Microsoft word - 2010-2011 - sample brochure - u.s. fire

STUDENT OSTEOPATHIC MEDICAL ASSOCIATION
COLLEGE HEALTH INSURANCE PROGRAM
2010-2011 SCHOOL YEAR
▲ 2 Medical Plans
▲ Dental Plan Option
▲ Vision Plan Option
Description
Plan 1 - Medical Insurance Schedule of Benefits Plan 2 - High Deductible Medical Insurance Schedule of Benefits On Line Enrollment Available – www.somainsurance.com
Questions?
Call Toll-Free 1-800-349-1039
Email: soma@mmicinsurance.com
SOMA 2010-2011
SCHEDULE OF BENEFITS FOR 2010-2011 POLICY YEAR (Will
Not Exceed Usual Reasonable & Customary Charges)
Plan 1 - Co-Pay Plan
SICKNESS AND INJURY BENEFITS (all benefit maximums are combined Preferred
In-Network
Out-of-Network
Providers/Out-of-Network unless otherwise noted)
Preferred Provider
Non-Preferred Provider

Aggregate Lifetime Maximum.

Policy Year Aggregate Maximum Amount Per Sickness/Injury.

Deductible Per Insured Person (09/01/10 - 08/31/11).
Coinsurance- Preferred Provider – 80% Out-of-Network- 60%.
Maximum Out-of-Pocket (Does Not Include Deductible).
After the Insured has incurred $9,750 out-of-pocket, this plan pays for 100% of
Preferred Providers and 100% of Out-of-Network for covered medical expenses.

Covered Charges - Inpatient Benefits
1. Room & Board /Hospital Misc.- $1,500 Aggregate max per day. 2. Intensive Care………………………………………………. 3. Routine Newborn Care (48 hours vaginal/96 hours caesarean). 4. Physiotherapy ……………………. 6. Asst. Surgeon (Secondary assistant surgeon fees are paid at 50% of Primary 7. Anethetist………………………………………………………. 10. Pre-admission Testing; $1,500 Maximum. Covered Charges - Outpatient Benefits
2. Day Surgery Miscellaneous - $1,500 max. 3. Asst. Surgeon (Secondary assistant surgeon fees are paid at 50% of Primary)………………………………………………………. 6. Physiotherapy. - $50 max per visit/10 visit max. 7. Outpatient Miscellaneous Benefits - $2,000 max. 15.Prescription Drugs (up to a $600 maximum per policy year), (after a $15 tier 1/$25 tier 2 Copay per prescription/31 day supply) After the per prescription deductible utilizing an Script Care, Ltd. Network pharmacy, the policy Deductible does not apply. Covered Charges - Other Benefits
2. Durable Medical Equipment.- $1,500 max. 3. Dental (Benefits for injury to Sound - Natural Teeth Only)$500 max. 4. Consultant………………………………………………………. 5. Needle Stick…………………………………………………. 8. Maternity(as mandated for maternity and post delivery care). 15. Home Health Care………………………………. 16. Cat Scan/MRI………………………………………………………………. 17. Wellness Benefit - $150 max per policy year. Wellness expense for the Insured and Dependents over the age of 18. Benefits include one examination/routine physical and one HIV/syphilis test each Policy Year, includes pre/post test counseling. For men, routine physical examination includes the office visit charge and a gonorrhea/Chlamydia test, a hemoglobin and urine test. For women, examination includes the office visit charge, pap smear, gonorrhea, Chlamydia test, hemocult for women over the age of 50, a hemoglobin and urine test. (Not subject to
Additional Benefits – mandate benefits vary by state. You may be eligible for
additional benefits depending on your state or residence Please contact 1-877-246-6997
to see if you qualify for other benefits not shown on this schedule.

2

SCHEDULE OF BENEFITS FOR 2010-2011 POLICY YEAR (Will Not Exceed Usual
Plan 2 - High Deductible Health Plan (HDHP)
Reasonable & Customary Charges)
SICKNESS AND INJURY BENEFITS
Preferred Provider
Out-of-Network

Aggregate Lifetime Maximum.

Policy Year Aggregate Maximum Amount Per Sickness/Injury.

Deductible Per Insured Person (09/01/ 10 - 08/31/11).
Coinsurance………………………………………………………….
Maximum Out-of-Pocket (Does Not Include Deductible).
After the Insured has incurred $8,000 out-of-pocket, this plan pays for 100% of
Preferred Providers and 100% of Out-of-Network for covered medical expenses.

