legend vitamin B12 (all dosage forms).
Dispensing Limits The dispensing limits are specified in the Schedule of Prescription Drug Coverage. Prescription Drug Benefit Exclusions Expenses for the following are not covered by the SHBP unless specifically listed as a benefit under Cov- ered Drugs: • Charges for drugs, medicines, services or supplies prescribed by a Physician or any other Health Care Provider only on the basis of an online, internet or telephonic consultation not preceded by an in-person medical examination with that Physician or other Health Care Pro-vider.
• Drugs not classified as Federal Legend Drugs (i.e., over-the-counter drugs and products).
• Non-systemic contraceptives, devices, or implants.
• Except as specifically provided for Oral Contraceptives, any drug intended to prevent pregnancy or
for voluntary termination of pregnancy. Contraceptive transdermal medications and contraceptive intravaginal devices are also excluded by the SHBP. Emergency contraceptives are only covered in cases of suspected rape or incest.
• Legend vitamins and nutritional supplements.
• Cosmetic drugs and drugs used to promote or stimulate hair growth.
• Glucowatch products and glucose monitors (refer to the Section of this Plan Document entitled Spe-
cial Provisions for benefits relating to diabetes).
• Biologicals, immunizations agents or vaccines, blood or blood plasma.
• Drugs labeled “Caution-Limited by Federal law to Investigational Use,” or experimental drugs, even
though a charge is made to the individual.
• Any prescription refilled in excess of the number of refills specified by the ordering Physician, or any
refill dispensed one year after the original order.
• Medication dispensed in excess of the Dispensing Limits.
• Charges for the administration or injection of any drug. • Anti-obesity medications. • Substance abuse treatments. • Ostomy supplies. • Therapeutic devices and supplies. • Medication for which the cost is recoverable under any Workers' Compensation or Occupational Dis-
ease Law or any State or Governmental Agency, or medication furnished by any other Drug or Medi-cal Service for which no charge is made to the member.
• Medication which is to be taken by or administered to an individual, in whole or in part, while he or
she is a patient in a licensed Hospital, rest home, sanitarium, extended care facility, Skilled Nursing Facility, convalescent Hospital, nursing home or similar institution which operates on its premises or allows to be operated on its premises, a facility for dispensing pharmaceuticals.
• Services or products that are determined by the SHBP as not Medically Necessary. • Injectable medications, except as listed under Covered Drugs.• Mail order medications for 90 day supplies after July 1 of any Plan Year.
• Claims originally submitted more than one year after the date on which the service or supply was in-
SPECIAL PROVISIONS Unless otherwise specified, all Special Provision benefits will be subject to the Deductible and Coinsur- ance provisions of the SHBP. The medical necessity requirement also applies to all Special Provisions unless otherwise specified. Reconstructive Breast Surgery Benefits will be paid the same as any other Sickness for reconstructive breast Surgery following a mastec- tomy on one breast or both breasts. This benefit includes a minimum of 72 hours of inpatient care follow- ing a modified radical mastectomy and a minimum of 48 hours of inpatient care following a simple mas- tectomy. This benefit also includes the cost of a prosthesis. Diabetes Benefits will be paid the same as any other Sickness for the following equipment and supplies for treat- ment of diabetes if recommended or prescribed by a Physician or other Health Care Provider: blood glu- cose monitors and blood glucose monitors for the legally blind; test strips for glucose monitors and visual reading and urine testing strips; insulin; injection aids; cartridges for the legally blind; syringes; insulin pumps and appurtenances thereto; insulin infusion devices; and oral agents for controlling blood sugar. Mammography Benefits will be paid the same as any other Sickness for a mammography according to the following guidelines:
1. One baseline mammogram for women who are at least thirty-five but less than forty years of age; 2 One mammogram every year, or more frequently if recommended by a Physician, for women age
3 Medically Necessary mammograms are covered at any age.
Colorectal Cancer Screening Benefits will be paid the same as any other Sickness for colorectal cancer screening at regular intervals for SHBP-Covered Persons age 50 and over and for SHBP-Covered Persons of any age who are considered to be at high risk for colorectal cancer. High risk for colorectal cancer means a person has:
a. family history of: familial adenomatous polyposis; hereditary non-polyposis colon cancer; or
breast, ovarian, endometrial or colon cancer or polyps;
b. chronic inflammatory bowel disease; or c. a background, ethnicity or lifestyle that a Physician believes puts the person at elevated risk for
The methods of screening for which benefits shall be provided shall include:
a. a screening fecal occult blood test, flexible sigmoidoscopy, colonoscopy, barium enema, or any
b. the most reliable, medically recognized screening test available.
The method and frequency of screening to be utilized shall be in accordance with the most recent pub-lished guidelines of the American Cancer Society and as determined to be Medically Necessary.
