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UNITEDHEALTHCARE INSURANCE COMPANY Cal Poly San Luis Obispo UNITEDHEALTHCARE INSURANCE COMPANY STUDENT INJURY AND SICKNESS INSURANCE PLAN CERTIFICATE OF COVERAGE Designed Especially for the International Students of Cal Poly San Luis Obispo 2018-2019 This Certificate of Coverage is Part of Policy # 2018-200412-4 This Certificate of Coverage (“Certificate”) is part of the contract between UnitedHealthcare Insurance Company (hereinafter referred to as the “Company”) and the Policyholder. Please keep this Certificate as an explanation of the benefits available to the Insured Person under the contract between the Company and the Policyholder. This Certificate is not a contract between the Insured Person and the Company. Amendments or endorsements may be delivered with the Certificate or added thereafter. The Master Policy is on file with the Policyholder and contains all of the provisions, limitations, exclusions, and qualifications of your insurance benefits, some of which may not be included in this Certificate. The Master Policy is the contract and will govern and control the payment of benefits. PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS HEALTH CARE MAY BE OBTAINED. NOTICE: THE INSURED SHOULD REVIEW THE DEFINITIONS IN THIS CERTIFICATE OF COVERAGE TO UNDERSTAND HOW BENEFITS ARE PAID. READ THIS ENTIRE CERTIFICATE CAREFULLY. IT DESCRIBES THE BENEFITS AVAILABLE UNDER THE POLICY. IT IS THE INSURED PERSON’S RESPONSIBILITY TO UNDERSTAND THE TERMS AND CONDITIONS IN THIS CERTIFICATE. COL-17-CA CERT 04-200412-4 Table of Contents Introduction................................................................................................................................................................................................................... 1 Section 1: Who Is Covered ...................................................................................................................................................................................... 1 Section 2: Effective and Termination Dates ......................................................................................................................................................... 2 Section 3: Extension of Benefits after Termination ............................................................................................................................................. 2 Section 4: Pre-Admission Notification ................................................................................................................................................................... 2 Section 5: Preferred Provider Information ............................................................................................................................................................ 2 Section 6: Medical Expense Benefits – Injury and Sickness ........................................................................................................................... 4 Section 7: Mandated Benefits ............................................................................................................................................................................... 11 Section 8: Coordination of Benefits Provision ................................................................................................................................................... 18 Section 9: Accidental Death and Dismemberment Benefits .......................................................................................................................... 21 Section 10: Definitions ............................................................................................................................................................................................ 22 Section 11: Exclusions and Limitations ............................................................................................................................................................... 26 Section 12: How to File a Claim for Injury and Sickness Benefits ............................................................................................................... 27 Section 13: General Provisions............................................................................................................................................................................. 28 Section 14: Notice of Appeal Rights ................................................................................................................................................................... 28 Section 15: Online Access to Account Information ......................................................................................................................................... 33 Section 16: ID Cards ............................................................................................................................................................................................... 34 Section 17: UHCSR Mobile App .......................................................................................................................................................................... 34 Section 18: Important Company Contact Information ..................................................................................................................................... 34 Section 19: Pediatric Dental Services Benefit .................................................................................................................................................. 34 Section 20: Pediatric Vision Care Services Benefit ......................................................................................................................................... 55 Section 21: UnitedHealthcare Pharmacy (UHCP) Prescription Drug Benefits ......................................................................................... 59 Additional Policy Documents Schedule of Benefits .............................................................................................................................................................................. Attachment Assistance and Evacuation Benefits .................................................................................................................................................. Attachment COL-17-CA CERT Introduction Welcome to the UnitedHealthcare StudentResources Student Injury and Sickness Insurance Plan. This plan is underwritten by UnitedHealthcare Insurance Company (“the Company”). The school (referred to as the “Policyholder”) has purchased a Policy from the Company. The Company will provide the benefits described in this Certificate to Insured Persons, as defined in the Definitions section of this Certificate. This Certificate is not a contract between the Insured Person and the Company. Keep this Certificate with other important papers so that it is available for future reference. This plan is a preferred provider organization or “PPO” plan. It provides a higher level of coverage when Covered Medical Expenses are received from healthcare providers who are part of the plan’s network of “Preferred Providers.” The plan also provides coverage when Covered Medical Expenses are obtained from healthcare providers who are not Preferred Providers, known as “Out-of-Network Providers.” However, a lower level of coverage may be provided when care is received from Out- of-Network Providers and the Insured Person may be responsible for paying a greater portion of the cost. To receive the highest level of benefits from the plan, the Insured Person should obtain covered services from Preferred Providers whenever possible. The easiest way to locate Preferred Providers is through the plan’s web site at www.uhcsr.com/montereypc. The web site will allow the Insured to easily search for providers by specialty and location. The Insured may also call the Customer Service Department at 1-800-767-0700, toll free, for assistance in finding a Preferred Provider. Please feel free to call the Customer Service Department with any questions about the plan. The telephone number is 1-800- 767-0700. The Insured can also write to the Company at: UnitedHealthcare StudentResources P.O. Box 809025 Dallas, TX 75380-9025 Section 1: Who Is Covered The Master Policy covers students and their eligible Dependents who have met the Policy’s eligibility requirements (as shown below) and who: 1. Are properly enrolled in the plan, and 2. Pay the required premium. All international students, visiting faculty, scholars or other persons possessing and maintaining a current passport and valid visa status (F-1, J-1 or M-1, etc.), engaged in educational activities at Cal Poly San Luis Obispo who are temporarily located outside their home country and have not been granted permanent residency status, are required to be insured under the Policy and are automatically enrolled in this insurance plan. Coverage is available for students engaged in “Practical Training”. Enrollment must be accompanied by confirmation of Practical Training from the insured student in the form of a copy of your EAD (OPT coverage is available for the first 12 months of OPT only). Contact USI Student Insurance for more details. (A person who is an immigrant or permanent resident alien is not eligible for coverage under the international plan.) Eligible students who do enroll may also insure their Dependents. Eligible Dependents are the student’s legal spouse or Domestic Partner and dependent children under 26 years of age. See the Definitions section of this Certificate for the
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