09COL1227 Colorado School of Mines User Guide v10.qxp

Student Health Program

2009-2010

Coulter Student Health Center

Counseling Center at Student Development and Academic Services

Student Health Insurance Plan (SHIP)

Athletic Trainer for Intercollegiate Athletes

Health Education and Wellness Programs

09COL1227

Dear CSM Student, Parent, or Guardian,

We are pleased to provide you with this brochure describing Mines Student Health Program. A healthy student body is

essential for a vibrant and dynamic learning environment and student success. The Student Health Program is

committed to assisting students in making healthier choices during their academic careers at the Colorado School of

Mines. The relationship between academic success and health is inseparable. Mines requires that all degree-seeking

students have adequate health insurance.

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• be proactive in addressing their health care issues.

• have access to timely and accurate health information and preventative measures.

• have quality health care that provides the least interruption of their academic progress, and not be hindered by the cost of obtaining the

care needed.

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• Coulter Student Health Center • Health Information and Wellness Programs

• Student Health Insurance Plan (SHIP)* • Athletic Trainer for Intercollegiate Athletes

• Counseling Center at Student Development and Academic Services

Providing good health care supports academic success at Mines, through appropriate access to health care services, information, and the

highest possible quality of care. Primary care and mental health care services, paid through student fees, for all degree-seeking students,

is where our program starts. In cases where additional care is needed, health insurance is very important. Student and parents/guardians

must carefully consider their health insurance options to assure appropriate access to health care services, beyond Mines’ primary care and

mental health care, and have financial protection in the event of a major injury or illness.

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• Minor injuries may require local care at a hospital, urgent care facility or specialist.

• Academic momentum should be supported by local access to follow-up care.

• Mental health care visits are best if access is within 2 miles.

• Students should not have to choose between paying for an education or paying for health care.

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Online enrollment/waiver process: Completion is required for all US citizens for the SHIP. (International students and intercollegiate

athletes participating in NCAA-sanctioned sports can enroll in the SHIP online, but

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complete a paper waiver process.) The deadline

to waive the SHIP is September 9, 2009.

The SHIP cost for 2009-2010 is $780 per semester for single student coverage. The spring semester automatically includes summer

coverage. The average monthly cost of coverage is $130. We know of no other individual health insurance program available to Mines

students that provides comparable coverage at or below this cost. Many parents/guardians also find that the SHIP costs less than the

contributions required for employer sponsored health plans.

Our program provides Injury and Sickness coverage, as explained in this brochure, through the nation’s

largest health insurance organization, UnitedHealthcare. UnitedHealthcare StudentResources is also one

of the leading providers of health insurance coverage for college students. Our program has a fully insured

component (e.g., SHIP coverage) and a self-funded component (e.g., dental care services at the Coulter

Student Health Center). Other services provided to SHIP participants include after-hours phone

consultation and an improved process to obtain insurance identification cards.

Best wishes for a successful and healthy year.

Best Regards,

Ron Brummett, MBA, MA

Director of Student Services

EMERGENCIES

For life-threatening emergencies, students should call CSM Public Safety at 303-273-3333 and/or 911. If

appropriate, proceed directly to the nearest emergency room. For urgent health care situations, please call or visit the

Coulter Student Health Center. For psychological crisis situations on campus during normal CSM business hours,

please call the CSM Counseling Center at 303-273-3377.

* One Year Non-Renewable Term Policy underwritten by UnitedHealthcare Insurance Company

TABLE OF CONTENTS

CSM Health Insurance Requirement and Online Enrollment/Waiver Process . . . . . . . . . . . . . . . . . .2

Notices and Questions: Need More Information? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Coulter Student Health Center . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

Dental Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

CSM Counseling Center . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

Student Health Insurance Plan (SHIP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

Students Who Participate in NCAA-Sanctioned Intercollegiate Sports . . . . . . . . . . . . . . . . . . . . . .12

Pharmacy / Vision Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

SHIP Schedule of Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

State Mandates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

The Colorado School of Mines Student Health Insurance Program Notice of Privacy Practices .20

Emergency Services for SHIP-Covered Persons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22

CSM Counseling Center Referral Benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23

Contact Section

Service Student Health Program Entity Phone Web Site

Primary Care and Dental Care

Coulter Student Health Center

After-Hours and Week-ends,

New West Physicians

(see below for 24-hour nurse/counseling-

line for SHIP-covered students)

303-273-3381

303-278-4600

http://healthcenter.mines.edu

www.nwphysicians.com (@Golden West

Location)