Prostate Cancer Screening Benefits will be paid the same as any other Sickness for an annual medically recognized diagnostic ex- amination including, but not limited to a digital rectal examination and a prostate-specific antigen (PSA) test for men age 50 and over who are asymptomatic. These screen benefits are also provided for men with a family history of prostate cancer or other prostate cancer risk factors. Treatment of Wilm’s Tumor Benefits will be paid the same as any other Sickness for the treatment of Wilm’s tumor, including autolo- gous bone marrow transplants when standard chemotherapy treatment is unsuccessful, notwithstanding that any such treatment may be deemed Experimental or Investigational. Audiology and Speech Language Pathology Benefits will be paid the same as any other Sickness for Audiology and Speech Language Pathology when such services are determined by a Physician to be Medically Necessary and are performed or rendered to the SHBP-Covered Person by a licensed audiologist or speech language pathologist. Annual Pap Smears Benefits will be paid on the same as any other Sickness for an annual pap smear or a pap smear done more frequently than annually if recommended by a Physician. This benefit includes coverage for all labora- tory tests associated with the pap smear and any subsequent confirmatory testing. Maternity Testing Benefits will be paid the same as any other Sickness for routine maternity tests and screening exams. Wellness Health Exams and Counseling Benefits will be paid the same as any other Sickness subject to the maximum benefits specified in the Schedule of Medical Benefits for the following tests and services:
For all SHBP-Covered Persons 20 years of age or older:
a. Annual tests to determine blood hemoglobin, blood pressure, blood glucose level, amid
blood cholesterol level; or, alternatively, low-density lipoprotein (LDL) level and blood high-density lipoprotein (HDL) level: and
b. Annual consultation with a Physician to discuss lifestyle behaviors that promote health
and well-being including, but not limited to smoking control, nutrition and diet recom-mendations, exercise plans, lower back protection, weight control, immunization prac-tices, breast self-examination, testicular self-examination and seat belt usage in motor ve-hicles.
For all SHBP-Covered Persons 35 years of age or older: a glaucoma eye test every five years.
For all SHBP-Covered Persons 40 years of age or older: an annual stool examination for presence of blood.
For all SHBP-Covered Persons 45 years of age or older: a left-sided colon examination of 35 to 60 centimeters every five years.
Inherited Metabolic Disease Benefits will be paid the same as any other Sickness for Covered Expenses/Services incurred in the thera- peutic treatment of Inherited Metabolic Diseases, including the purchase of medical foods and Low Pro- tein Modified Food Products, when diagnosed and determined to be medically necessary by the Physi- cian. Inherited metabolic disease means a disease caused by an inherited abnormality of body chemistry. Low Protein Modified Food Product means a food product that is specially formulated to have less than one gram of protein per serving and is intended to be used under the direction of a Physician for the die- tary treatment of an inherited metabolic disease, but does not include a natural food that is naturally low in protein. Medical food means a food that is intended for the dietary treatment of a disease or condition for which nutritional requirements are established by medical evaluation and is formulated to be either consumed under the direction of a Physician or administered internally under direction of a Physician. Hospital Confinements for Pregnancy A Hospital confinement for the purpose of delivery of a Newborn Child will be allowed for no less than 48 hours following a vaginal delivery and 96 hours following a cesarean section. COORDINATION OF BENEFITS
When you and/or your dependents are covered under more than one medical plan, one plan is considered primary and the other secondary. The primary plan always pays first and usually pays full regular benefits while the secondary plan may pay a portion of the claim not paid by the other plan. This is known as co-ordination of benefits. Except as specifically provided, the SHBP will be primary in coordinating benefits with other insurance programs. As primary coverage, the SBHP will reimburse eligible medical expenses before other insur-ance makes payments for a claim. This Coordination of Benefits provision is subject to some limitations: (1) the SHBP will pay no more than it would have paid if it had been primary, and (2) the amount that the SHBP pays, combined with the amount paid by the other plan, will not exceed the total amount of eligible medical expenses incurred. For purposes of coordination, eligible medical expenses mean any Medically Necessary chargesconsid-ered in part or full by the SHBP. The Student Health Benefits Plan will coordinate coverage for dependents: • When the SHBP covers a dependent child of non-divorced or non-separated parents and the parent
with coverage under the SHBP has the earlier birth date (month and day) in the year. If both parents have the same birth date, the SHBP covering the child for the longest period of time will be primary.
• When the SHBP covers the dependent child of the natural parent designated by court order to be re-
sponsible for the child’s health care expenses
• In the absence of a court order specifying otherwise, the SHBP covers the dependent child of the
natural parent having legal custody of the child.
• In the absence of a court order specifying otherwise, the SHBP covers the stepchild residing with a
stepparent who is the spouse of the natural parent having legal custody of the child.
Government Programs The regulations governing Medicare, Medicaid and CHAMPUS/Tricare take precedence over the deter-mination of the SHBP. For example, in determining the benefits payable under the SHBP, the SHBP will not take into account the fact that you or any eligible dependent(s) are eligible for or receive benefits un-der a Medicaid plan. Other Group Plans Any group health plan that does not contain a coordination of benefits provision will be considered pri-mary. Right To Make Payments To Other Organizations Whenever payments, which should have been made by the SHBP, have been made by any other plans(s), the SHBP has the right to pay the other plan(s) any amount necessary to satisfy the terms of this coordina-tion of benefits provision. Amounts paid will be considered benefits paid under the SHBP and, to the ex-tent of such payments, the SHBP will be fully released from any liability regarding the SHBP-Covered Person for whom payment was made.
