State University and Community College System of Tennessee    

2007 - 2008 Domestic Student Insurance Plan

 

 

   
 

 

 

  Features of this plan include:

  ]Guaranteed Acceptance

  ]Coverage of Spouse and Children

  ]Your choice of health care providers

  ]Coverage for outpatient prescription drugs for a covered injury or sickness

  ]Covered charges incurred at the Student Health Center will be paid at 100% with no deductible

   ]Annual or semester premiums may be paid by check, credit card, or monthly bank draft

1.   How do I enroll in the Plan?
 

Determine your eligibility. All domestic students enrolled for classes at a Community College, Technical Institute, Technology Center or University in the State University and Community College System of Tennessee are eligible to enroll the Plan. Students must be enrolled at least half-time to be eligible to participate in this program, except for those students who are physically and/or mentally disabled. Such disability must prevent the student from taking 6 credits as verified by the attending physician. Insured persons actively must attend classes for at least the first 31 days after the date for which coverage is purchased. If the student is enrolled at least half-time and is degree seeking, internet or on-line classes fulfill the eligibility requirements that the Named Insured actively attend classes. Home study, correspondence, internet classes and television courses do not fulfill the Eligibility requirements that the Insured person actively attend classes. If the Company discovers the Eligibility requirements have not been met, its only obligation is to refund premium. 2007-08 Eligibility Student Accident & Sickness Plan domestic students at all schools Complete the enrollment form and mail during the 31 day open enrollment period for each coverage period. Coverage may be purchased prior to the open enrollment with coverage beginning on the effective date of the coverage period purchased. Information and Enrollment form may be obtained: by contacting agent 1.800.463.2317 ]  ]  ]  click to view or  print brochure ]  ]  ]  click to view or print enrollment card     ]  ]  ] bank form These are pdf files which have been created by Adobe. All downloadable information on this site is in the Adobe PDF File format. To view this file you will need to have the Adobe Acrobat Reader Plug-in installed on your computer. Get the free Adobe Acrobat Reader Plug-in here: www.adobe.com/products/acrobat/readstep.htm by www.gmsouthwest.com  to print brochure and enrollment form ENROLL ON LINE at www.gmsouthwest.com  from your Campus. University Campus Location Austin Peay State University Student Health Services East Tennessee State University Student Health Services Middle Tennessee State University Student Health Services Tennessee State University Student Health Services Tennessee Technological University Student Health Services University of Memphis Student Health Services J. H. Quillen College of Medicine Assistant Dean Office Community Colleges Campus Location Chattanooga State Technical Community College Student Services Cleveland State Community College Student Services Columbia State Community College Student Services Dyersburg State Community College Student Services Jackson State Community College Student Services Motlow State Community College Student Services Nashville State Technical Community College Student Services Northeast State Community College Student Services Pellissippi State Community College Student Services Roane State Community College Student Services Southwest Tennessee Community College Student Services Volunteer State Community College Student Services Walters State Community Colleges Student Services Tennessee Technology Centers Directors Office, Student Services or Admission Office

Maximum Benefits

Domestic Insurance Plan	2007- 08
Plan Benefits
Student	$100,000
Spouse/Each Child	$100,000
Optional Catastrophic Benefits*
Student	$250,000
Spouse/Each Child	No Benefit
Optional Repatriation & Medical Evacuation*	$ 10,000
Optional Dental Benefit**	$500

*Monthly Bank Draft: Students should submit 2 payments up font with completed Bank Draft
Authorization Form, and 7 remaining drafts will be drafted each month beginning on October 20^th
and ending April 20^th. The Monthly Bank Draft Option is not available for the Optional Catastrophic
Coverage nor Optional Dental Coverage.
 

*Monthly Bank Draft: Students should submit 2 payments up font with completed Bank Draft
Authorization Form, and 7 remaining drafts will be drafted each month beginning on
October 20^th and ending April 20^th. The Monthly Bank Draft Option is not available for the
Optional Catastrophic Coverage nor Optional Dental Coverage.  back to FAQ 

The plan may be purchased for your specific coverage periods.

back to FAQ

Yes. A renewal notice for semi-annual and semester payments will be mailed to the Insureds 31 days
prior to the termination date of the purchased coverage period. Enrollment forms may be downloaded from number 1 above.

However, it is the Insured’s responsibility for timely payments
the 31 day grace period to re-enroll and maintain continuous coverage.

back to FAQ

If the premium is not paid within the 31 day grace period, coverage will lapse at the end of the coverage period.
If premium is subsequently paid, a new effective date of coverage will be established and the pre-existing
condition exclusion will be active.

 

No. Your canceled check or credit card statement is your receipt and proof of coverage.

 

Yes. Attached to the enrollment brochure is the temporary identification card.
Detach and retain until you receive your permanent card in about four to five weeks.

back to FAQ

No. The Master Policy is on file at the Tennessee Board of Regents. No individual policies will be issued.
In the event of a claim dispute, the Master Policy will prevail.
Please retain the brochure as it outlines the provisions of coverage.

 

No. The only situation that allows for a refund is:

the insured enters or becomes active in the armed services of any country.