Counseling

Student Development and Academic

Services

303-273-3377 http://counseling.mines.edu

Sports Medicine for NCAA-

Sanctioned Intercollegiate Sports

CSM Athletic Trainer 303-273-3375 http://athletics.mines.edu

Emergencies and Crisis

Intervention

Life-Threatening Emergencies

CSM Public Safety

CSM Counseling

Suicide and Crisis Hot-Line

911

303-273-3333

303-273-3375

303-425-0300

N/A

http://publicsafety.mines.edu

http://counseling.mines.edu

www.suicidehotlines.com/colorado

Student Health Insurance Plan (SHIP)

On-Campus Service

CSM Student Health Insurance

Coordinator

303-273-3388 www.UHCSR.com/CSM

SHIP Benefits (including vision

care), Claims Information, and

Identification Cards

United Healthcare StudentResources

Pharmacy (Medco)

866-458-4954

877-417-7345

www.UHCSR.com/CSM

24-Hour Nurse/Counseling Line United Healthcare StudentResources 877-643-5130 www.liveandworkwell.com

Medical Evacuation United Healthcare StudentResources 877-488-9833 www.assistamerica.com/student

Confidential Secure Messaging

for Student Health Program

(available to all students

regardless of type of personal

health insurance coverage)

WordSecure for CSM Student Health

Program

303-273-3381

To subscribe visit:

https://csm.wordsecure.com/

CSM Health Insurance Requirement

All degree-seeking students who are (1) United States citizens

or permanent residents, (2) international students regardless of

degree seeking status, or (3) INTERLINK students must have

health insurance that meets or exceeds CSM’s coverage

requirements.

International and NCAA Student Athletes

International students and INTERLINK students cannot use the

on-line system to waive enrollment in the SHIP; they can only

use this system to enroll themselves in the SHIP. International

students must contact the International Student Program office

if they have embassy/other-sponsored coverage that they would

like considered by CSM for waiver of SHIP coverage.

Students participating in NCAA-sanctioned intercollegiate

sports cannot use the on-line system to waive enrollment in

the SHIP; they can only use this system to enroll themselves

in the SHIP. Athletes should contact Jennifer McIntosh, the

Head Athletic Trainer, if they wish to waive enrollment in the

SHIP.

Annual On-Line Enrollment/Waiver Process –

September 9, 2009 deadline!

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Students

are strongly encouraged to use the on-line system to either

enroll or waive SHIP coverage. Using the default, automatic

enrollment in the SHIP will delay your access to an insurance

identification card and result in your receiving numerous email

notices about the SHIP enrollment/waiver deadline. Graduate

students must complete the enrollment process even though

their academic departments may be paying for the cost of the

SHIP.

Upon a student’s bona fide request and submission of

appropriate documentation, the School may grant a waiver of

the insurance requirement based on the student’s sincerely-held

religious belief which prevents the student from buying or having

health insurance. All waiver requests must be submitted in

writing and will be reviewed by the Student Health Insurance

Coordinator.

DO NOT FALSIFY YOUR PERSONAL INSURANCE

INFORMATION REQUIRED FOR WAIVING SHIP

COVERAGE. Students who falsify insurance information

may be required to enroll in the SHIP as an Unqualified Late

Enrollee, which includes both cost and benefit penalties.

Sanctions by CSM may also be imposed if students are

found to have intentionally falsified an official CSM required

document.

Requests for waiving SHIP coverage after the deadlines

stated above will be considered on an individual case basis

with presumption against students who were automatically

enrolled in the SHIP rather than using the on-line

enrollment/waiver system. If granted, SHIP waiver requests

after the enrollment/waiver deadline will be subject to a $60

late waiver fee for requests submitted prior to October 9,

2009 (February 28, 2010, for spring semester). This fee

increases to $120 for late waiver fee requests submitted

prior to November 9, 2009 (March 28, 2010, for spring

semester). Otherwise, refunds of the cost of SHIP coverage

will only be made upon the entry of any covered person into

the armed services of any country. A pro-rated refund will be

returned to such person upon request to the Insurance

Coordinator at the CSM Student Health Center.

Instructions for Using the SHIP On-Line

Enrollment/Waiver Process

click on the Student link, then the Registration link. Near the

bottom of the list, click on “Enroll/Waive in Student Health

Insurance Plan (SHIP)” and follow the instructions on the

page that appears. A confirmation page will appear indicating

your waiver has been approved or denied. Please print this

page for your records. An additional confirmation will be sent

to your Mines email address. If you encounter problems or

have questions, contact the Student Insurance Coordinator

at the Student Health Center at 303-273-3388 or subscribe

to WordSecure (see Table of Contents page) and send

message using the web-based system to the Student

Insurance Coordinator.