SUBROGATION, REIMBURSEMENT AND RECOVERY The SHBP’s Subrogation Rights The SHBP’s subrogation provisions apply when another party (including an insurance carrier) is or may be liable for a covered individual’s Sickness or Injury and the SHBP has already paid benefits for treat- ment of that Sickness or Injury. Subrogation refers to the right of the SHBP to be substituted in place of any covered individual with respect to that covered individual’s legal right of action against the person who may have wrongfully caused the Sickness or Injury that resulted in the payment of benefits by the SHBP. The SHBP may, at its discretion, start any legal action or administrative proceeding it deems necessary to protect its right to recover any amount it has paid as plan benefits and it may try or settle any such action or proceeding in the name of and with the full cooperation of the covered individuals. However in doing so, the SHBP will not represent or provide legal representation for any covered individual with respect to that covered individual’s damages to the extent those damages exceed the amount of plan benefits. In addition, the SHBP may, at its discretion, intervene in any claim, legal action, or administrative proceeding started by any covered individual against any person or that person’s insurer on account of any alleged negli-
gent, intentional, or otherwise wrongful action that may have caused or contributed to the covered individ- ual’s injury or illness that resulted in the payment of benefits by the SHBP. The SHBP’s legal costs in subrogation matters will be borne by the SHBP. The legal costs of covered individuals will be borne by such covered individuals. The SHBP’s Reimbursement Rights
The SHBP’s reimbursement provisions apply when you or the individuals you cover under the SHBP (i.e., covered individuals) receive any payment by settlement, verdict or otherwise, including from an in- surance policy, for an Sickness or Injury caused by a third party. These payments are referred to here as a recovery. If you or another covered individual have received a recovery, the SHBP will subtract the amount of the recovery from the benefits it would otherwise pay for treatment of that Sickness or Injury. If the SHBP has already paid benefits for treatment of the Sickness or Injury, you or the covered individual must promptly reimburse the SHBP from any recovery received for the amount of benefits paid by the SHBP. Reimbursement must be made regardless of whether the covered individual is fully compensated (i.e., made whole) by the recovery and regardless of how the payment is characterized. Unless agreed to in writing by the SHBP Claims Administrator, the reimbursement may not be reduced for any legal or other expenses incurred in connection with the recovery against the third party or that third party’s insurer. By accepting benefits from the SHBP, all covered individuals are deemed to agree to this repayment provi- sion. Covered individuals may be required to execute an agreement under which they jointly and severally: • Grant the SHBP a first priority lien against the proceeds of any recovery received.
• Assign to the SHBP any benefit they may have under any insurance policy or other coverage.
• Agree to hold the proceeds of any recovery received in trust for the SHBP.
• Cooperate with the SHBP and its agents in order to protect the SHBP’s reimbursement rights.
Payments of benefits under the SHBP may be conditioned on execution of this agreement.
The SHBP is only responsible for those legal costs to which it agrees in writing and will not otherwise bear the legal costs of covered individuals. If any covered individual fails to reimburse the SHBP as required by this Section, the SHBP may apply any future plan benefits that may become payable on behalf of all covered individuals to the amount not reimbursed or it may enforce its rights through other legal or equitable means. The SHBP’s Right of Recovery
Whenever payments have been made in excess of the amount necessary to satisfy the provisions of the SHBP, the SHBP has the right to recover these excess payments from any individual (including yourself), insurance company or other organization to whom the excess payments were made or to withhold pay- ment, if necessary, on future benefits until the overpayment is recovered.
If excess payments were made for services rendered to your dependent(s), the SHBP has the right to withhold payment on your benefits until the overpayment is recovered. Further, whenever payments have been made based on fraudulent information provided by you, the SHBP will exercise its right to withhold payment on future benefits until the over payment is recovered.
OTHER IMPORTANT PLAN PROVISIONS Assignment of Benefits
All benefits payable by the SHBP may be assigned to the provider of services or supplies at your option. Payments made in accordance with an assignment are made in good faith and release the SHBP’s obliga- tion to the extent of the payment. Payments will also be made in accordance with any assignment of rights required by a state Medicaid plan. Alternate Payees
Generally, benefits are payable to you and can only be paid directly to another party upon signed authori- zation from you. If conditions exist under which a valid release or assignment cannot be obtained, the SHBP may make payment to any individual or organization that has assumed the care or principal support for you and is equitably entitled to payment. The SHBP must make payments to your separated/divorced spouse, state child support agencies or Medicaid agencies if required by a qualified medical child support order (QMCSO) or state Medicaid law. The SHBP may also honor benefit assignments made prior to your death in relation to remaining benefits payable by the SHBP. Any payment made by the SHBP in accordance with this provision will fully release the SHBP of its li- ability to you. Necessary Information
When you request benefits, you must furnish all the information required to implement plan provisions. Your signature on the claim form permits Princeton Theological Seminary to release or obtain informa- tion without your further authorization. The SHBP may, without further authorization or notice to any person, release to or obtain from any organization or person, information needed to implement plan provi- sions. The SHBP's privacy practices are described in the Health Service Notice on Privacy Practices. Regulation of the SHBP The SHBP is not an employer-sponsored health plan. Accordingly, the rules and regulations of the Em- ployee Retirement Income Security Act of 1974 (ERISA) , the Consolidated Omnibus Budget Reconcilia- tion Act of 1996 (COBRA), and other federal laws that apply exclusively to employer-sponsored health plans are not applicable to the SHBP. As a partially self-funded health plan, the SHBP is not regulated by the State of New Jersey’s Department of Banking and Insurance.
