The Student Medical Plan, subject to the outlined benefits, limits and exclusions, protects the student during the term for which the fee has been paid. The Plan reserves the right to coordinate benefits with any other medical coverage.
Participants of the Student Medical Plan are encouraged to access a national network of Preferred Providers in the Aetna network. Participants may realize substantial savings by utilizing Preferred Providers.
A complete listing of Participating Providers is available through the internet by accessing Aetna's DocFind® Service. Additionally, information regarding Preferred Providers can be obtained by contacting Aetna Student Health at 877.850.6038.
Failure to utilize a network provider will result in a benefit reduction to 60% of covered charges.
In the case of a medical emergency, as determined by the claims administrator, a participant who obtains health care from an out-of-network provider will be subject to the in-network limits and restrictions with respect to such care. When hospital or medical care is required because of a sickness or injury eligible for benefits under this plan, the reasonable and customary expense actually incurred will be paid, up to the specified limits for each sickness or injury.
You need pre-approval from us for some eligible medical services. Pre-approval is also called precertification.
Precertification for Medical Services and Supplies
In-network care: Your in-network physician is responsible for obtaining any necessary precertification before you get the care. If your in-network physician doesn't get a required precertification, we won't pay the provider who gives you the care. You won't have to pay either if your in-network physician fails to ask us for precertification. If your in-network physician requests precertification and we refuse it, you can still get the care but the plan won't pay for it. You will find additional details on requirements in the Certificate of Coverage.
Out-of-network 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, your benefits may be reduced, or the plan may not pay any benefits. This does not apply to services and supplies deemed to be medically necessary. Refer to your schedule of benefits for this information. The list of services and supplies requiring precertification appears later in this section
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.
|Type of precertification needed||Requirements|
|Non-emergency admissions:||You, your physician or the facility will need to call and request precertification at least 14 days before the date you are scheduled to be admitted.|
|An emergency admission:||You, your physician or the facility must call within 48 hours or as soon as reasonably possible after you have been admitted.|
|An urgent admission:||You, your physician or the facility will need to call before you are scheduled to be admitted. An urgent admission is a hospital admission by a physician due to the onset of or change in an illness, the diagnosis of an illness, or an injury.|
|Outpatient non-emergency services requiring precertification:||You or your physician must call at least 14 days before the outpatient care is provided, or the treatment or procedure is scheduled.|
|Delivery:||You, your physician, or the facility must call within 48 hours of the birth or as soon thereafter as possible. No penalty will be applied for the first 48 hours after delivery for a routine delivery and 96 hours for a cesarean delivery.|
We will provide a written notification to you and your physician of the precertification decision, where required by state law. If your precertified services are approved, the approval is valid for 30 days as long as you remain enrolled in the plan.
Once we authorize eligible medical services, we will not refuse to pay if your physician or PCP, in good faith, submitted complete, accurate, and all necessary information to us.
If you require an extension to the services that have been precertified, you, your physician, or the facility will need to call us at the number on your ID card as soon as reasonably possible, but no later than the final authorized day.
If precertification determines that the stay or outpatient services and supplies are not covered benefits, the notification will explain why and how you can appeal our decision. You or your provider may request a review of the precertification decision. See the When you disagree - claim decisions and appeals procedures section of Certificate of Coverage.
What If You Don't Obtain the Required Recertification?
If you don't obtain the required precertification:
- Your benefits may be reduced, or the plan may not pay any benefits. This does not apply to services and supplies deemed to be medically necessary. See the schedule of benefits Precertification penalty section.
- You will be responsible for the unpaid balance of the bills.
- Any additional out-of-pocket expenses incurred will not count toward your deductibles or maximum out-of-pocket limits.
What Types of Services and Supplies Require Precertification?
Precertification is required for the following types of services and supplies:
Inpatient Services and Supplies
- Stays in a hospice facility
- Stays in a hospital
- Stays in a rehabilitation facility
- Stays in a residential treatment facility for treatment of mental disorders and substance abuse
- Stays in a skilled nursing facility
Outpatient Services and Supplies
- Applied behavior analysis
- Certain prescription drugs and devices*
- Complex imaging
- Cosmetic and reconstructive surgery
- Intensive outpatient program (IOP) – mental disorder and substance abuse diagnoses
- Kidney dialysis
- Knee surgery
- Medical injectable drugs, (immunoglobulins, growth hormones, multiple sclerosis medications, osteoporosis medications, botox, hepatitis C medications)*
- Outpatient back surgery not performed in a physician's office
- Outpatient detoxification
- Partial hospitalization treatment – mental disorder and substance abuse diagnoses
- Private duty nursing services
- Psychological testing/neuropsychological testing
- Sleep studies
- Transcranial magnetic stimulation (TMS)
- Wrist surgery
When you receive precertification for a chronic condition, we will honor this previous precertification for an approved drug from the date of approval to the lesser of either: a) 12 months or b) the last day of your eligibility under this policy.
*For a current listing of the prescription drugs and medical injectable drugs that require precertification, contact Member Services by calling the toll-free number on your ID card in the How to contact us for help section or by logging onto the Aetna website at www.aetnastudenthealth.com.