Nova Southeastern University - Aetna Student Health

RatesRates may vary depending on your program's term start and end date. Please check with the Nova SoutheasternUniversity Student Health Insurance Department or visit www.aetnastudenthealth.com/nsu for informationabout your insurance cost if not showing on the price sheet above.RatesAnesthesiology Assistant (M.S.)—except final yearOccupational Therapy (O.T.D., M.O.T.)Medical and Cardiovascular Sonography (B.S., Concurrent B.S.)Physical Therapy Doctoral PTPhysician Assistant (M.M.S., Concurrent M.M.S. and M.P.H.)—except final yearStudentAnnualFall 2146 1441Winter 705RatesAnesthesiology Assistant (M.S.)—final yearPhysician Assistant (M.M.S., Concurrent M.M.S. and M.P.H.)—final yearInternational Program for Dental (DM) & Pharmacy (Advanced Standing) GraduatesPharmacy PHD, MS entry 2StudentAnnualFall 2687 1441Winter 1246RatesClinical Vision, Research, Health Science (M.H.S., D.H.S.) Law Masters,Postdoctoral Dental ProgramsAnnualStudent 2146Nova Southeastern University 2020-2021Fall 1258Winter 888Page 12

RatesHealth Sciences MS and DoctoralPost Doc, Dental, Clinical Vision, Research with Optometry, Masters LawStudentAnnualFall 2146 1082Winter 1064RatesAbraham S. Fischler College of Education and School of Criminal Justice College of Arts,Humanities, and Social Sciences ( all levels and programs)College of Engineering and Computing (all levels and programs)Athletic Training (B.S.), Audiology (AuD) on campus residential programBiomedical Science (M.B.S.), Dental Medicine (D.M.D.)Dr. Kiran C. Patel College of Allopathic Medicine, Exercise and Sports Science (B.S.)H. Wayne Huizenga College of Business and Entrepreneurship (all levels and programs)Halmos College of Natural Sciences and Oceanography (all levels and programs)Health Science (Ph.D.), Law Full-time Day Program (J.D.)Ron and Kathy Assaf College of Nursing (all levels and programs)Pharmacy (Pharm.D., Ph.D.), Physical Therapy (Ph.D. and Transitional), Public Health(M.P.H) Residential Students (all levels and programs),Respiratory Therapy First-Professional Program (B.S.)Speech-Language and Communication Disorders (B.S.)Speech-Language Pathology (M.S., SLP.D.), Occupational Therapy (Dr. O.T., Ph.D.)Optometry (O.D.),Osteopathic MedicineCollege of Psychology (all graduate and doctoral programs), Undergraduate StudentsAnnualStudent 2146Fall 900Winter 1246Continuation Plan*3-MonthsStudentNova Southeastern University 2020-2021 1,073Page 13

Student CoverageEligibilityMandatory Student RequirementNova Southeastern University (NSU) takes its institutional responsibility to provide for a safe learning environmentseriously and is committed to the health and well-being of all enrolled students. As the recent outbreaks ofcommunicable diseases in many parts of the country illustrate, the physical health of a community can quicklybecome compromised with lapses in precautions. To safeguard the physical and mental health of all NSU Sharks,the university requires all students regardless of level, campus location, or modality, to carry adequate medicalinsurance. If you have adequate health care coverage and do not need the NSU Student Health Insurance Plan, youmust opt out of this plan each academic year by the given waiver deadline for your program. Students not enrolledin classes the first 31 days of the semester are not eligible for coverage.EnrollmentAll students will be automatically enrolled in this Plan, unless the completed waiver application has been receivedby Nova Southeastern University by the specified enrollment deadline dates listed in the next section of this PlanDesign and Benefits Summary.If you withdraw from school within the first 31 days of a coverage period, you will not be covered under the Policyand the full premium will be refunded, less any claims paid. After 31 days, you will be covered for the full periodthat you have paid the premium for, and no refund will be allowed. (This refund policy will not apply if you withdrawdue to a covered Accident or Sickness.)*Three-Month Continuation Option for Expiring 2020-2021 InsuranceStudents graduating or otherwise leaving school whose 2019-2020 student health insurance coverage is terminatingmay elect to purchase a continuation option that will provide an additional three months of coverage based on the2020-2021 Policy year benefits. Please note you can only enroll one time into the continuation option plan.Medicare Eligibility NoticeYou are not eligible to enroll in the student health plan if you have Medicare at the time of enrollment in thisstudent plan. The plan does not provide coverage for people who have Medicare.In-network Provider NetworkAetna Student Health offers Aetna’s broad network of In-network Providers. You can save money by seeing Innetwork Providers because Aetna has negotiated special rates with them, and because the Plan’s benefits arebetter.If you need care that is covered under the Plan but not available from an In-network Provider, contact MemberServices for assistance at the toll-free number on the back of your ID card. In this situation, Aetna may issue a preapproval for you to receive the care from an Out-of-network Provider. When a pre-approval is issued by Aetna, thebenefit level is the same as for In-network Providers.Nova Southeastern University 2020-2021Page 14