The SHBP federal laws and regulations, including but not limited to: • Title IX of the Education Amendments of 1972. The SHBP provides pregnancy benefits on
the same basis as any other temporary disability pursuant to the requirements of Title IX of the Education Amendments of 1972.
• Section 504 of the Rehabilitation Act of 1973 • Age Discrimination Act of 1975. • Health Insurance Portability and Accountability Act of 1996 (refer to the Privacy Notice in
• Regulations of the United States Information Agency that are applicable to VISA recipients. CLAIM PROCEDURES How to File a Claim for Medical Benefits
All claims must be filed with the SHBP within a 12-month period from the date the expense is in- curred. Medical claim forms may be obtained from the Office of Admissions and Financial Aid. Claim forms may also be downloaded from the Klais & Company web site at www.klais.com. One claim must be filed for each Sickness or Injury for which expenses are incurred. Follow the follow- ing steps in completing the claims process:
1. Complete the student’s portion of the claim form in full. Answer all questions. State “none” or
“N/A” when the question does not apply.
2. Attach all necessary documentation of expenses to the claim form (many providers may submit
their billing for you). Documents must include:
• a description of services or supplies provided, detailing the charge for each service or supply; • the diagnosis; • the patient’s name and date(s) of service; • the Provider’s name, address, phone number, and degree; and • the Federal Tax Identification Number of the Provider.
3. Complete a separate claim form for each person for whom benefits are being requested. 4. If another plan is the primary payor, a copy of the other plan’s Explanation of Benefits (EOB)
5. Mail the completed claim forms with supporting documents to the SHBP Claims Administrator:
Klais & Company, Inc. 1867 West Market Street
All claims must be filed within 12 months of the date the charge was incurred by the SHBP-SHBP- Covered Person. If you have questions, please call 800-331-1096. From outside the United States, please call (330) 867- 8443. Information about your claim is also available at the Klais & Company web site for students who are registered users. For Prescription Drug Claims Participating MEDCO pharmacies will submit claims for you if you have an SHBP identification card. To submit claims to MEDCO for non-participating pharmacies, mail the original prescription drug receipt to: MEDCO
The MEDCO prescription drug claim form may be downloaded at the Klais & Company web site: www.klais.com. Questions concerning MEDCO coverage should be directed to Klais & Company.
If a student believes a claim for medical or prescription drug benefits was not correctly administered or settled, the following process is available: Initial Appeal Within 60 days of receipt of an Explanation of Benefit form or claim declination letter, the covered SHBP person may request (either in writing or by telephone) that a claim be reviewed. Klais & Company and/or MEDCO will review the processed claim and inform the SHBP-Covered Person whether or not the claim was correctly administered. Any errors will be corrected promptly. Second Appeal If you are not satisfied with the results of the initial appeal, submit a written request for a second review. This request must be submitted to Klais & Company. The request should state in clear and concise terms the basis for the disagreement with the way the claim was processed. When the request is received, the claim will be reviewed again and the results of this review will be furnished in writing within 60 days in most cases, but in no case more than 120 days. Third and Final Appeal A third and final appeal may be submitted to the consultant retained by the Seminary for its Student Health Program. The consultant will establish a review team of medical and/or mental health care profes- sionals and claims administration experts, none of whom will have had any previous role in adjudicating the claim or have any financial interest in the claim. This review team will issue a final determination for the claim within 60 days in most cases, but in no case more than 120 days. This third and final review must be submitted through the Dean of Student Affairs at the Seminary.
No appeals for SHBP claims review will be accepted by the Seminary outside of this process. All requests for review of denied benefits should include a copy of the initial denial letter and any other pertinent in-
formation. Send all information to Klais & Company except as specified for the third and final appeal process.