Enrolling Your Dependents in SHIP

Enrolling dependents in the SHIP cannot be done through the on-

line system. Students wanting to enroll a spouse or child(ren) in

the SHIP must visit the Student Insurance Coordinator’s office at

the Student Health Center to complete an enrollment form and

have the additional cost of coverage added to their tuition/fee

billing.

Other SHIP Eligibility Provisions

Please see page 11 for other provisions relating to access to

SHIP coverage in the event you involuntarily lose your group

health insurance coverage during the plan year (see Qualified

Late Enrollee provisions).

CSM HEALTH INSURANCE REQUIREMENT AND

ONLINE ENROLLMENT/WAIVER PROCESS

The Colorado School of Mines complies with the Health

Insurance Portability and Accountability Act of 1996. Privacy

policies for the Coulter Student Health Center and the

Counseling Center may be obtained by visiting either facility

or at the following websites.

http://healthcenter.mines.edu

http://counseling.mines.edu

NOTICES

The SHIP provided by CSM complies with the standards for

student health insurance/benefit programs recommended by

the American College Health Association.

www.acha.org

QUESTIONS — NEED MORE INFORMATION?

For further information, please contact:

CSM NCAA Intercollegiate Athletics at (303) 273-3375

Student Health Insurance Plan at (303) 273-3388

(email: SHI[email protected])

Student Development and Academic Services at (303) 273-3377

UnitedHealthcare StudentResources at (866) 458-4954 or

www.UHCSR.com/CSM

Preferred providers also may be found at this website.

The SHIP complies fully with Title IX of the Education

Amendments of 1972, Section 504 of the Rehabilitation Act

of 1973, and the Age Discrimination Act of 1975, as all three

laws were amended by the Civil Rights Restoration Act of

1987. Pregnancy benefits are provided on the same basis as

any other temporary disability. The Consolidated Omnibus

Budget Reconciliation Act of 1986 (COBRA) does not apply

to plans that are not employer-sponsored.

Kathryn van Susante

Student Health Insurance (SHIP)

Coordinator

Overview

The Coulter Student Health Center (http://healthcenter.mines.edu)

offers a variety of services which meet the health care needs of

most students. Every effort is made to help students obtain

appropriate consultation or referral when additional or special

services are required.

The clinic is staffed by nationally certified nurse practitioners

and registered nurses. Physician coverage is provided by a

group of family practice physicians who are on site from

3:00pm-4:45pm Monday-Friday, and are on call at all times.

Eligibility for Services

Students who are enrolled in at least four credit hours pay a

Health Center fee which allows access to services provided

at the Student Health Center. INTERLINK students are

eligible to use the Student Health Center only during their

session at CSM. Spouses may be seen at the Health Center,

for the same per semester fee as students. Spouses do not

have access to dental services provided at the Student

Health Center. The Student Health Center does not provide

services for children, faculty, staff or campus visitors.

Students may only be seen during the session in which they

are enrolled and paying fees.

Mark Pattridge, Medical Director of the Coulter Student Health Center, is

board certified in Family Medicine. He completed his residency/internship at

St. Mary’s Hospital in Grand Junction, Colorado. He has been affiliated with

the SHC for more than 20 years and has served as the Medical Director for the

past 12 years.

He maintains a family practice in Golden, New West Family Physicians. This

practice provides medical coverage for the SHC Monday – Friday 3:00-4:45

pm during the academic year. Drs. Julia Atkins, Harold Richardson, and

Patricia Brumbaugh share this coverage as well as phone consultation on

nights and weekends.

Debra Roberge, Director of the Coulter Student Health Center, is a board

certified Adult Nurse Practitioner. She has worked in college health for over 20

years. She received her Master’s Degree in Primary Care/NP from Boston

College.

COULTER STUDENT

HEALTH CENTER

EMERGENCIES

For life-threatening emergencies, students should call CSM Public Safety at 303-273-3333 and/or 911. If appropriate,

proceed directly to the nearest hospital emergency room. For urgent health care situations, please call or visit the Coulter

Student Health Center. For psychological crisis situations on campus during normal CSM business hours, please call the

CSM Counseling Center at 303-273-3377.

Services Provided Without Charge:

●

Over-the-counter medications (Advil, Tylenol, cold

medications, Mylanta, etc.)

●

Evaluation and treatment for common illnesses and

injuries.

●

Evaluation and treatment for depression, anxiety and other

uncomplicated mental health concerns.

●

Throat cultures.

●

Wart treatment with liquid nitrogen

(Wed. & Thurs.: 9-11:30 am and 1-2:30 pm).

