The usc student health insurance plan

Aetna Student Health Plan Design and Benefits Summary OA Managed Choice POS

University of Southern California

USC Student Health Services is where you receive your primary medical care. Once you’ve seen a medical professional at the Student Health Services and it is determined that you require additional medical care, USC Student Health Services will make every attempt to refer you to a USC Designated Tier 1 Provider; however it is your responsibility to verify that the doctor you’ve been referred to is actually a USC Designated Tier 1 Provider.

Coverage Periods

Rates
The rates below include both premiums for the Plan underwritten by Aetna Life Insurance Company (Aetna), as well as a University of Southern California administrative fee.

Rates ON Campus Students

	Annual	Fall Semester
	$2,273.00	$805.00	$1,468.00

Student Coverage

	Page 2

Enrollment Process/Procedure

All students registered in six (6) units or more will be automatically enrolled in this plan, unless the completed Request for Waiver Form has been received by the University of Southern California by the applicable enrollment/waiver deadline dates listed in the previous section of this Plan Design and Benefits Summary and the Request for Waiver has been approved. All students registered in less than six (6) units are eligible to enroll in the plan voluntarily. To enroll online or obtain an enrollment application for voluntary coverage, log on to www.aetnastudenthealth.com/usc then click on Enroll/Request to Waive to begin the enrollment process.

Waiver Process/Procedure

If you already have a health insurance plan (or you are on your parents’ plan) you may be eligible to waive enrollment in the USC Student Health Insurance Plan by providing proof of comparable coverage (see criteria below).

• Provide continuous year-round coverage while you are a student at the University of Southern California.

• Your insurance plan must meet Affordable Care Act (ACA) criteria. Only plans compliant with ACA criteria will be accepted.

sports.

• Have an annual out-of-pocket expense of individual = less than $8,700 / family= less than $17,400.

If you are eligible to waive coverage, you must submit a request for waiver online before the deadline date. To submit a request to waive out of the USC Student Health Insurance Plan, you will begin by going to
https://studenthealth.usc.edu/. On the right side of the page click Insurance Waiver. A link to the Aetna Student Health online waiver request can be found in the center of the page, clicking this link will bring you to the Aetna Student Health online waiver system where you will follow the instructions to complete your online request for waiver. Before you begin the request for waiver process, please make sure you have your current insurance card with you as you will need information off this card to submit a request for waiver.

Medicare Eligibility Notice
You are not eligible to enroll in the student health plan if you have Medicare at the time of enrollment in this student plan. The plan does not provide coverage for people who have Medicare.

	Page 4

You need pre-approval from us for some eligible health services. Pre-approval is also called precertification. Your in-network physician is responsible for obtaining any necessary precertification before you get the care. When you go to an out-of-network provider, it is your responsibility to obtain precertification from us for any services and supplies on the precertification list. If you do not precertify when required, up to a $500 penalty for each type of eligible health service that was not precertified. For a current listing of the health services or prescription drugs that require precertification, contact Member Services or go to www.aetnastudenthealth.com.

Precertification Call
Precertification should be secured within the timeframes specified below. To obtain precertification, call Member Services at the toll-free number on your ID card. This call must be made:

You do not need to obtain pre-certification for any services. However, your provider is required to obtain pre-

certification for certain Preferred Care services. Refer to the Precertification provisions in the Coverage section of the

Some people have health coverage under more than one health plan. If you do, we will work together with your other

plan(s) to decide how much each plan pays. This is called coordination of benefits (COB). A complete description of the

	Page 5

University of Southern California 2022-2023	Page 6


Routine physical exams
Performed at a physician’s office	100% (of the negotiated charge) per visit
Maximum age and visit limits per policy year through age 21	Subject to any age and visit limits provided for in the comprehensive guidelines supported by the American Academy of Pediatrics/Bright Futures//Health Resources and Services Administration guidelines for children and adolescents.
	1 visit

	No copayment or policy year deductible applies	100% (of the negotiated charge) per visit

Routine gynecological exams (including Pap smears and cytology tests)
Performed at a physician’s, obstetrician (OB), gynecologist (GYN) or OB/GYN office			50% (of the recognized charge) per visit
Maximum visits per policy year	1 visit

		100% (of the negotiated charge) per visit No copayment or policy year deductible applies

		In-network coverage	Out-of-network coverage
		No copayment or policy year deductible applies	50% (of the recognized charge) per visit
		No copayment or policy year deductible applies	50% (of the recognized charge) per visit
		No copayment or policy year deductible applies	50% (of the recognized charge) per visit

Lung cancer screening maximums	1 screening every 12 months*
	No copayment or policy year deductible applies	100% (of the negotiated charge) per visit
	No copayment or policy year deductible applies	100% (of the negotiated charge) per visit
	No copayment or policy year deductible applies	100% (of the negotiated charge) per item

	100% (of the negotiated charge) per visit No copayment or policy year deductible applies

Eligible health services	Select care coverage
	100% (of the negotiated charge) per item No copayment or policy year deductible applies
	100% (of the negotiated charge) No copayment or policy year deductible applies