DEFINITIONS The following terms define specific wording used in the SHBP. These definitions should not be inter- preted to extend coverage unless specifically provided for under previously explained provisions of the SHBP. Accident. An unforeseen and unavoidable event resulting in an Injury. Annual Open Enrollment Period. Eligible students and their eligible dependents may enroll in the SHBP at the beginning of any Plan Year. Both new and returning eligible students may enroll in the SHBP dur- ing the fall open enrollment period, this includes students who have previously waived participation in the SHBP based on approved personal health insurance coverage. The deadline for submission of SHBP enrollment forms is published in the Student Health Program bro- chure (and Student Health Program web site) for the fall semester Annual Open Enrollment Period for each Plan Year. Students who waive participation in the SHBP during the fall semester are not allowed to later enroll in the SHBP during the Plan Year, except as specifically provided in the Section of this Plan Document entitled Late Enrollments. For eligible students first enrolling at the Seminary following the fall semester Annual Open Enrollment Period, a limited period is allowed for enrolling in the SHBP or waiving SHBP coverage based on an ap- proved personal health insurance program. These deadlines area published in the Student Health Program brochure for each period of coverage during the Plan Year. These enrollment deadlines are also available at the Student Health Program web site: www.ptsem/current/healthresources/. Aggregate Plan Year Deductible. Except as specifically provided for coverage that is subject to a Co- payment, the Aggregate Plan Year Deductible is the amount of Covered Expenses/Services you must pay during each Plan Year before the SHBP will consider expenses for reimbursement. Ambulatory Surgical Facility. A public or private facility, licensed and operated according to the law, which does not provide services or accommodations for a patient to stay overnight. The facility must have an organized medical staff of Physicians; maintain permanent facilities equipped and operated primarily for the purpose of performing surgical procedures; and supply registered professional nursing services whenever a patient is in the facility. Biologically-Based Mental Illness. Mental or Nervous Disorders that are caused by a biological disorder of the brain that results in a clinically significant or psychological syndrome or pattern that substantially limits the functioning of the person with the illness, including but not limited to, schizophrenia, schizoaf- fective disorder, major depressive disorder, bipolor disorder, paranoia and other psychotic disorders, ob- sessive-compulsive disorder, panic disorder and pervasive developmental disorder or autism. Birthing Center. A public or private facility, other than private offices or clinics of Physicians, which meets the free standing birthing center requirements of the State Department of Health in the state where the SHBP-Covered Person receives the services.
The Birthing Center must provide: a facility which has been established, equipped and operated for the purpose of providing prenatal care, delivery, immediate postpartum care and care of a child born at the center; supervision of at least one specialist in obstetrics and gynecology; a Physician or certified Nurse midwife at all births and immediate postpartum period; extended staff privileges to Physicians who prac- tice obstetrics and gynecology in an area Hospital; at least 2 beds or 2 birthing rooms; full-time nursing services directed by an R.N. or certified Nurse midwife; arrangements for diagnostic X-ray and lab ser- vices; and the capacity to administer local anesthetic or to perform minor surgery. In addition, the facility must only accept patients with low risk pregnancies, have a written agreement with a Hospital for emergency transfers and maintain medical records on each patient and child. Chiropractic Services. The detection and correction, by manual or mechanical means, of the interference with nerve transmissions and expressions resulting from distortion, misalignment or dislocation of the spinal (vertebrae) column. Close Family Member (Family Member). The spouse, brother, sister, parent, child, uncle, or aunt of an SHBP-Covered Person. For the purpose of Dependent Coverage, a family member is the spouse or child, adopted-child, stepchild, or foster-child of living with the SHBP-Covered student. Copayment. A Copayment is the amount of Covered Expenses/Services you must pay before the SHBP will consider expenses for reimbursement under the Schedule of Medical Expense Benefits or Schedule of Prescription Drug Benefits provided in this Plan Document. Unless otherwise specified, Copayments may not be used to satisfy the Deductible. Coinsurance. Thepercentage of Covered Expenses/Services to be paid by the SHBP and the Covered Person after satisfaction of the Aggregate Plan Year Deductible or Copayment. These percentages apply only to Covered Expenses/Services which do not exceed Usual and Customary Charges. The Covered Person is responsible for all non-Covered Expenses/Services and any amount which exceeds the Usual and Customary Charge for Covered Expenses/Services Cosmetic Surgery. A procedure performed primarily for psychological purposes or to preserve or im- prove appearance rather than to restore the anatomy and/or functions of the body which are lost or im- paired due to an Sickness or Injury. Covered Expenses/Services: A health service or supply that is eligible for benefits when performed by a Provider or Physician. A Covered Expenses/Services must be a medical expense charge that is specifi- cally identified in this Plan Document as being covered by the SHBP and not otherwise excluded by the SHBP. Custodial Care. Services and supplies furnished primarily to assist an individual in the activities of daily living. Activities of daily living include such things as bathing, feeding, administration of oral medicines, or other services that can be provided by persons without the training of a Health Care Provider. Diagnostic Charges. The Medically Necessary chargesfor X-ray or laboratory examinations made or or- dered by a Physician or practitioner in order to detect a medical condition. Durable Medical Equipment. Equipment able to withstand repeated use for the therapeutic treatment of an active Sickness or Injury. Such equipment will not be covered under the SHBP if it could be useful to a person in the absence of an Sickness or Injury and could be purchased without a Physician’s prescription. Experimental or Investigational. Services, including but not limited to transplants, which are educational in nature or any treatment (including pharmacological regimes) that are not recognized as generally ac- cepted medical practice by the medical profession. Criteria for determining whether or not a procedure or treatment will be considered Experimental or Investigational will include, but not be limited to, the fol- lowing:
• Whether the service has final approval from the appropriate government regulatory bodies (FDA, or
other regulatory authority as appropriate).
• Whether the procedure or treatment is generally accepted by the medical profession.
• Whether the scientific evidence permits conclusions concerning the effect of the service on health
outcomes, and whether, in the predominant opinion of the experts, as expressed in the published au-thoritative literature, that (i) usage should be substantially confined to research settings, or (ii) that further research is necessary, or the written protocol describes among its main objectives the neces-sity, to determine safety, toxicity, efficacy, or effectiveness of that service compared with conven-tional treatment alternatives.