●

Allergy shots given during doctors' hours until 4:15 pm.

Serum and instructions must be provided by the student.

●

Women's health care (annual women’s health exams must

be scheduled by appointment).

●

Safe sex education, condoms, and contraception options.

●

Brochures and information about various health related

topics (nutrition, STDs, AIDS, smoking, alcohol abuse,

etc.).

●

Crutches, knee braces, and heating pads can be checked

out for a short period of time.

●

Certain prescription medications (antibiotics, pain medications,

skin ointments, etc.).

●

Unlimited doctor visits during the academic year

(Mon.-Fri.: 3:00-4:45 pm).

●

Suturing of simple lacerations during doctors' hours,

wound care supplies, suture (stitches) removal.

●

MMR and tetanus (as result of injury) vaccines (when

available).

●

PPD (tuberculosis) skin test.

●

Flu shots (late October or early November while supplies last).

Services Available for an Additional Fee

●

PAP smears and other lab tests are available through the

Health Center; students will be billed for these tests.

●

Tetanus update

●

Hepatitis A/B combo immunization

●

Hepatitis A immunization

●

Hepatitis B immunization

●

Meningitis immunization

●

Gardasil/HPV

●

Dental Services

Health Center staff will facilitate referrals to

specialists/facilities for treatment not available at the

Student Health Center.

Location and Accessibility

The Student Health Center is located at 17th and Elm, across

from the IM field (and just to the south of the Student

Recreation Center). The building is handicapped accessible.

Hours of Services, Appointments, and Contact

Information

Clinic hours are Monday-Friday, 8:00am to 12:00pm and

1:00pm to 4:45pm (refer also to the Dental Clinic section for

dental care service hours).

Most services are provided without an appointment. Services

at the Dental Clinic and annual women’s health exams require

an appointment.

The Coulter Student Health Center telephone number is

303-273-3381. Students are encouraged to subscribe to our

secure messaging program to communicate with all student

health program staff at Colorado School of Mines, including

many of our affiliated external service companies. Students

may subscribe using their CSM email addresses by visiting

our secure web site at https://csm.wordsecure.com.

Confidentiality

The Coulter Student Health Center complies with both the

Health Insurance Portability and Accountability Act of 1996

(HIPAA) and all applicable State of Colorado laws and

regulations pertaining to the confidentiality of health records.

Certain educational records and other personal information is

governed by the Family Educational Rights and Privacy Act

(FERPA) rather than HIPAA.

Please review the complete Notice of Privacy Practices

statement in this brochure. Your health records and medical

information will be kept confidential by the Coulter Student

Health Center, except as specifically provided for in our

privacy policies and/or as pursuant to a valid release of health

records and medical information.

DENTAL CARE

Mission

The Dental Clinic at the Coulter Student Health Center

emphasizes patient education to prevent disease and

provides treatment options when procedures are needed.

Dental treatment is provided in the same non-threatening,

responsive, and considerate manner that students have come

to expect of all health care services at the Coulter Student

Health Center.

Eligibility and Fees

All CSM students who are enrolled in four credit hours and

who have paid the Health Center Fee are eligible for services

at the Dental Clinic. In most cases, treatment will require a

copayment. Students enrolled in the SHIP will receive priority

in scheduling appointments and will pay approximately 50%

less for dental care than students not participating in the

SHIP.* Students may only be seen during the session in which

they are enrolled and paying fees.

Telephone

Appointments: (303) 273-3381

Routine Appointment Hours of Service**

Tuesday 8:00 AM – 4:30 PM

Wednesday 8:00 AM – 4:30 PM

Friday 8:00 AM – 4:30 PM

Dental Clinic copayments

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Initial, with X-rays as needed $ 10.00 $ 20.00

Emergency exam with

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Prophylaxis/hour

(includes recall exam) $ 15.00 $ 30.00

Four bitewing X-rays $ 10.00 $ 15.00

Sealant per tooth $ 10.00 $ 15.00

Full Mouth X-rays $ 15.00 $ 25.00

Peri-Apical films $ 0 $ 5.00

Vitality Testing $ 0 $ 10.00

Fluoride Treatment $ 5.00 $ 10.00

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Amalgam-I surface $ 20.00 $ 30.00

Amalgam-2 surfaces $ 25.00 $ 35.00

Amalgam-3 surfaces $ 30.00 $ 40.00

Amalgam-4 surfaces $ 35.00 $ 45.00

Resin-I surface $ 20.00 $ 30.00

Resin-2 surfaces $ 25.00 $ 35.00

Resin-3 surfaces $ 30.00 $ 40.00

Resin-4 surfaces $ 35.00 $ 45.00

Dental care is one of the services most valued by students at CSM

Jeanette Courtad, DDS

Staff Dentist

*Discount provided by CSM’s Dental Clinic. Dental care is

not provided by or underwritten by UnitedHealthcare

Insurance Company

**One third of the available appointment times will be reserved

for SHIP participants.

