ITT Technical Institute Plan Have Their Medical ID Cards As STUDENT MASSACHUSETTS REQUIREMENT to Early As Possible

ELIGIBILITY AND ENROLLMENT the ITT Technical Institute plan have their medical ID cards as STUDENT MASSACHUSETTS REQUIREMENT TO early as possible. It is your responsibility to carefully compare PURCHASE HEALTH INSURANCE: your current insurance plan with that offered by ITT Technical As of January 1, 2009, the Massachusetts Health Care Institute to ensure the coverage is truly comparable. If you do HEALTH Reform Law requires that Massachusetts residents, not have comparable health insurance or do not complete the eighteen (18) years of age and older, must have health waiver by the deadline, you will be required to purchase the INSURANCE coverage that meets the Minimum Creditable Coverage Student Health Insurance Plan and will be automatically standards set by the Commonwealth Health Insurance enrolled; refunds will not be given. PLAN Connector, unless waived from the health insurance PREMIUMS requirement based on affordability or individual hardship. For more information call the Connector at 1-877-MA- ITT Quarter Quarter Start and Rate per ENROLL or visit the Connector website End Dates Student per Designed for the (www.mahealthconnector.org). Quarter Summer 2014 6/13/14-9/11/14 $368 Students of This health plan satisfies Minimum Creditable Coverage standards that are effective during the term of coverage as Fall 2014 9/12/14-12/4/14 $368 part of the Massachusetts Health Care Reform Law. If you Winter 12/5/14-3/11/15 $368 ITT Technical Institute purchase this plan, you will satisfy the statutory requirements 2014/2015 that you have health insurance meeting these standards. Spring 2015 3/12/15- 6/12/15 $368 If you have questions about this notice, you may contact The above rates include an administrative fee retained by the 2014-2015 the Division of Insurance by calling (617)521-7794 or servicing agent. visiting its website at www.mass.gov/doi. Massachusetts State Law mandates that all students who are DEFINITIONS full-time and three-quarter time carry adequate medical Accident means a sudden, unexpected and unforeseen, external Underwritten by: insurance to help cover the extra expenses of medical event that causes injury to an Insured Person. The Accident must National Guardian Life Insurance Company treatment. occur while coverage is in effect for the Insured Person. Policy Number: 2014I5A31 The ITT Technical Institute Health Insurance Plan provides Co-payment means the cost an Insured Person pays as a fixed coverage to students for a twelve (12) month period June 13, dollar amount for a covered service This amount represents the Effective: June 13, 2014 to June 12, 2015 2014 through June 12, 2015. amount of Usual and Reasonable expenses for treatment that Group Number: S210306 PLEASE NOTE: If you are currently covered under a non-US We do not pay, which are listed on the Schedule of Benefits. The Insured Person is responsible for paying this portion of the based insurance carrier, a foreign National Health Service program (socialized medicine), or the Massachusetts expenses incurred. Any Copayment amounts are shown in the Schedule of Benefits. This health plan satisfies Minimum Creditable Uncompensated Care Pool (known as “free care”), you are Coverage standards and will satisfy the individual NOT eligible to waive the ITT Technical Institute Student Covered Injury means a bodily injury that is: mandate that you have health insurance. Please Health Insurance plan. These types of plans are not 1. Sustained by an Insured Person while he/she is insured see page 2 for additional information. considered comparable coverage by Massachusetts State under the Policy or the School’s prior policies; and Law, and you will be required to enroll in the ITT Technical 2. Caused by and accident directly and independently of all Institute Student Health Insurance Plan. other causes. Coverage under the School’s policies must have remained EVERY STUDENT attending ITT Technical Institute MUST continuously in force: record their medical insurance information. You must let us know if you are enrolling in the Student Health Insurance Plan 1. From the date of Injury; and offered by ITT Technical Institute or if you prefer to waive this 2. Until the date services or supplies are received, for them to plan. Please go to www.universityhealthplans.com for be considered as a Covered Medical Expense under the information on completing your waiver form. ALL STUDENTS Policy. must record their waiver by July 12, 2014 in order to ensure 14-I5A31 (cert.) your bill accurately reflects your choice, and those enrolling in 2 3 Covered Medical Expense means those charges for any a. Placing the health of the individual (or with respect to social workers and psychiatric nurses to the same extent that treatment, service or supplies that are: a pregnant woman, the health of the woman or her their services would be covered if performed by a Physician. 