PrecertificationYou need pre-approval from us for some eligible health services. Pre-approval is also called precertification. Your innetwork physician is responsible for obtaining any necessary precertification before you get the care. When you goto an out-of-network provider, it is your responsibility to obtain precertification from us for any services andsupplies on the precertification list. If you do not precertify when required, there is a 500 penalty for each type ofeligible health service that was not precertified. For a current listing of the health services or prescription drugs thatrequire precertification, contact Member Services or go to www.aetnastudenthealth.com/.Precertification CallPrecertification should be secured within the timeframes specified below. To obtain precertification, call MemberServices at the toll-free number on your ID card. This call must be made:Non-emergency admissions:You, your physician or the facility will need to call and requestprecertification at least 14 days before the date you are scheduled to beadmitted.An emergency admission:You, your physician or the facility must call within 48 hours or as soon asreasonably possible after you have been admitted.An urgent admission:You, your physician or the facility will need to call before you arescheduled to be admitted. An urgent admission is a hospital admission bya physician due to the onset of or change in an illness, the diagnosis of anillness, or an injury.Outpatient non-emergency servicesrequiring precertification:You or your physician must call at least 14 days before the outpatientcare is provided, or the treatment or procedure is scheduled.We will provide a written notification to you and your physician of the precertification decision, where required bystate law. If your precertified services are approved, the approval is valid for 30 days, as long as you remain enrolledin the plan.Coordination of Benefits (COB)Some people have health coverage under more than one health plan. If you do, we will work together with yourother plan(s) to decide how much each plan pays. This is called coordination of benefits (COB). A completedescription of the Coordination of Benefits provision is contained in the certificate issued to you.Nova Southeastern University 2020-2021Page 15

Description of BenefitsThe Plan excludes coverage for certain services and has limitations on the amounts it will pay. While this PlanSummary document will tell you about some of the important features of the Plan, other features that may beimportant to you are defined in the Certificate. To look at the full Plan description, which is contained in theCertificate issued to you, go to www.aetnastudenthealth.com.This Plan will pay benefits in accordance with any applicable Florida Insurance Law(s).Policy year deductibleIn-network coverageOut-of-network coverageStudent 400 per policy year 800 per policy yearThis is the amount you owe for in-network and out-of-network eligible health services each policy year beforethe plan begins to pay for eligible health services. After the amount you pay for eligible health services reachesthe policy year deductible, this plan will begin to pay for eligible health services for the rest of the policy year.Eligible health services applied to the out-of-network policy year deductible will not be applied to satisfy the innetwork policy year deductible. Eligible health services applied to the in-network policy year deductible will notbe applied to satisfy the out-of-network policy year deductible.Policy year deductible waiverThe policy year deductible is waived for all of the following eligible health services: In-network care for Preventive care and wellness In-network care for Pediatric Preventive Dental Services In-network and out-of-network care for Prescribed Medicines Expense, Routine Mammograms, and PediatricPreventive Vision ServicesMaximum out-of-pocket limit per policy yearStudent 5,750 per policy yearNoneEligible health services applied to the out-of-network maximum out-of-pocket limit will not be applied to satisfythe in-network maximum out-of-pocket limit and eligible health services applied to the in-network maximum outof-pocket limit will not be applied to satisfy the out-of-network maximum out-of-pocket limit.Referral penaltyYou must get a referral from school health services for off-campus care.If you do not get a referral, then we won’t pay the provider.Exceptions Treatment for an emergency medical conditionObstetric and gynecological carePediatric careThe school health services is closedYou are more than 25 miles from the school health serviceChiropractic careDermatologyPreventive/Routine Services (services considered preventive according to Health Care Reform and/orservices rendered not to diagnosis or treat an accident or sickness)Services provided by Tier 1 providers listed in plan documentsNova Southeastern University 2020-2021Page 16