Physicians and other health professionals
Physician, specialist including Consultants Office visits (non-surgical/ non-preventive care by a physician and specialist) includes telemedicine consultations)
Allergy testing and treatment
Allergy testing & Allergy injections treatment including Allergy sera and extracts administered via injection performed at a physician’s or specialist’s office

Inpatient surgery performed during your stay in a hospital or birthing center by a surgeon (includes anesthetist and surgical assistant expenses)	90% (of thenegotiated charge)

Eligible health services
	90% (of thenegotiated charge) per visit	80% (of thenegotiated charge) per visit


Walk-in clinic visits (non-emergency visit)	$50 copayment then the plan pays 100% (of the balance of the negotiated charge) per visit thereafter		No policy year deductible applies
Hospital and other facility care
			$150 copayment then the plan pays 50% (of the balance of the recognized charge) per admission
Preadmission testing	Covered according to the type of benefit and the place where the service is received.

Alternatives to hospital stays
Outpatient surgery (facility charges) performed in the outpatient department of a hospital or surgery center
• The services of any other physician who helps the operating physician • A stay in a hospital (See the Hospital care – facility charges benefit in this section)
		80% (of thenegotiated charge) per visit	50% (of the recognized charge) per visit
	100


Eligible health services	Select care coverage
	90% (of thenegotiated charge) per admission	80% (of thenegotiated charge) per admission
Hospice-Outpatient	90% (of thenegotiated charge) per visit
- Transportation - Maintenance of the house

Maximum days of confinement per policy year	unlimited
Hospital emergency room
	Not Applicable	Not covered
Separate copayment/coinsurance amounts may apply for certain services given to you in the hospital emergency room • that are not part of the hospital emergency room benefit. These copayment/coinsurance amounts may be different from the hospital emergency room copayment/coinsurance. They are based on the specific service given to you. • Services given to you in the hospital emergency room that are not part of the hospital emergency room benefit may be



Eligible health services	Select care coverage
	No policy year deductible applies	$50 copayment then the plan pays 100% (of the balance of the negotiated charge) per visit thereafter
	Not covered	Not covered


	Not Applicable	100% (of the negotiated charge) per visit
		100% (of the negotiated charge) per visit No copayment or deductible applies
		No copayment or deductible applies	50% (of the recognized charge) per visit
			50% (of the recognized charge) per visit
Dental emergency services

and vestibuloplasty, and other substances to protect, clean, whiten bleach or alter the appearance of teeth; whether or not for psychological or emotional reasons. Facings on molar crowns and pontics will always be considered cosmetic. or reposition teeth • Dentures, crowns, inlays, onlays, bridges, or other appliances or services used: • Treatment of any jaw joint disorder and treatments to alter bite or the alignment or operation of the jaw, including temporomandibular joint dysfunction disorder (TMJ) and craniomandibular joint dysfunction disorder (CMJ) treatment, • Mail order and at-home kits for orthodontic treatment • Orthodontic treatment except as covered in this section - Done where there is no evidence of pathology, dysfunction, or disease other than covered preventive services - Provided for your personal comfort or convenience or the convenience of another person, including a provider
	Select care coverage	In-network coverage

	Covered according to the type of benefit and the place where the service is received.
The following are not covered under this benefit: - Supplies (including orthopedic shoes), foot orthotics, arch supports, shoe inserts, ankle braces, guards, protectors, creams, ointments and other equipment, devices and supplies

		In-network coverage	Out-of-network coverage

Accidental injury to sound natural teeth	90% (of thenegotiated charge)

	Covered according to the type of benefit and the place where the service is received.
The following are not covered under this benefit: • Dental implants


Clinical trial (routine patient costs)	Covered according to the type of benefit and the place where the service is received.

Dermatological treatment	Covered according to the type of benefit and the place where the service is received.

Eligible health services	Select care coverage

	$130	$130
			$130
Maximum benefit payable for lodging expenses per patient and companion for the pre-surgical and follow-up visits	$100 per day, up to two days	$100 per day, up to two days	$100 per day, up to two days
	$100 per day, up to four days	$100 per day, up to four days	$100 per day, up to four days


The following are not covered under this benefit: • Any services and supplies related to births that take place in the home or in any other place not licensed to perform deliveries
		No policy year deductible applies	50% (of the recognized charge) per visit

		80% (of the negotiated charge)	50% (of the recognized charge)

Eligible health services
	90% (of the negotiated charge)	80% (of the negotiated charge)


Mental Health & Substance Abuse Treatment Coverage provided under the same terms, conditions as any other illness.
Inpatient hospital (room and board and other miscellaneous hospital services and supplies)		80% (of the negotiated charge) per admission	50% (of the recognized charge) per admission
		$10 copayment then the plan pays 100% (of the balance of the negotiated charge) per visit thereafter No policy year deductible applies
		80% (of thenegotiated charge) per visit No policy year deductible applies
			Out-of-networkcoverage
Transplant services


Transplant services-travel and lodging	Covered
		$10,000	$10,000

Maximum payable for Lodging Expenses per companion	$50 per night

University of Southern California 2022-2023	Page 17

University of Southern California 2022-2023	Page 18

University of Southern California 2022-2023	Page 19

	Page 20