Cisco College 552 Athlete Plan

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Short Term Health Insurance for Student Athletes

Underwritten by Nationwide Life Insurance Company

Group Number: S212114

SCHEDULE OF BENEFITS: This is a summary of the Injury and Sickness Benefits. Please refer to the Insurance Plan Brochure & Policy upon issuance for a complete listing of all benefits, limitations, definitions and exclusions.

Policy Year Aggregate Maximum Benefit 

$100,000 per Policy Term

Deductible

$250 per Injury or Illness

Policy Term

Note: Student may only enroll for 2 consecutive terms

8/1/2014 - 12/31/2014
1/1/2015 - 5/31/2014
6/1/2015 - 7/31/2015

Outpatient Miscellaneous Maximum per Policy Term (including physical therapy; chiropractic expense; DME)

$2,500

Physician Visit

In-Network: 80% of Preferred Allowance (PA) after $25 co-pay per visit
Out-of-Network: 60% of Reasonable and Customary Charges (R&C) after $25 co-pay per visit

Emergency Room Visit  (Co-pay is waived if admitted)

In-Network: 80% of PA after $150 co-pay per visit
Out-of-Network: 60% of R&C after $150 co-pay per visit

Inpatient Expense (including room & board; intensive care; hospital miscellaneous expenses)

In-Network: 80% of PA
Out-of-Network: 60% of R&C

Surgery Expense (inpatient/outpatient- including services of surgeon, anesthetist and assistant surgeon)

In-Network: 80% of PA
Out-of-Network: 60% of R&C

Athletic Coverage
80% of R&C up to $15,000 per Policy Term
Ambulance Services
$500 per Trip

Prescription Drugs
Note: Students must pay for prescriptions and submit a claim for reimbursement from CHP.

$10 Generic copay; $15 Brand-name copay
$250 maximum per Policy Term

Medical Evacuation

$25,000 per Policy Term

Repatriation

$10,000 per Policy Term

Servicing Agent: Dissinger Reed
8700 Indian Creek Parkway, STE 320
Overland Park, KS 66210
Phone: (800) 386-9183
www.dissingerreed.com

Plan Administrator: Consolidated Health Plans
2077 Roosevelt Avenue
Springfield, MA 01104
Phone (800) 633-7867
www.consolidatedhealthplan.com

 


Please note: If you are eligible for Medicare, the open enrollment period for the Medicare Prescription Drug program (Medicare Part D) begins October 15, 2014 and ends December 7, 2014. If you are currently eligible for Medicare or will become eligible after this enrollment period, please contact Consolidated Health Plans for information on your current prescription drug coverage with Nationwide and your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan.  

 


Your plan includes the following programs: Please consult your plan document for additional information: