University of Missouri Kansas City International SBC 500499912071900371 FINAL 2

Aetna Student Health: University of Missouri System International
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: beginning on or after 8/1/14

Coverage for: Individual Plan Type: PPO
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document
at http://www.aetnastudenthealth.com/umkc or by calling 1-877-375-7905.
Important Questions
Answers
Why this Matters:
What is the overall

deductible?
Student: $450 (Reduced to $300 with referral

from Student Health Center)/Dependent:
$300 per Policy Year. Waived for Preferred
Preventive Care Services, immunizations
from birth to 19, & Preferred Care Pediatric
Preventive Dental & Vision Services.
You must pay all the costs up to the deductible amount before this plan begins to pay
for covered services you use. Check your policy or plan document to see when the
deductible starts over (usually, but not always, January 1st). See the chart starting on
page 2 for how much you pay for covered services after you meet the deductible.
Are there other

deductibles for specific
services?
No
You dont have to meet deductibles for specific services, but see the chart starting on
page 2 for other costs for services this plan covers.
Is there an outof
pocket limit on my
expenses?
Yes, Individual: $6,350/Family: $12,700

Preferred Care Only
The out-of-pocket limit is the most you could pay during a coverage period (usually one
year) for your share of the cost of covered services. This limit helps you plan for health
care expenses.
What is not included in

the outofpocket
limit?
Penalties, premiums, balance-billed charges,

and health care this plan doesnt cover
Even though you pay these expenses, they dont count toward the outofpocket limit.
Is there an overall
annual limit on what
the plan pays?
No
The chart starting on page 2 describes any limits on what the plan will pay for specific
covered services, such as office visits.
Does this plan use a

network of providers?
Yes. For a list of preferred providers, see

http://www.aetnastudenthealth.com/um
kc or call 1-877-375-7905
If you use an in-network doctor or other health care provider, this plan will pay some or
all of the costs of covered services. Be aware, your in-network doctor or hospital may use
an out-of-network provider for some services. Plans use the term in-network, preferred,
or participating for providers in their network. See the chart starting on page 2 for how
this plan pays different kinds of providers.
Do I need a referral to
see a specialist?
Yes, Students only. When a referral is

obtained for required services, the deductible
is reduced to $300. Refer to Policy for details
This plan will pay some or all of the costs to see a specialist for covered services but
only if you have the plans permission before you see the specialist.
Are there services this

plan doesnt cover?
Yes
Some of the services this plan doesnt cover are listed on page 4. See your policy or plan
document for additional information about excluded services.
Questions: Call 1-877-375-7905 or visit us at http://www.aetnastudenthealth.com/umkc.

If you arent clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary
at www.healthreformplanSBC.com.
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Common
Medical Event
Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the
plans allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 20% would be $200. This may change if you
havent met your deductible.
The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed
amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed
amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
This plan may encourage you to use participating providers by charging you lower deductibles, co-payments and co-insurance amounts.
Services You May Need
Primary care visit to treat an injury or
illness
If you visit a health

care providers office or Specialist visit
clinic
Other practitioner office visit
Preventive care/screening/immunization
Diagnostic test (x-ray, blood work)
If you have a test
Imaging (CT/PET scans, MRIs)
If you need drugs to
Generic drugs
treat your illness or
condition
Preferred brand drugs
More information about
Non-preferred brand drugs
prescription drug
coverage is available at
http://www.aetnastud Specialty drugs
enthealth.com/umkc
Facility fee (e.g., ambulatory surgery
If you have outpatient
center)
surgery
Physician/surgeon fees
Your cost if you use an

Non-Preferred
Preferred Provider
Provider
$20 Copay per visit,
50% Coinsurance
20% Coinsurance
50% Coinsurance
20% Coinsurance
20% Coinsurance
50% Coinsurance
No Charge
30% Coinsurance
20% Coinsurance
50% Coinsurance
20% Coinsurance
50% Coinsurance
$15 Copay per prescription $15 Copay per
(retail)
prescription (retail)
(retail)
(retail)
Limitations & Exceptions

---none-----none--Includes Chiropractic.
---none-----none-----none---
Covers up to a 30 day supply. Two

Copays covers up to a 90 day supply
(mail).
$50 Copay per prescription

(retail)
$50 Copay per

20% Coinsurance
50% Coinsurance
---none---
20% Coinsurance
50% Coinsurance
---none---