Then the company will issue a pro-rata refund for the period not covered by the policy.
Claims filed for payment will also determine the amount of refund.

 back to FAQ

Yes. Maternity is treated as any other illness. Conception must occur after the Insured’s effective date of coverage.
Maternity Benefits will be covered on the same basis as any other Sickness, after the Insured’s expiration
date of coverage for an Insured’s pregnancy which commenced while insured under the Policy.

                 

back to FAQ

Yes. The plan includes the following deductibles per Injury or Sickness:

2007-08	Deductible
Plan Deductible	$50 per Insured for each Injury or Sickness
Student Health Center	$0 - deductible waived
Inpatient/Outpatient Hospital Deductible	$250 per occurrence

Yes. After the deductible has been satisfied, outpatient prescription drugs for a covered injury or sickness are payable for Usual & Customary Charges (U&C) as follows:

Preferred Providers in your local school area are Humana/Choice Care Hospitals and Physicians.

The availability of specific providers is subject to change without notice.
You should always confirm that a Preferred Provider is participating at the time services are required by:

Telephone: 1-877-877-0715 extension 4058

Internet: www.choicecarenetwork.com/global/Home.asp#

or

Asking the provider when you make an appointment

back to FAQ

 

Receipt of premium can be verified by contacting GM-Southwest by:

Telephone: 1-800-477-4415 extension 312

Or

Internet: www.gmsouthwest.com

 

Verification of coverage may be obtained by contacting GM-Southwest by:

Telephone: 1-800-477-4415 extension 312

Or

Internet: www.gmsouthwest.com

back to FAQ

20. How do I file a claim?

1) Report the Student Health Center for treatment or referral, or when not in school,
to their physician or hospital.

3) File claim within 30 days of Injury or first treatment for Sickness. Bill should be received by the
company within 90 days of services to be considered for payment or as soon as reasonably possible.
Bills submitted after one year will not be considered for payment except in the absence of legal capacity.

Choice Care Preferred Provider Organization (PPO): the PPO physicians and hospitals will automatically file the claim.

Non Choice Care PPO providers: A claim must be filed by mailing to:

Yes. The plan provides coverage 24-hours a day anywhere in the world. Apart from the insurance
coverage, participants also have the availability of the travel assistance program administered
by MEDEX Assistance Corporation.

MEDEX Assistance Corporation
9515 Deereco Road, 4^th Floor
Timonium, MD 21093

1-800-537-2020

Refer to the Schedule of Benefits in your brochure to determine coverage and Covered Services.
You should also review the Exclusions section of the brochure and the definitions of Pre-existing
conditions and Elective Surgery & Elective Treatment to understand what conditions are not covered.

If you have any questions, please contact GM-Southwest by:

Telephone: 1-800-550-4870 option 1

Or

Internet: www.gmsouthwest.com

 

No. Your plan does not require pre-certification of hospital stays.
You should however, always consult your student health service to be sure the level of care you are receiving is appropriate.

back to FAQ

28. Does the insurance plans include a prescription drug card?

No. The student insurance plans do not include a prescription drug card. The insured must pay
for the prescription then file a claim with GM-Southwest for reimbursement of a covered injury or sickness.

29. Does the plan included vision and dental benefits?

The insurance plan does not provide vision benefits as part of the Student Injury and Sickness Insurance Plan.

VSP Optional Vision Discount Plan, an optional discount Vision Plan is available for review at
the www.gmsouthwest.com

Dental Benefits – Injury Only: The insurance plan includes a dental benefit for injury to sound
natural teeth in the amount of $100 maximum per tooth up to a maximum benefit of $500.

Optional Dental Benefit.

The optional dental plan is available on an annual or semester basis and only to Policyholders enrolled
in the Student Health Insurance Plan. The Dental Plan provides a Policy Year Maximum Benefit of
$500.00 with a policy year deductible of $50.00.

If a student experiences a break in coverage or terminates the medical plan, the dental plan is
also terminated. There will be no refund of premium when the dental plan is terminated.

Optional dental is available on a annual premium basis. 
Students initially enrolling in the Spring can purchase the dental coverage. However, the premiums are not prorated.

Diagnostic and Preventative Services: the insured pays 0% of the Allowable Charge after the deductible has been satisfied,

Oral Exams     Space Maintainers X-rays

Biopsies of oral tissues     Prophylaxis Pulp vitality tests

Emergency Treatment

Primary Services: the insured pays 20% of the Allowable Charge after the deductible has been satisfied.

Filings Re-cement crowns, inlays and bridges

Oral Surgery Anesthesia

Repair dentures

Endodontics and Periodontics: the insured pays 50% of the Allowable Charge after the deductible has been satisfied.

Dental Exclusions:

Gold Foil Restoration Gold Fillings Inlays

Crowns Bridges Dentures

Dental Limitations:

Two (2) of each of the following per Policy year: Oral Exams

One (1) of each of the following per Policy year: Bitewings x-rays. Topical Fluoride application Pulp vitality tests,

One (1) full mouth x-ray every three (3) years. Benefits for Fluoride applications and space maintainers are available only to participants under age 19

back to FAQ

2007-08 Wellness Benefits

Mammography Screening

STD Testing

Pap Smear

Rectal & Prostate Exams

                 Detoxification

State University and Community College System of Tennessee    

2007 - 2008 Domestic Student Insurance Plan