Covered Charges - Inpatient Benefits
1. Room & Board Hospital Miscellaneous. 3. Routine Newborn Care (48 hours vaginal/96 hours caesarean)………………………. 4. Physiotherapy……………………. 6. Asst. Surgeon (Secondary assistant surgeon fees are paid at 50% of Primary)…………………… Covered Charges - Outpatient Benefits
3. Asst. Surgeon (Secondary assistant surgeon fees are paid at 50% of Primary). 7. Medical Emergency. 7. 80% of Preferred Allowance 14. Prescription Drugs (up to a $2,500 maximum per policy year). Covered Charges - Other Benefits
3. Dental (Benefits for injury to Sound - Natural Teeth). 4.Consultant…………………………………………………………………………………. 5.Needle Stick………………………………………………………………………………. 7. Drug Abuse. 7. Paid under Psychotherapy 8. Maternity (as mandated for maternity and post delivery care). 16. CAT Scan/MRI……………………………………………………………………………. Wellness expense for the Insured and Dependents over the age of 18. Benefits include one examination/routine physical and one HIV/syphilis test each Policy Year, includes pre/post test counseling. For men, routine physical examination includes the office visit charge and a gonorrhea/Chlamydia test, a hemoglobin and urine test. For women, examination includes the office visit charge, pap smear, gonorrhea, Chlamydia test, hemocult for women over the age of 50, a hemoglobin and urine test. Additional Benefits – mandate benefits vary by state. You may be eligible for *Except as otherwise specified
additional benefits depending on your state or residence Please contact 1-877-246-6997
to see if you qualify for other benefits not shown on this schedule.
PRESCRIPTION DRUG CARD
Plan 1 - Co-Pay Plan Only
Benefits are available for outpatient Prescription Drugs on our Prescription Drug List (PDL) when dispensed by a Script Care, Ltd. Network Pharmacy. Benefits are subject to supply limits (up to 31 days) and copayments that vary depending on which tier of the PDL the outpatient drug is listed. There are a few Prescription Drugs that require your Physician to notify us to verify their use is covered within your benefit. You are responsible for paying the applicable copayments. Your copayment is determined by the tier to which the Prescription Drug is assigned on the PDL. Tier status may change periodically and without prior notice to you. Please access http://www.scriptcare.com or call 800-880-9988 or the customer service number on your ID card for the most up-to-date tier status. $15 copay per prescription order or refill for a Tier 1 Prescription Drug
$25 copay per prescription order or refill for a Tier 2 Prescription Drug
Your maximum allowed benefit is $600 per policy year. Please present your ID card to the network pharmacy when the prescription is filled. If you do not use a network pharmacy, you will be responsible for paying the full cost for the prescription. If you do not present the card, you will need to pay the prescription and then submit a reimbursement form for
prescriptions filled at a network pharmacy along with the paid receipt in order to be reimbursed. To obtain
reimbursement forms, or for information about mail-order prescriptions or network pharmacies, please call Summit
America Insurance Services, LC at 877-246-6997 or the customer service number on your ID card.

MEDICAL PLAN ACCIDENTAL DEATH, DISMEMBERMENT AND LOSS OF SIGHT BENEFIT

ACCIDENTAL DEATH, DISMEMBERMENT AND LOSS OF SIGHT BENEFIT
Loss of Life/Dismemberment (two or more members). $10,000
Loss of One Member *.$5,000
* Member means hand, arm, foot, leg or eye