• Whether the service is being delivered or should be delivered subject to the approval and supervision
of an institutional review board as required and defined by federal regulations, particularly those of the Food and Drug Administration or the Department of Health and Human Services.
• The failure rate and side effects of the treatment or procedure.
• Whether other, more conventional methods of treatment have been exhausted.
• Whether the service is as beneficial as any established alternatives.
• Whether the procedure or treatment is medically necessary and is expected to improve the net health
• Whether the procedure or treatment is recognized for reimbursement by Medicare, Medicaid, other
insurers or self-funded plans, or other applicable third party payers.
• Whether the procedure or treatment is a complication of an Experimental or Investigational service.
Procedures in question for their Experimental or Investigational nature will be reviewed by appropriate members of the medical profession for recommendation. To be covered, the procedure or treatment in question must not be determined to be Experimental or Investigational and the covered individual must meet the criteria for treatment or other procedure with regard to age, general health, etc., and have been determined to be a good candidate for the procedure or treatment by an accredited facility. Final decisions regarding coverage under the SHBP will be at the sole discretion of the SHBP Claims Administrator.
Health Care Provider. A Physician, Health Care Provider, nurse, Hospital or Specialized Treatment Fa- cility as those terms are specifically defined in this Section. A Health Care Provider must not be spouse, child, or other close family relative of the SHBP-Covered Person receiving services. Health Care Provider includes, but is not limited: a Physician, Doctor of Dental Surgery (D.D.S.), Doctor of Dental Medicine (D.M.D.), Doctor of Podiatry Medicine (D.P.M.), Doctor of Chiropractic (D.C.), Doc- tor of Optometry (O.D.), Certified Nurse Midwife (C.N.M.), Certified Registered Nurse Anesthetist
(C.R.N.A.), Registered Physical Therapist (R.P.T.), Psychologist (Ph. D., Ed. D., Psy. D., MA), Regis- tered Nurse (R.N.), Licensed Clinical Social Worker (L.C.S.W.), Master of Social Work (M.S.W.), Speech Therapist, Occupational Therapist, Physician’s Assistant, Registered Respiratory Therapist, Nutri- tionist, Nurse Practitioner (A.R.N.P.), Naturopath (N.D.) or Pastoral Counselor. Spiritual Directors as designated by Princeton Theological Seminary will be treated as Health Care Providers. Home Health Care Agency. A public or private agency or organization licensed and operated according to the law that specializes in providing medical care and treatment in the home. The agency must have policies established by a professional group and at least one Physician and one registered graduate Nurse to supervise the services provided. Hospice (Home Hospice). A program, licensed and operated according to state law, which is approved by the attending Physician to provide palliative, supportive and other related care in the home for a termi- nally ill SHBP-Covered Person. Hospice Facility. A public or private organization, licensed and operated according to the law, primarily engaged in providing palliative, supportive and other related fare for an SHBP-Covered Person diagnosed as terminally ill. The facility must have an inter-disciplinary medical team consisting of at least one Phy- sician, one registered nurse, one social worker, one volunteer and a volunteer program. A Hospice Facility is not a facility or part thereof which is primarily a place for rest, Custodial Care, the aged, drug addicts, alcoholics or a hotel or similar institution. Hospital. A public or private facility licensed and operated according to the law, which provides care and treatment by Physicians and nurses at the patient’s expense of an Sickness or Injury through medical, sur- gical and diagnostic facilities on its premises. A Hospital does not include a facility or any part thereof which is, other than by coincidence, a place for rest, the aged or convalescent care. Injury. A condition which results independently of an Sickness and all other causes and is a result of an externally violent force or accident. In-Network (In-Network Provider). Physicians and other Health Care Providers in the Princeton Area who have contracted with the SHBP to provide specific medical care at negotiated prices or a Preferred Allowance are referred to collectively as In-Network Providers. Outside of the Princeton Area, the SHBP has contracted with the managed care network identified in the Schedule of Medical Benefits to provide In-Network services. Inpatient. Treatment in an approved facility during the period when charges are made for room and board. Intensive Care Unit. A section, ward or wing within a Hospital which is operated exclusively for criti- cally ill patients and provides special supplies, equipment and constant observation and cure by registered graduate nurses or other highly trained personnel. Intensive Care Unit does not include any Hospital fa- cility maintained for the purpose of providing normal post-operative recovery treatment or service. Legend Drug. A Legend Drug is any drug or medication designated as “Rx Only” by the Federal Food, Drug and Cosmetic Act, as amended. They cannot be dispensed without prescription.