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Common
Medical Event
If you need immediate
medical attention
If you have a hospital
stay
If you have mental

health, behavioral
health, or substance
abuse needs

Emergency room services
Emergency medical transportation
Urgent care
Facility fee (e.g., hospital room)
Physician/surgeon fee
Mental/Behavioral health outpatient
services
Mental/Behavioral health inpatient
services
Substance use disorder outpatient services
Substance use disorder inpatient services
Prenatal and postnatal care

If you are pregnant
Delivery and all inpatient services

Non-Preferred
Preferred Provider
Provider
20% Coinsurance
20% Coinsurance
20% Coinsurance
$200 Copay per admission,
20% Coinsurance
20% Coinsurance
20% Coinsurance
20% Coinsurance
20% Coinsurance
20% Coinsurance
Prenatal:
No Charge
Postnatal:
20% Coinsurance
Diagnostic:
20% Coinsurance
Inpatient:
20% Coinsurance
Delivery:
20% Coinsurance

20% Coinsurance
20% Coinsurance
50% Coinsurance
---none-----none---
50% Coinsurance
Requires pre-certification.
50% Coinsurance
---none---
50% Coinsurance
---none---
50% Coinsurance
50% Coinsurance
---none---
50% Coinsurance
Prenatal:
30% Coinsurance
Postnatal &
Diagnostic:
50% Coinsurance
---none---
Inpatient:
5% Coinsurance
Delivery:
50% Coinsurance

---none---
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Common
Medical Event
If you need help

recovering or have
other special health
needs
If your child needs

dental or eye care

Non-Preferred
Preferred Provider
Provider

Home health care
Rehabilitation services
Habilitation services
50% Coinsurance
50% Coinsurance
50% Coinsurance
---none--Includes Physical, Occupational &

Speech Therapies
50% Coinsurance
Durable medical equipment

Hospice service
Eye exam
20% Coinsurance
20% Coinsurance
20% Coinsurance
20% Coinsurance
20% Coinsurance
20% Coinsurance
No Charge
50% Coinsurance
50% Coinsurance
30% Coinsurance
Glasses
No Charge
30% Coinsurance
Dental check-up
No Charge
30% Coinsurance
---none--Requires pre-certification.
---none--Coverage is limited to 1 pair of glasses
(lenses and frames) per Policy Year.
Coverage is limited to 1 every 6
months.
Skilled nursing care
Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isnt a complete list. Check your policy or plan document for other excluded services.)
Acupuncture
Infertility treatment
Routine eye care (Adult)
Cosmetic surgery
Long term care
Routine foot care
Dental care (Adult)
Weight loss programs

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Other Covered Services (This isnt a complete list. Check your policy or plan document for other covered services and your costs for these services.)
Bariatric surgery
Glasses (Child)
Routine eye care (Child)
Chiropractic care
Hearing aids
Private-duty nursing
Dental care (Child)
Non-emergency care when traveling outside

the U.S.
Your Rights to Continue Coverage:

Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay your premium. There are
exceptions, however, such as if:
You commit fraud

The insurer stops offering services in the State
You move outside the coverage area
For more information on your rights to continue coverage, contact the insurer at 1-877-375-7905. You may also contact your state insurance department
at 1-800-726-7390.
Your Grievance and Appeals Rights:

If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For
questions about your rights, this notice, or assistance, you can contact Aetna at 1-877-375-7905. You may also contact your state insurance department at
1-800-726-7390.
Language Access Services:

Para obtener asistencia en Espaol, llame al 1-877-375-7905.
Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-877-375-7905.
1-877-375-7905.
Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-877-375-7905.
To see examples of how this plan might cover costs for a sample medical situation, see the next page.
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Coverage Examples
About these Coverage

Examples:
These examples show how this plan might cover
medical care in given situations. Use these
examples to see, in general, how much financial
protection a sample patient might get if they are
covered under different plans.
This is
not a cost
estimator.
Dont use these examples to
estimate your actual costs
under this plan. The actual
care you receive will be
different from these
examples, and the cost of
that care will also be
different.
See the next page for
important information about
these examples.
Having a baby
Managing type 2 diabetes
(normal delivery)
(routine maintenance of
a well-controlled condition)
Amount owed to providers: $7,540

Plan pays $5,520
Patient pays $2,020
Amount owed to providers: $5,400

Plan pays $4,000
Patient pays $1,400
Sample care costs:

Hospital charges (mother)
Routine obstetric care
Hospital charges (baby)
Anesthesia
Laboratory tests
Prescriptions
Radiology
Vaccines, other preventive
Total
$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540
Sample care costs:

Prescriptions
Medical Equipment and Supplies
Office Visits and Procedures
Education
Laboratory tests
Vaccines, other preventive
Total
$2,900
$1,300
$700
$300
$100
$100
$5,400
Patient pays:
Deductibles
Co-pays
Co-insurance
Limits or exclusions
Total
$300
$200
$1,350
$150
$2,020
Patient pays:
Deductibles
Co-pays
Co-insurance
Limits or exclusions
Total
$300
$600
$420
$80
$1,400

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Coverage Examples

Questions and answers about the Coverage Examples:

What are some of the assumptions
behind the Coverage Examples?
Costs dont include premiums.