MEDICAL EXCLUSIONS
No benefits will be paid for: a) loss or expense caused by or
correction surgery, or other treatment for visual defects and resulting from; or b) treatment, services or supplies for, at or problems; except when due to a disease process; hearing, apart from the disease process. 9. Hearing examinations or hearing aids; or other treatment for hearing defects and problems. "Hearing defects" means any physical defect of the ear which does or can impair normal hearing, apart from the disease process. 3. Circumcision, except if medically necessary due to Injury, illness, disease, or functional congenital disorder; 4. Cosmetic procedures, except cosmetic surgery required to 11. Immunizations, preventive medicines or vaccines, except correct an Injury for which benefits are otherwise payable under where required for treatment of a covered Injury; this policy or for newborn or adopted children; removal of 12. Injury caused by, or resulting from the use of alcohol, intoxicants, hallucinogenics, illegal drugs, or any drugs or 5. Dental treatment, except for accidental Injury to Sound, medicines that are not taken in the recommended dosage or for the purpose prescribed by the Insured Person's Physician; intoxication is defined and determined by the laws of the state 6. Elective Surgery or Elective Treatment; where the loss or cause of the loss was incurred; 13. Injury or Sickness for which benefits are paid or payable under any Workers' Compensation or Occupational Disease Law 8. Eye examinations, eye refractions, eyeglasses, contact lenses, prescriptions or fitting of eyeglasses or contact lenses, vision MEDICAL EXCLUSIONS CONTINUED
14. Injury sustained while (a) participating in any impotence, organic or otherwise; tubal ligation; vasectomy; interscholastic, club, intercollegiate, or professional sport, sexual reassignment surgery; reversal of sterilization procedures; contest or competition; (b) traveling to or from such sport, contest or competition as a participant; or (c) while participating 19. Routine Newborn Infant Care, well-baby nursery and related in any practice or conditioning program for such sport, contest Physician charges in excess of 48 hours for vaginal delivery or 96 15. Organ transplants; only those considered experimental are 20. Routine physical examinations and routine testing; preventive testing or treatment; screening exams or testing in the absence of Injury or Sickness, except as specifically provided in 16. *Pre-existing Conditions, except for individuals who have been continuously insured under the SOMA student insurance policy for at least 12 consecutive months; The Pre-existing 21. Services provided normally without charge by the Health condition exclusionary period will be reduced by the total Service of the Policyholder; or services covered or provided by number of months that the Insured provides documentation of continuous coverage under a prior health insurance policy which provided benefits similar to this policy; 22. Skeletal irregularities of one or both jaws, including orthognathia and mandibular retrognathia; temporomandibular 17. Prescription Drugs, services or supplies as follows: joint dysfunction; deviated nasal septum, including submucous resection and/or other surgical correction thereof; nasal and sinus (a) Therapeutic devices or appliances, including hypodermic needles, syringes, support garments and other non-medical substances, regardless of intended use, except as specifically 24. Suicide or attempted suicide while sane or insane (including (b) Immunization agents, biological sera, blood or blood drug overdose); or intentionally self-inflicted Injury; products administered on an outpatient basis; 25. Surgical breast reduction, breast augmentation, breast (c) Drugs labeled, "Caution - limited by federal law to implants or breast prosthetic devices, or gynecomastia, except as investigational use" or experimental drugs; (d) Products used for cosmetic purposes; 26. Treatment in a Government hospital, unless there is a legal obligation for the Insured Person to pay for such treatment; (e) Drugs used to treat or cure baldness, anabolic steroids used 27. War or any act of war, declared or undeclared; or while in the armed forces of any country (a pro-rata premium will be (f) Anorectics - drugs used for the purpose of weight control; refunded upon request for such period not covered); and (g) Fertility agents or sexual enhancement drugs, such as 28. Weight management, weight reduction, nutrition programs, Parlodel, Pergonal, Clomid, Profasi, Metrodin, Serophene, or treatment for obesity, surgery for removal of excess skin or fat, and treatment of eating disorders such as bulimia and anorexia, except as specifically provided in the policy. Exception: benefits (h) Growth hormones, except when a Medical Necessity; or will be provided for the treatment of dehydration and electrolyte imbalance associated with eating disorders. (i) Refills in excess of the number specified or dispensed after one (1) year of date of the prescription; * the time the Insured was covered under previous creditable coverage will be credited if previous coverage was continuous to 18. Reproductive/Infertility services including but not limited a date not more than 63 days before the effective date of this to: family planning; fertility tests; infertility (male or female), including any services or supplies rendered for the purpose or with the intent of inducing conception; premarital examinations; Exclusions and Limitations may vary by state
This brochure is not a contract of insurance. Terms and conditions of coverage and benefits are set forth in a
Master Certificate issued to Student Osteopathic Medical Association. These plans are underwritten by
United States Fire Insurance Company (Medical), United Concordia Life And Health Insurance Company
(Dental), and VSP (Vision).

