2015-2016-insurance-benefits-booklet.pdf - University of...

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University of Houston (Clear Lake Campus) 2015-2016 Student Health Insurance Plan Overview Administrator Policy Number: CHH9073386 Underwriter Reference Number: CAS9148747 Insurance underwritten by National Union Fire Insurance Company of Pittsburgh, Pa., with its principal place of business in New York, NY (“the Company”) Who Is Eligible for coverage under the University of Houston Student Health Insurance Plan (“the Plan”)? Domestic students attending UH Clear Lake Campus who are enrolled for 6 or more credit hours (3 for summer session) are eligible to enroll for coverage under the Plan and may enroll online at prior to the following enrollment deadlines: Annual/Fall - 9/24/15; Spring/Summer – 2/19/16; Summer Only - 7/6/16. Enrollment deadlines are also posted online at . Non-Immigrant International Students attending UH Clear Lake on an “F” or “J” visa who are enrolled in any amount of credit hours will be automatically enrolled in and billed each semester for coverage under the Plan unless a request for a waiver of coverage has been submitted and approved by the waiver deadline each semester. A waiver of coverage request must be submitted online at: . Additional waiver procedures and deadline information are available at: . Waiver deadlines: Fall - 9/11/15; Spring/Summer – 2/5/16; Summer Only – 6/16/16. Brief Overview of the U H Student Health Insurance Plan: Aggregate Maximum Benefit per Policy Year: Unlimited DEDUCTIBLE AMOUNT : (Deductibles do not apply to Eligible Expenses incurred at the UHCL Health Center) Outpatient per policy year: In Network: $250/ Out of Network: $250 Inpatient per confinement: In Network: $150 Out of Network: $250 OUT OF POCKET LIMITATION PER COVERED PERSON In Network: $6,350/ Out of Network: $6,350 The Out-of-Pocket Limit is reached when the amount of Eligible Expenses incurred by the Covered Person during the Policy Year for which the Covered Person is responsible due to covered percentages being less than 100% reach the Out-of-Pocket Limit. The Out-of-Pocket Limit includes deductibles, copays and coinsurance. The Out-of-Pocket Limit does not include charges in excess of Reasonable and Customary; charges in excess of any specified maximum; or charges incurred for any services not covered under the Policy. When the Out-of- Pocket Limit is met during a Policy Year, covered percentages are increased to 100% for all Eligible Expenses incurred by the Covered Person in the remainder of that Policy Year up to any benefit maximum that may apply. COVERED PERCENTAGE ( UNLESS OTHERWISE STATED ) (When services are rendered at UHCL Health Center, Eligible Expenses will be payable at 100%) Inpatient: In Network: 80% of Allowable Charges (AC) Out of Network: 60% of Reasonable and Customary Charges (R&C) Outpatient: In Network: 80% of Allowable Charges (AC) Out of Network: 80% of Reasonable and Customary Charges (R&C) PRESCRIPTION DRUGS (Copays are per
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  • Fall '08
  • Husband,E
  • Covered Person

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