Eligible health servicesIn-network coverageOut-of-network coverage100% (of the negotiatedcharge) per visit50% (of the recognized charge)per visitRoutine physical examsPerformed at a physician’s officeNo copayment or policy yeardeductible appliesMaximum age and visit limits per policyyear through age 21Subject to any age and visit limits provided for in thecomprehensive guidelines supported by the American Academy ofPediatrics/Bright Futures/Health Resources and ServicesAdministration guidelines for children and adolescents.Maximum visits per policy year age 22 andover1 visitPreventive care immunizationsPerformed in a facility or at a physician'soffice100% (of the negotiatedcharge) per visit50% (of the recognized charge)per visitNo copayment or policy yeardeductible appliesMaximumsSubject to any age limits provided for in the comprehensiveguidelines supported by Advisory Committee on ImmunizationPractices of the Centers for Disease Control and Prevention.Routine gynecological exams (including Pap smears and cytology tests)Performed at a physician’s, obstetrician(OB), gynecologist (GYN) or OB/GYN office100% (of the negotiatedcharge) per visit50% (of the recognized charge)per visitNo copayment or policy yeardeductible appliesMaximum visits per policy year1 visitPreventive screening and counseling servicesPreventive screening and counselingservices for Obesity and/or healthy dietcounseling, Misuse of alcohol & drugs,Tobacco Products, Depression Screening,Sexually transmitted infection counseling &Genetic risk counseling for breast andovarian cancer100% (of the negotiatedcharge) per visit50% (of the recognized charge)per visitNo copayment or policy yeardeductible applies(continued next page)Nova Southeastern University 2020-2021Page 17

Eligible health servicesIn-network coverageOut-of-network coveragePreventive screening and counseling services (continued)Obesity/Healthy Diet maximum per policyyear (Applies to covered persons age 22and older)26 visits10 visits will be allowed under the plan for healthy diet counselingprovided in connection with hyperlipidemia (high cholesterol) andother known risk factors for cardiovascular and diet-relatedchronic diseaseMisuse of Alcohol maximum per policy year5 visitsTobacco Products Counseling maximumper policy year8 visitsDepression screening maximum per policyyear1 visitSTI maximum per policy year2 visitsRoutine cancer screenings100% (of the negotiatedcharge) per visit50% (of the recognized charge)per visitNo copayment or policy yeardeductible appliesMaximumsLung cancer screening maximumsPrenatal care services (Preventive careservices only)Subject to any age; family history; and frequency guidelines as setforth in the most current: Evidence-based items that have in effect a rating of A or B in thecurrent recommendations of the United States PreventiveServices Task Force; and The comprehensive guidelines supported by the HealthResources and Services Administration.1 screening every 12 month100% (of the negotiatedcharge) per visit50% (of the recognized charge)per visitNo copayment or policy yeardeductible appliesLactation support and counseling services100% (of the negotiatedcharge) per visit50% (of the recognized charge)per visitNo copayment or policy yeardeductible appliesLactation counseling services maximum perpolicy yearBreast pump supplies and accessories6 visits100% (of the negotiatedcharge) per item50% (of the recognized charge)per itemNo copayment or policy yeardeductible appliesNova Southeastern University 2020-2021Page 18

Eligible health servicesIn-network coverageOut-of-network coveragePreventive screening and counseling services (continued)Female contraceptive counseling servicesoffice visit100% (of the negotiatedcharge) per visit50% (of the recognized charge)per visitNo copayment or policy yeardeductible appliesContraceptive counseling servicesmaximum per policy yearFemale contraceptive prescription drugsand devices2 visits100% (of the negotiatedcharge) per item50% (of the recognized charge)per itemNo copayment or policy yeardeductible appliesFemale voluntary sterilizationInpatient & Outpatient provider services100% (of the negotiatedcharge)50% (of the recognized charge)No copayment or policy yeardeductible appliesPhysicians and other health professionalsPhysician, specialist including ConsultantsOffice visits (non-surgical/non-preventivecare by a physician and specialist)Includes telemedicine consultations) 30 copayment then the planpays 70% (of the balance of thenegotiated charge) per visitthereafter50% (of the recognized charge)per visitCovered according to the typeof benefit and the place wherethe service is receivedCovered according to the typeof benefit and the place wherethe service is receivedAllergy testing and treatmentAllergy testing & Allergy injectionstreatment (including Allergy sera andextracts administered via injection)performed at a physician’s or specialist’sofficePhysician and specialist - surgical servicesInpatient surgery performed during yourstay in a hospital or birthing center by asurgeon (includes anesthetist and surgicalassistant expenses)70% (of the negotiated charge)50% (of the recognized charge)Outpatient surgery performed at aphysician’s or specialist’s office oroutpatient department of a hospital orsurgery center by a surgeon (includesanesthetist and surgical assistant expenses)70% (of the negotiated charge)per visit50% (of the recognized charge)per visit 30 copayment then the planpays 70% (of the balance of thenegotiated charge) per visitthereafter50% (of the recognized charge)per visitAlternatives to physician office visitsWalk-in clinic visits (non-emergency visit)Nova Southeastern University 2020-2021Page 19

Eligible health servicesIn-network coverageOut-of-network coverage70% (of the negotiated charge)per admission50% (of the recognized charge)per admission70% (of the negotiated charge)per visit50% (of the recognized charge)per visitOutpatient surgery (facility charges)performed in the outpatient department ofa hospital or surgery center70% (of the negotiated charge)per visit50% (of the recognized charge)per visitHome Health Care70% (of the negotiated charge)per visit50% (of the recognized charge)per visitHospice-Inpatient70% (of the negotiated charge)per admission50% (of the recognized charge)per admissionHospice-Outpatient70% (of the negotiated charge)per visit50% (of the recognized charge)per visitSkilled nursing facility - Inpatient70% (of the negotiated charge)per admission50% (of the recognized charge)per admissionHospital and other facility careInpatient hospital (room and board) andother miscellaneous services andsupplies)Includes birthing center facility chargesIn-hospital non-surgical physician servicesAlternatives to hospital staysMaximum days of confinement per policyyear60Hospital emergency room 300 copayment then the planpays 70% (of the balance of thenegotiated charge) per visitPaid the same as in-networkcoverageNon-emergency care in a hospitalemergency roomNot coveredNot coveredImportant note: As out-of-network providers do not have a contract with us the provider may not accept payment of yourcost share, (copayment/coinsurance), as payment in full. You may receive a bill for the difference betweenthe amount billed by the provider and the amount paid by this plan. If the provider bills

Nova Southeastern University Policy Year: 2020 - 2021 Policy Number: 867897 . www.aetnastudenthealth.com (855) 821-9720 . This is a brief description of the Student Health Plan. The plan is available for Nova Southeastern University . Medical and Cardiovascular Sonography (B.S., Concurrent B.S.) Physical Therapy Doctoral PT .