This plan issued to SOMA is a one year non-renewable term policy. This policy is excess to any other insurance
policy you may have. No benefit of this policy is payable for any expense incurred for Injury or Sickness which is
paid or payable by other valid and collectible insurance. This excess provision will not be applied to the first $100
of medical expenses incurred. Benefits are provided as mandated by the State of Illinois.
Benefits may vary by state. 5
OPTIONAL DENTAL PROGRAM

Dental benefits are provided through a stand-alone group dental insurance policy.
• Contract Year Maximum per Covered Person • Contract Year Deductible per Covered Person/Family – Class I exempt Class I Dental Plan Payment (no waiting period or deductible)
• Cleanings • Fluoride Treatments • Sealants • Palliative Treatment Class II Dental Plan Payment (no waiting period, deductible applies)
• Space Maintainers • Basic Restorative • Non-surgical Periodontics • Repairs of Crowns, Inlays, Onlays, Bridges and Dentures • Simple Extractions Class III Dental Plan Payment (six-month waiting period, deductible applies)
• Endodontics
• Surgical Periodontics
• Complex Oral Surgery
• General Anesthesia
• Inlays, Onlays, Crowns
• Prosthetics
Orthodontics
* Plan payment percentages are based on the insurance company's Maximum Allowable charge. Network dentists accept their contracted Maximum Allowable Charge as payment in full for covered services DENTAL EXCLUSIONS
No coverage will be provided for services, supplies or charges: 8. Administration of nitrous oxide, general anesthesia and i.v. sedation, 1. Not specifically listed as a Covered Service on the Schedule of unless specifically indicated on the Schedule of Benefits. Benefits and those listed as not covered on the Schedule of Benefits. 9. Which are Cosmetic in nature as determined by the Company, 2. Which are necessary due to patient neglect, lack of cooperation with including, but not limited to bleaching, veneer facings, personalization or the treating dentist or failure to comply with a professionally prescribed characterization of crowns, bridges and/or dentures. Treatment Plan. This exclusion does not apply to Group Policies and Certificates issued and delivered in California. This exclusion does not apply to Group Policies and Certificates issued and delivered in Pennsylvania for Cosmetic services required as the result 3. Stated prior to the Member's Effective Date or after the Termination of an accidental injury. This exclusion does not apply to Group Policies Date of coverage with the Company, including, but not limited to multi- issued and delivered in New Jersey for Cosmetic services for newlyborn visit procedures such as endodontics, crowns, bridges, inlays, onlays and children of Members as defined in the definition of Dependent. 10. Elective procedures including but not limited to the prophylactic 4. Services or supplies that are not deemed generally accepted standards 11. For the following which are not included as orthodontic benefits - retreatment of orthodontic cases, changes in orthodontic treatment necessitated by patient neglect, or repair of an orthodontic appliance. 6. That are the responsibility of Worker's Compensation or employer's liability insurance, or for treatment of any automobile related injury in 12. For congenital mouth malformations or skeletal imbalances, which the Member is entitled to payment under an automobile insurance including, but not limited to treatment related to cleft lip or cleft palate, policy. The Company's benefits would be in excess to the third party disharmony of facial bone, or required as the result of orthognathic benefits and therefore, the Company would have right of recovery for surgery including orthodontic treatment. For Group Policies and Certificates issued and delivered in Georgia, For Group Policies and Certificates issued and delivered in Arizona, Missouri, and Virginia, only services that are the responsibility of Kentucky, and Pennsylvania this exclusion shall not apply to newly born Workers Compensation or employer's liability insurance shall be children of Members as defined under the definition of Dependent including adoptive children, regardless of age. For Group Policies and Certificates issued and delivered in Texas, only For Group Policies issued and delivered in Colorado, this exclusion shall services that are the responsibility the employer's liability insurance, or not apply to orthodontic or dental services for a newly born Dependent for treatment of any automobile related injury shall be excluded from with cleft lip or cleft palate and shall be covered as listed on the Schedule 7. For prescription or non-prescription drugs, vitamins, or dietary For Group Policies and Certificates issued and delivered in Florida, this exclusion shall not apply for diagnostic or surgical dental (not medical) procedures rendered to a Member of any age. DENTAL EXCLUSIONS CONTINUED
13. For dental implants including placement and restoration of implants attempt to commit a felony or engagement in an illegal occupation or of unless specifically covered under a rider to the Certificate. This the Member's being intoxicated or under the influence of illicit exclusion does not apply if dental services are required for sound teeth narcotics. This exclusion does not apply to Group Policies and Certificates issued and delivered in Maryland. 14. For oral or maxillofacial services including but not limited to 22. For house or hospital calls for dental services. associated hospital, facility, anesthesia, and radiographic imaging even if the condition requiring these services involves part of the body other 23. Replacement of existing crowns, onlays, bridges and dentures that than the mouth or teeth. This exclusion shall not apply to Group Policies issued and delivered in Georgia when such services are 24. Preventive restorations in the absence of dental disease. 