Dartmouth Student Group Health Plan (DSGHP) Plan Document 2019 - Effective Date: September 1, 2018 8 201 Mailing Address: 7 Rope Ferry Rd, HB# 6143 Hanover, NH 03755-1421 Physical Address: 37 Dewey Field Rd, 4th Floor Email: Dartmouth.Student.Health [email protected] Phone: (603) 646-9438 Fax: (603) 646-8893 For The Most Current Information Regarding The Photo: B. Murray Plan, Notices & General Information, Refer To The IMPORTANT INFORMATION DSGHP Website THIS DOCUMENT REFLECTS THE KNOWN REQUIREMENTS FOR COMPLIANCE dartgo.org/studentinsurance UNDER THE AFFORDABLE CARE ACT AS PASSED ON MARCH 23, 2010. AS ADDITIONAL GUIDANCE IS FORTHCOMING FROM THE US DEPARTMENT OF HEALTH AND HUMAN SERVICES, AND THE NEW HAMPSHIRE INSURANCE DEPARTMENT, THOSE CHANGES WILL BE INCORPORATED INTO THE HEALTH INSURANCE DOCUMENT. Dartmouth Student Group Health Plan (DSGHP), 9/1/2018 Page 1 of 64 TABLE OF CONTENTS Introduction .................................................................................................................................................................................................................................. 3 DSGHP Coverage & The Affordable Care Eligibility & Participation.......................................................................................................................................................................................................... 4-5 Enrollments ............................................................................................................................................................................................................................... 5-6 Effective Dates .......................................................................................................................................................................................................................... 6-7 Contact Information ..................................................................................................................................................................................................................... 8 Medical Benefits & Requirements ......................................................................................................................................................................................... 9-16 Benefits for Services from Dartmouth College Health Service ............................................................................................................................................ 9 PPO Network Benefits ......................................................................................................................................................................................................... 9 Deductibles, Co-payments & Co-insurance ....................................................................................................................................................................... 10 Plan Maximums ................................................................................................................................................................................................................. 11 DSGHP Benefit Chart ............................................................................................................................................................................................................ 12-13 PPACA Preventive Care Benefits ............................................................................................................................................................................................. 14 Covered Preventive Services for Adults ............................................................................................................................................................................ 14 Covered Preventive Services for Women and Children .................................................................................................................................................... 14 General Requirements ....................................................................................................................................................................................................... 15 Health Care Management Program & Notification Requirements ..................................................................................................................................... 15 Medical & Substances Abuse Case Management ............................................................................................................................................................ 16 Covered Expenses & Services ............................................................................................................................................................................................ 17-26 College Provided International Travel Benefit ........................................................................................................................................................................ 27 Excluded Expenses & Services ........................................................................................................................................................................................... 28-29 Prescription Drug Benefits .................................................................................................................................................................................................. 30-31 General Requirements & Covered Drugs .......................................................................................................................................................................... 30 Dispensing Limits & Excluded Drugs ................................................................................................................................................................................. 31 Dental Savings Program ........................................................................................................................................................................................................... 32 Pediatric Dental and Vision benefits ………………………………………………………………………………………………………………………………..…32-34 Other Important Plan Provisions ......................................................................................................................................................................................... 34-36 Claim Procedures ................................................................................................................................................................................................................. 36-42 How to File a Medical Claim .............................................................................................................................................................................................. 38 How to File a Prescription Claim ........................................................................................................................................................................................ 38 How to Appeal a Denial of Benefits .............................................................................................................................................................................. 39-42 Plan Definitions ..................................................................................................................................................................................................................... 43-48 General Information ................................................................................................................................................................................................................... 49 DSGHP Staff ............................................................................................................................................................................................................................... 50 State of NH Consumer Guide to Appeal ............................................................................................................................................................................. 51-64 The DSGHP complies fully with Title IX of the Education Amendments of 1972, Section 504 of the Rehabilitation Act of 1973, and the Age Discrimination Act of 1975, as all three laws were amended By the Civil Rights Restoration Act of 1987. Pregnancy Benefits are provided on the same Basis as any other temporary disability. Dartmouth College Nondiscrimination policy may be found at http://www.dartmouth.edu/~health/docs/2017_2018_dartmouth_college_dsghp_non_discrimination_notice.pdf Dartmouth Student Group Health Plan (DSGHP), 9/1/2018 Page 2 of 64 INTRODUCTION Welcome to the Dartmouth Student Group Health Plan (DSGHP). Dartmouth College has prepared this document to help you understand your medical and prescription drug benefits as a participant in the DSGHP. This document replaces any document that may have been given to you in the past. Please read it carefully. Treatment or services rendered outside the United States of America or its territories are covered on the same Basis as treatment or services rendered within the United States. As used in this document, the term plan year is the twelve (12) month period beginning September 1 and ending the subsequent August 31. Benefit Maximums