Sample care costs are based on national
averages supplied by the U.S.
Department of Health and Human
Services, and arent specific to a
particular geographic area or health plan.
The patients condition was not an
excluded or preexisting condition.
All services and treatments started and
ended in the same coverage period.
There are no other medical expenses for
any member covered under this plan.
Out-of-pocket expenses are based only
on treating the condition in the example.
The patient received all care from innetwork providers. If the patient had
received care from out-of-network
providers, costs would have been higher.
What does a Coverage Example

show?
Can I use Coverage Examples to

compare plans?
For each treatment situation, the Coverage

Example helps you see how deductibles, copayments, and co-insurance can add up. It
also helps you see what expenses might be left
up to you to pay because the service or
treatment isnt covered or payment is limited.
Yes. When you look at the Summary of
Does the Coverage Example predict

my own care needs?
No. Treatments shown are just examples.

The care you would receive for this
condition could be different based on your
doctors advice, your age, how serious your
condition is, and many other factors.
Does the Coverage Example predict

my future expenses?
No. Coverage Examples are not cost

estimators. You cant use the examples to
estimate costs for an actual condition. They
are for comparative purposes only. Your
own costs will be different depending on
the care you receive, the prices your
providers charge, and the reimbursement
your health plan allows.
Benefits and Coverage for other plans,

youll find the same Coverage Examples.
When you compare plans, check the
Patient Pays box in each example. The
smaller that number, the more coverage
the plan provides.
Are there other costs I should

consider when comparing plans?
Yes. An important cost is the premium

you pay. Generally, the lower your
premium, the more youll pay in out-ofpocket costs, such as co-payments,
deductibles, and co-insurance. You
should also consider contributions to
accounts such as health savings accounts
(HSAs), flexible spending arrangements
(FSAs) or health reimbursement accounts
(HRAs) that help you pay out-of-pocket
expenses.
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Aetna Student Health: University of Missouri System International

Coverage Period: beginning on or after 8/1/14

Why this Matters:

What is the overall

Student: $450 (Reduced to $300 with referral

Are there other

Yes, Individual: $6,350/Family: $12,700

What is not included in

Penalties, premiums, balance-billed charges,

Does this plan use a

Yes. For a list of preferred providers, see

Yes, Students only. When a referral is

Are there services this

Questions: Call 1-877-375-7905 or visit us at http://www.aetnastudenthealth.com/umkc.

Aetna Student Health: University of Missouri System International

Coverage Period: beginning on or after 8/1/14

If you visit a health

Your cost if you use an

Limitations & Exceptions

Covers up to a 30 day supply. Two

$50 Copay per prescription

$50 Copay per

Questions: Call 1-877-375-7905 or visit us at http://www.aetnastudenthealth.com/umkc.

Aetna Student Health: University of Missouri System International

Coverage Period: beginning on or after 8/1/14

If you have mental

Services You May Need

Prenatal and postnatal care

Delivery and all inpatient services

Your cost if you use an

Limitations & Exceptions

$100 Copay per visit,

Questions: Call 1-877-375-7905 or visit us at http://www.aetnastudenthealth.com/umkc.

Aetna Student Health: University of Missouri System International

Coverage Period: beginning on or after 8/1/14

If you need help

If your child needs

Your cost if you use an

Services You May Need

Limitations & Exceptions

---none--Includes Physical, Occupational &

Durable medical equipment

Skilled nursing care

Excluded Services & Other Covered Services:

Routine eye care (Adult)

Long term care

Routine foot care

Dental care (Adult)

Weight loss programs

Questions: Call 1-877-375-7905 or visit us at http://www.aetnastudenthealth.com/umkc.

Aetna Student Health: University of Missouri System International

Coverage Period: beginning on or after 8/1/14

Routine eye care (Child)

Dental care (Child)

Non-emergency care when traveling outside

Your Rights to Continue Coverage:

You commit fraud

Your Grievance and Appeals Rights:

Language Access Services:

Aetna Student Health: University of Missouri System International

Coverage Period: beginning on or after 8/1/14

About these Coverage

Managing type 2 diabetes

Amount owed to providers: $7,540