25. Periodontal splinting of teeth by any method. 15. Diagnostic services and treatment of jaw joint problems by any method unless specifically covered under a Rider to the Certificate. 26. For duplicate dentures, prosthetic devices or any other duplicate These jaw point problems include but are not limited to such conditions as temporomandibular joint disorder (TMD) and craniomandibular disorders or other conditions of the joint linking the jaw bone and the 27. For services determined to be furnished as a result of a referral to an complex of muscles, nerves and other tissues related to the joint. entity in which the referring dentist, or the dentist's immediate family; For Group Policies and Certificates issued in Florida, this exclusion (a) owns a beneficial interest; or (b) has a compensation arrangement. does not apply to diagnostic or surgical dental (not medical) procedures The dentist's immediate family includes the spouse, child, child's souse, for Treatment of TMD rendered to a Member of any age as a result of parent, spouse's parent, sibling or sibling's spouse of the dentist or that congenital or developmental mouth malformation, disease or injury and such procedures are covered under a Rider to the Certificate or the 28. For which in the absence of insurance the Member would incur no 16. For treatment of fractures and dislocations of the jaw. This exclusion does not apply to Group Policies and Certificates issued in 29. For plaque control programs, oral hygiene, and dietary instructions. Pennsylvania if the dental condition is as a result of an accidental injury. 30. For any condition caused by or resulting from declared or 17. For treatment of malignancies or neoplasms. undeclared war or act thereof, or resulting from service in the guard or in the armed forces of any country or international authority. This 18. Services and/or appliances that alter the vertical dimension, exclusion does not apply to Group Policies and Certificates issued and including but not limited to full mouth rehabilitation, splinting, fillings to restore tooth structure lost from attrition, erosion or abrasion, appliances or any other method. This exclusion does not apply to 31. For training and/or appliance to correct or control harmful habits, Group Policies and Certificates issued in Pennsylvania if the dental but not limited to muscle training therapy (myofunctional therapy). condition is as a result of an accidental injury. 32. For any claims submitted to the Company by the Member or on 19. Replacement of lost, stolen or damaged prosthetic or.orthodontic behalf of the Member in excess of twelve (12) months after the date of 33. Which are not Dentally Necessary as determined by the Company. This exclusion does not apply to Group Policies and Certificates in 21. Arising from any intentionally self-inflicted injury or contusion when the injury is a consequence of the Member's commission of or DENTAL LIMITATIONS
The following services will be subject to limitations as set forth below: 14. Subsequent denture relining or rebasing - limited to one 1. Full mouth x-rays - one every five years. 2. One set(s) of bitewing x-rays per six months through age 15. Surgical periodontal procedures - one per two year period per area thirteen, and one set(s) of bitewing x-rays per twelve months for age 16. Sealants - one per tooth per three year(s) through age 3. Periodic oral evaluation - one per six months. fifteen on permanent first and second molars. 4. Limited oral evaluation (problem focused) - limited to one 17. Pulpal therapy - through age five on primary anterior teeth and through age eleven on primary posterior molars. 18. Root canal treatment and retreatment - one per tooth per lifetime. 6. Fluoride treatment - one per six months through age eighteen. 19. Recementations by the same dentist who initially inserted the 7. Space maintainers - only eligible for Members through age crown or bridge during the first twelve months are included in the eighteen when used to maintain space as a result of prematurely lost crown or bridge benefit, then one per twelve months thereafter; one per deciduous molars and permanent first molars, or deciduous molars and twelve months for other than the dentist who initially inserted the permanent first molar that have not, or will not develop. 8. Prefabricated stainless steel crowns - one per tooth per 20. Replacement restorations - limited to one per twelve lifetime for age fourteen years and younger. 9. Crown lengthening - one per tooth per lifetime. 21. Contiguous surface posterior restorations not involving the 10. Periodontal maintenance following active periodontal occlusal surface will be payable as one surface restoration. therapy - two per twelve months in addition to routine prophylaxis. 22. Posts are only covered as part of a post buildup. 11. Periodontal scaling and root planing - per two year period 23. An Alternate Benefit Provision (ABP) will be applied if a dental condition can be treated by means of a professionally 12. Placement or replacement of single crowns, inlays, onlays, acceptable procedure which is less costly than the treatment single and abutment buildups and post and cores, bridges, full and recommended by the dentist. The ABP does not commit the member partial dentures - one within five years of their placement. to the less costly treatment. However, if the member and the dentist 13. Denture relining, rebasing or adjustments - are included in the choose the more expensive treatment, the member is responsible for denture charges if provided within six months of insertion by the same the additional charges beyond those allowed for the ABP. 24. Payment for orthodontic services shall cease at the end of the OPTIONAL VISION PROGRAM