1. Not in excess of the Usual and Reasonable charges; unborn child) in serious jeopardy; Physician also includes Christian Science Practitioners listed in 2. Not in excess of the charges that would have been made b. Serious impairment to bodily functions; or the Christian Science Journal at the time the service is provided in the absence of this insurance; and c. Serious dysfunction of any bodily organ or part. and who adheres to the rules and regulations of the First Church 3. Incurred while the Policy is in force as to the Insured Essential Health Benefits mean benefits that are defined as of Christ, Scientist, Boston, Massachusetts. Person, except with respect to any expenses payable such by the Secretary of Labor and are to be provided in a The term Physician does not mean any person who is an under the Extension of Benefits Provision. manner that is equal to the scope of benefits provided under a Immediate Family Member. Covered Medical Expense includes those charges for treatment, typical employer plan. This applies to the following general Usual and Reasonable (U&R) means the normal charge, in the services or supplies delivered in accordance with the healing categories and the items and services covered within the absence of insurance, of the provider for a service or supply, but practices of Christian Science. categories: not more than the prevailing charge in the area for a: 1. Ambulatory patient services; Covered Sickness means Sickness, disease or trauma related 1. Like service by a provider with similar training or 2. Emergency services; disorder due to Injury which: experience; or 3. Hospitalization; 1. Causes a loss while the Policy is in force; and 2. Supply that is identical or substantially equivalent. 2. Which results in Covered Medical Expenses. 4. Maternity and newborn care; 5. Mental health and substance use disorder services, We, Our, or Us means National Guardian Life Insurance Elective Surgery or Elective Treatment means surgery or including behavioral health treatment; Company, or its authorized agents. medical treatment that is: 6. Prescription drugs; You, Your, Yours means the insured student. 1. Not necessitated by a pathological or traumatic change in 7. Rehabilitative and habilitative services and devices; SCHEDULE OF BENEFITS the function or structure of any part of the body; and 8. Laboratory services; When initial medical treatment is received within 30 days of the 2. Which occurs after the Insured Person’s effective date of 9. Preventive and wellness services and chronic disease occurrence of a Covered Injury or the onset of a Covered coverage. management; and Sickness the Policy will pay 80%, except as specifically stated, Elective Treatment includes, but is not limited to, treatment for 10. Pediatric services, including oral and vision care. of Covered Medical Expenses incurred by an Insured Person acne, warts and moles removed for cosmetic purposes, weight Insured Person means a student of the Policyholder who is due to a Covered Sickness or Covered Injury for Domestic and reduction, infertility, learning disabilities, routine physical eligible and insured for coverage under the Policy. International Students with J-1 visas. Covered Medical examinations, fertility tests and pre-marital examinations, Loss means medical expense caused by Injury or Sickness and Expenses are considered incurred on the date the treatment or preventive medicines or vaccines except when required for the covered by the Policy. service is rendered or the supply is furnished. Covered treatment of Covered Injury or Covered Sickness to the extent Medical Expenses are shown in the Schedule of Benefits. coverage is not required by state or federal law. Physician means a: MANDATED BENEFITS Elective Surgery includes, but is not limited to, circumcision, 1. Doctor of Medicine (M.D); or vasectomy, breast reduction, sexual reassignment surgery, 2. Doctor of Osteopathy (D.O); or State mandated benefits will be subject to all deductibles, submucous resection and/or other surgical correction for a 3. Doctor of Dentistry (D.M.D. or D.D.S.); or Co-payments, co-insurance, limitations, or other deviated nasal septum, other than for necessary treatment of 4. Doctor of Chiropractic (D.C.); or provisions of the policy, unless specifically stated acute sinusitis to the extent coverage is not required by state 5. Doctor of Optometry (O.D.); or otherwise. or federal law. Elective surgery does not include Plastic or 6. Doctor of Podiatry (D.P.M.) Mandate Disclaimer: If any Preventive Services Benefit is Cosmetic Surgery required to correct an abnormality caused Who is licensed to practice as such by the governmental subject to the mandated benefits required by state law, they by a Covered Injury or Covered Sickness. authority having jurisdiction over the licensing of such will be administered under the federal or state guideline, whichever is more favorable to the student. Emergency Medical Condition means a medical condition, classification of doctor in the state where the service is which: rendered.

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