Lifetime. The period of time your or your eligible dependents participate in the SHBP or any other plan sponsored by Princeton Theological Seminary for Princeton Theological Seminary students and/or their eligible dependents. MEDCO Network Maximum Allowable Cost. The maximum amount that a pharmacy in the MEDCO Network will be reimbursed for a particular prescription drug Medicaid. Title XIX (Grants to states for Medical Assistance Programs) of the United States Social Secu- rity Act as amended. Medicare. Title XVIII (Health Insurance for the Aged and Disabled) of the United States Social Security Act as amended. Medical Emergency. Medical Emergency means the occurrence of a sudden, serious, and unexpected Sickness or Injury manifesting itself by acute symptoms of sufficient severity including, but not limited to, severe pain, psychiatric disturbances and/or symptoms of substance abuse such that a prudent lay per- son who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate to attention to result in: death; placement of the SHBP-Covered Person’s health in jeopardy; serious impairment of bodily functions; serious dysfunction of any body organ or part; or in the case of a pregnant woman, serious jeopardy to the health of the fetus. Medically Necessary (Medical Necessity). An intervention that is or will be provided for the diagnosis, evaluation, and treatment of the condition, Sickness, disease, or Injury and that is determined by the Claims Administrator for the SHBP to be all of the following: • Medically appropriate for and consistent with the symptoms and proper diagnosis or treatment of the
condition, Sickness, disease, or Injury.
• Not Experimental/Investigational. • Obtained from a Physician or licensed, certified, or registered Health Care Provider. • Provided in accordance with the applicable medical and/or professional standards. • Known to be effective, as proven by scientific evidence, in materially improving health outcomes. • The most appropriate supply, setting or level of service that can safely be provided to the member and
which cannot be omitted consistent with recognized professional standards of care (which, in the case of hospitalization, also means that safe and adequate care could not be obtained as an Outpatient).
• Cost-effective compared to alternative interventions, including no intervention. • Not primarily for the convenience of the SHBP-Covered Person, the SHBP-Covered Person’s family,
or a Health careProvider.
• Is a Covered Expense/Service under the SHBP. Because a Health Care Provider has prescribed, ordered or recommended a service or supply does not, in itself, mean that it is Medically Necessary as defined above. Mental/Nervous Disorder. For purposes of the SHBP, a Mental/Nervous Disorder is any diagnosed con- dition listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM, most recent edition, re- vised), except as specified in Medical Expenses Not Covered, for which treatment is commonly sought from a psychiatrist or mental health Physician. The DSM is a clinical diagnostic tool developed by the American Psychiatric Association and used by mental health professionals. Diagnoses described in the DSM will be considered Mental/Nervous in nature, regardless of etiology. Mental/Nervous Treatment Facility. A public or private facility, licensed and operated according to the law, which provides: a program for diagnosis, evaluation and effective treatment of Mental/Nervous Dis- orders; and professional nursing services provided by licensed practical nurses who are directed by a full- time R.N. The facility must have a Physician on staff or on call. The facility must also prepare and maintain a written plan of treatment for each patient. The SHBP must be based on medical, psychological and social needs. Nurse. A person acting within the scope of applicable state licensure/certification requirements and hold- ing the degree of Registered Graduate Nurse (R.N.) or Licensed Practical Nurse (L.P.N.). Oral Surgery. Necessary procedures for surgery in the oral cavity, including pre- and postoperative care. Outpatient. Treatment either outside of a Hospital setting or at a Hospital when room and board charges are not incurred. Partial Hospitalization. A distinct and organized intensive ambulatory treatment service, less than 24- hour daily care specifically designed for the diagnosis and active treatment of a mental/nervous disorder when there is a reasonable expectation for improvement or to maintain the individual’s functional level and to prevent relapse or hospitalization. Partial Hospitalization programs must provide diagnostic services; services of social workers; psychiatric Nurses and staff trained to work with psychiatric patients; individual, group and family therapies; activi- ties and occupational therapies; patient education; and chemotherapy and biological treatment interven- tions for therapeutic purposes. The facility providing the Partial Hospitalization must prepare and maintain a written plan of treatment for each patient. The SHBP must be approved and periodically reviewed by a Physician. Physician. A licensed Doctor of Medicine or Doctor of Osteopathy practicing within the scope of their license and who is not a Close Family Member of the SHBP-Covered Person receiving services. Physically or Mentally Disabled. The inability of a person to be self-sufficient as the result of a condition such as mental retardation, cerebral palsy, epilepsy or another neurological disorder and diagnosed by a Physician as a permanent and continuing condition. Plan Administrator. Princeton Theological Seminary, is the sole fiduciary of the SHBP, and exercises all discretionary authority and control over the administration of the SHBP and the management and disposi- tion of plan assets. The Plan Administrator shall have the sole discretionary authority to determine eligi- bility for plan benefits or to construe the terms of the SHBP. The Plan Administrator has the right to amend, modify or terminate the SHBP in any manner, at any time, regardless of the health status of any plan participant or beneficiary. The Plan Administrator may retain a firm to perform claims processing and other specified services in relation to the SHBP. Any such contractor will not be a fiduciary of the SHBP and will not exercise any of the discretionary authority and responsibility granted to the Plan Administrator, as described above. Plan Sponsor. Princeton Theological Seminary for Princeton Theological Seminary students and/or their eligible dependents. Plan Year. The 