Vision Benefits are provided through a stand-aloneVision program
Frequency (based
Copayment
Coverage from a
Out-of-Network
on service year)
Network Doctor
Reimbursement

Eye Care Wellness - Regular exams are essential for protecting your visual wellness

Prescription Eyewear - You may choose between glasses or contacts. Remember if you choose contacts, you will not be eligible to
receive glasses (lenses and frame) in the same service period.
Contact Lenses
Your allowance applies to the cost of your contact lens exam and your contact lenses. You will receive a 15 percent savings off the cost of your contact lens exam from a VSP doctor. Your contact lens exam is performed in addition to your routine eye exam to check for eye health risks associated with improper wearing or fitting of contacts.
Value Added Discounts
Laser VisionCare - The Vision Coverage Company has contracted with many of the nation's finest laser surgery
facilities and doctors, offering you a discount off PRK and LASIK surgeries, available through contracted laser centers.
Contact Lenses - Valuable savings are available on annual supplies of certain brands of contacts. You can receive
these member preferred prices, even if you use your coverage for glasses.
Prescription Glasses - Receive 20 percent savings when you purchase non- covered pairs of prescription g lasses, including
prescription sunglasses from the same in- network doctor within 12 months of your last eye exam.
1. Lens options, which can enhance the appearance, durability and function of your glasses, are available to you at member preferred pricing. Ask your doctor for details. 2. If you choose a frame valued at more than your allowance, you’ll save 30% on your out-of-pocket costs for frames.
VISION LIMITATIONS & EXCLUSIONS
As a plan designed to meet the typical visual needs of its members, we limit or do not cover some materials and certain elective
options chosen for cosmetic purposes. We also do not cover medical or surgical eye care services, with the exception of discounts
available for laser vision correction services. The following lists materials and services with either limited or no coverage under
the Standard Plan.
Cosmetic Options
Exclusions (services and materials not covered)
• Orthoptics or vision training and any associated • Contact lenses (except as noted elsewhere) • Two pairs of glasses instead of bifocals • Complete pairs of glasses furnished under this program that are lost or broken (except at the normal intervals when services are otherwise • Photochormic or tinted lenses other than Pink 1 or 2 • Medical or surgical treatment of the eyes • Experimental vision services, treatments and * Cosmetic Options: Lens features not covered under the plan and chosen for cosmetic reasons, such as blended/
progressive lenses, special lens tints or coatings are price controlled by VSP. These cost controlled prices can save
8 our members an average of 20% off doctor's usual and customary fees.
2010-2011 PREMIUM RATES
MONTHLY PREMIUM
Medical Plan
Plan 1 Plan 2
Vision Plan Dental Plan
Co-Pay Plan High Deductible
Student Only
Under Age 30
Age 30 & Over
Spouse Only
Under Age 30
Age 30 & Over
(Based on Student’s Age)
Child(ren)
Under Age 30
Age 30 & Over
HOW TO APPLY
Enroll On-Line at www.somainsurance.com
1) Complete and Sign the Enrollment form on Page 11. Applicants who choose the credit card or check -o-matic method of payment must also complete the Monthly Automatic Enrollment Form (Page 12). 2) Payment Options (Refer to Premiums above) Applicants Who Wish To Have Their Monthly Premiums Charged To Their Credit Card
Complete the Enrollment Form (Page 11) and Monthly Automatic Enrollment Form (Page 12) b) Do not send any payment - premium will be charged to your MasterCard or VISA Credit Card
Applicants Who Wish To Have Their Monthly Premiums Debited From a Checking Account
Complete the Enrollment Form (Page 11) and Monthly Automatic Enrollment Form Send 2 checks; 1st check equal to the monthly payment payable to Mass Marketing Insurance Consultants, Inc. and the 2nd check marked "void" and unsigned.
Send enrollment form, check(s), and Monthly Automatic Pay Plan form (if applicable) to:
SOMA College Health Insurance Plan • P.O. Box 95 • Orland Park, IL 60462

MOST FREQUENTLY ASKED QUESTIONS ABOUT THE SOMA COLLEGE HEATH INSURANCE PLAN
Can I switch plans during the school year?
No - the plan you enroll in cannot be changed until September 1, 2011.
Is there a pre-existing condition limitation under the SOMA program?
Yes. Pre-existing Conditions are not covered for the first 12 months following an Insured Person’s effective Date
of coverage. However, the time an Insured Person was covered under previous creditable coverage will be credited
if previous coverage was continuous to a date not more than 63 days before the Effective Date of this coverage.
A Pre -existing Condition means: 1) the existence of symptoms which would cause an ordinarily prudent person to
seek diagnosis, care or treatment within the 12 months immediately prior to the Insured's effective date under the
policy or 2) any condition which originates, is diagnosed treated or recommended for treatment within the 12
months immediately prior to the Insured's effective date under the Policy. The pre-existing condition limitation
does not apply to the dental/vision option.
How do I get reimbursed for expenses?
- You must complete a claim form and send it along with your medical bills to Summit America Insurance
Services, LC, 7400 College Blvd., Suite 100 Overland Park, KS 66210. It is your responsibility to file a claim and provide written notice of your claim within 90 days from the date of any treatment. Dental - Participating providers file all claim forms and accept reimbursement from United Concordia as
payment in full. If an out-of-network provider is selected, a detailed bill provided by the dentist must be
submitted to United Concordia for reimbursement. (United Concordia Life and Health Insurance Company,
4401 Deer Path Road, Harrisburg, PA 17110).
Vision - Participating providers file all claim forms and accept reimbursement from VSP as payment in
full. If an out-of-network provider is selected, an out-of-network reimbursement form must be completed and submitted to VSP. (VSP, P.O. Box 997105, Sacramento, CA 95899 -7105). Do I need to inform the insurance company in advance of any hospitalization?
No pre-certification is required but pre-admission notification is recommended prior to planned
admissions or emergency admissions.
When will my coverage become effective?
The effective date will be the 1st of the month if the enrollment form is received by the
Administrator between the 1st and 15th of any month. If the postmark date of the enrollment form
is between the 16th and 31st of any month, your effective date will be the first of the following month.
Endorsed By:
Underwritten By:
by Fairmont Specialty, a part of Crum & Forster Arranged By:
Mass Marketing Insurance Consultants, Inc. United Concordia Life And Health Insurance Company Claims/ Eligibility Administration:
4401 Deer Path Road Harrisburg, PA 17110 3333 Quality Drive Rancho Cordova, CA 95670 MONTHLY AUTOMATIC PAY PLAN FORM
To Be Completed by Members Who Wish to Pay Insurance Premium Monthly SELECT METHOD OF PAYMENT
□ Monthly Credit Card □ Monthly Debit Card □ Monthly Check-O-Matic

Credit Card Authorization
I authorize Mass Marketing Insurance Consultants, Inc. (MMIC) to bill my credit card account for the total amount due. This authority is to remain effective until I provide MMIC with written notification of cancellation. I understand that two weeks notice will be needed to implement any action. Applicant Name:___________________________________________________________________
Month Date
Year
Signature:___________________________ Date:_________________________
Check-O-Matic Authorization
Applicant Name:___________________________________________________________________ Name of Depositor:________________________________________________________________ Print exact name as it appears on financial institution records Address:______________________________________________________________________________________ I (we) hereby authorize Mass Marketing Insurance Consultants, Inc. to initiate debit entries to my (our) checking account (or savings account) and the Financial Institution named below to debit the same to such account. Mass Marketing Insurance Consultants, Inc. will not be held responsible for a policy lapse or cancellation due to non-payment if the withdrawal is presented and not honored for any reason and the amount is not paid. Financial Institution Name:__________________________________________________________ Street Address:____________________________________________________________________ City:_______________________________ State:______________________ Zip:______________ This authority is to remain effective until I (we) provide Mass Marketing Insurance Consultants, Inc. with written notification of cancellation two weeks before the date of termination.
Note: If the direct payment by check transactions is returned for non-sufficient funds, a $25 non-refundable
service fee will be applied when allowed by state.

Signature:___________________________ Date:_________________________

Source: http://www.somainsurance.com/brochures/2010-11_Brochure.pdf