12-month fiscal period beginning September 1 and ending August 31. Preferred Allowance. The amount that payment is based on for given Covered Expenses/Services to an In-Network Provider who/which has entered into an agreement with the Plan Administrator to be an In- Netork Provider for the SHBP. Princeton Area. Princeton Area refers to the zip code geographic areas within Mercer County. Provider(s). Refer to definitions Health Care Providers and Physician. Psychiatric Day Treatment Facility. A public or private facility, licensed and operated according to the law, which provides: treatment for all its patients for not more than 8 hours in any 24-hour period; a struc- tured psychiatric program based on an individualized treatment plan that includes specific attainable goals and objectives appropriate for the patient; and supervision by a Physician certified in psychiatry by the American Board of Psychiatry and Neurology. The facility must be accredited by the Program for Psychiatric Facilities or the Joint Commission on Ac- creditation of Hospitals. Reconstructive Surgery. A procedure performed to restore the anatomy and/or functions of the body, which are lost or impaired due to Injury or Sickness. Rehabilitation Facility. A legally operating institution or distinct part of an institution which has a trans- fer agreement with one or more Hospitals, and which is primarily engaged in providing comprehensive multi-disciplinary physical restorative services, post-acute Hospital and rehabilitative inpatient care and is duly licensed by the appropriate government agency to provide such services. It does not include institutions which provide only minimal care, Custodial Care, ambulatory or part-time care services, or an institution which primarily provides treatment of Mental/Nervous Disorders, sub- stance abuse or tuberculosis, except if such facility is licensed, certified or approved as a Rehabilitation Facility for the treatment of Mental/Nervous Disorders or substance abuse in the jurisdiction where it is located, 29 or is accredited as such a facility by the Joint Commission for the Accreditation of Health Care Organizations or the Commission for the Accreditation of Rehabilitation Facilities. Residential Treatment Facility. A child-care institution that provides residential care and treatment for emotionally disturbed children and adolescents. The facility must be accredited as a Residential Treat- ment Facility by the Council on Accreditation, the Joint Commission on Accreditation of Hospitals, or the American Association of Psychiatric Services for Children. SHBP: The Student Health Benefits Plan explained in this Plan Document and provided by Princeton Theological Seminary. SHBP-Covered Person (Persons): A person who is eligible for coverage under the SHBP and is covered by the SHBP following the full payment of the applicable cost of coverage. Second Surgical Opinion. Examination by a Physician who is certified by the American Board of Medi- cal Specialists in a field related to the proposed Surgery to evaluate the medical advisability of undergo- ing a surgical procedure. Sickness. Any bodily Sickness or Mental/Nervous Disorder. For purposes of the SHBP, pregnancy will be considered as any other Sickness.
Skilled Nursing Facility. A public or private facility, licensed and operated according to the law, which provides: permanent and full-time facilities for 10 or more resident patients; a registered Nurse or Physi- cian on full-time duty in charge of patient care; at least one registered Nurse or licensed practical Nurse on duty at all times; a daily medical record for each patient; transfer arrangements with a Hospital; and a utilization review plan. The facility must be primarily engaged in providing continuous skilled nursing care for persons during the convalescent stage of their Sickness or Injury, and is not, other than by coincidence, a rest home for Cus- todial Care or for the aged. Specialized Treatment Facility. A Specialized Treatment Facility, as the term relates to the SHBP, in- cludes Birthing Centers, Ambulatory Surgical Facilities, Hospice Facilities, Skilled Nursing Facilities, Mental/Nervous Treatment Facilities, Substance Abuse Day Treatment Facilities, Psychiatric Day Treat- ment Facilities, Substance Abuse Treatment Facilities, and Rehabilitation Facilities as those terms are specifically listed as Covered Expenses/Services. Substance Abuse Treatment Facility. A public or private facility, licensed and operated according to the law and accredited by the Joint Commission on the Accreditation of Hospitals, which provides a program for diagnosis, evaluation and effective treatment of substance abuse, detoxification services and profes- sional nursing care provided by licensed practical Nurses who are directed by a full-time R.N. The facility must have a Physician on staff or on call. The facility must also prepare and maintain a written plan of treatment for each patient based on medical, psychological and social needs. Surgery. Any operative or diagnostic procedure performed in the treatment of an Injury or Sickness by instrument or cutting procedure through any natural body opening or incision. Total Disability (Totally Disabled). An individual will be considered Totally Disabled if, because of a non-occupational Injury or Sickness, he or she is prevented from engaging in all the normal activities of a person of like age who is in good health. Usual and Customary Charge. The charge most frequently made to the majority of patients for the same service or procedure. The charge must be within the range of the charges most frequently made in the same or similar medical service area for the service or procedure as billed by other Physicians or Health Care Providers.
Sodium Cromoglycate in the Management of Chronic or Recurrent Enterocolitis in Patients With Hirschsprung’s Disease Background/Purpose: Chronic or recurring enterocolitis is a Results: The follow-up of the patients ranges from 8 months rare but perplexing complication of Hirschsprung’s diseaseto 26 months. Three of the 5 patients with chronic enteroco-affecting especially patient
Osteoarthrosis - Treatment There are multiple ways of treating osteoarthrosis. It's the most important, however, for the treatment to be complex and include: non pharmacological treatment (healthy lifestyle, nutrition, dieting, wearinginsertions in shoes, doing exercises that increase the mass of muscles),pharmacological treatment (taking prescribed drugs),rehabiliation (kinesiotherapy an
PLAN DOCUMENT