Students will be charged for missed appointments if they do not

call to cancel 24 hours prior to the scheduled appointment.

Hours of dental service may be reduced during semester breaks

and summer sessions.

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Pulpectomy/pulpotomy $ 20.00 $ 30.00

Sedative Filling/interim

restoration $ 15.00 $ 25.00

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Limited scaling/root cleaning $ 25.00 $ 35.00

Perio scaling/root

planing/per hour $ 35.00 $ 50.00

Perio maintenance $ 20.00 $ 30.00

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Referrals will be made to qualified community specialists as

needed for services such as wisdom teeth extraction, root

canal treatment, periodontal evaluation and treatment,

orthodontics (braces), splints (night guards), bleaching, and

TMD or TMJ problems. These services are not covered by the

Dental Clinic.

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• More than two cleanings per benefit year unless

prescribed by the dentist

• Root Canals

• Crowns

• Bridges

• Dentures

• Complex Extractions

• Emergency care or other treatment rendered at

places other than the Coulter Student Health Center

Dental Clinic (including referrals)

• Any service or supply not listed in this brochure as a

covered service

The dental clinic is staffed by a dentist, a dental assistant,

and a dental hygienist and provides basic dental services

such as exams, cleaning, x-rays, simple restorations and

education regarding good dental hygiene. Dental services

are provided on a fee-for-services basis and are available to

all students who have paid the Health Center fee. Students

enrolled in CSM's Student Health Insurance Plan will receive

dental care for reduced fees.*

CSM COUNSELING CENTER

Overview

Counseling services are provided by Student Development and

Academic Services at CSM (http://counseling.mines.edu). A

student development approach to counseling focuses on the

developmental needs of students that typically occur between

the ages of 18 and 22. These needs include learning how to

develop, maintain and nurture relationships. Programs and

services address ways students can learn to cultivate healthy

lifestyles, leadership skills, assertiveness skills, communication

skills, and identify and minimize high-risk behaviors, including

use and abuse of alcohol and other drugs.

To best serve CSM students, we balance our student

development approach with professional mental health services.

Individual, short-term professional counseling is available to help

students identify personal, academic and/or career challenges,

and to learn positive coping skills to manage their lives.

Counselors are trained and experienced in providing crisis inter-

vention services as well as consultation regarding crises in order

to prevent, resolve, and/or minimize the effects of crisis on the indi-

vidual and the CSM community. Counseling appointments may be

scheduled from 8:00am-5:00pm, Monday through Friday. Office

hours vary during the summer session.

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Eligibility for Services

All students enrolled at CSM for four or more credit hours are

eligible to use the counseling and crisis intervention services

available from Student Development and Academic Services.

INTERLINK students are also eligible to use these services.

There is no charge to students for counseling services. Students

enrolled in fewer than four credit hours must pay all fees,

including student service fees, to be eligible for counseling

services. Spouses of students are not eligible for services unless

they are also a CSM student.

Services Provided Without Charge

Individual counseling sessions are provided without charge for

eligible undergraduate and graduate students. Examples of the

reasons students seek counseling services include the

following:

●

Depression, anxiety, and other behavioral health concerns

that are common for college students.

●

Stress Management

●

Problem Solving

●

Time Management

●

Decision Making

●

Goal Setting

●

Relationships

●

Making positive lifestyle choices

●

Personal wellness

●

Increasing self-confidence

Crisis intervention and consultation services are also available.

Students who need long-term services will be referred to

community mental health care providers (including psychiatrists,

psychologists, and other licensed mental health care providers).

As noted throughout this brochure, adequate health

insurance coverage is essential to ensuring students

have appropriate access to health care services.

Ron Brummett, MBA, MA

Director of Student Services

Location and Accessibility

Student Development and Academic Support Services is located

at the north end of the first floor of the Ben E. Parker Student

Center, Suite 8. The building is handicapped accessible.

Hours of Service, Appointments, and Contact

Information

Counseling appointments may be scheduled from 8:00am-

5:00pm, Monday through Friday. Office hours vary during the

summer session. Students in crisis do not need an appointment

to be seen for counseling services. The Student Development

and Academic Services telephone number is 303-273-3377.

Students are encouraged to subscribe to our secure messaging

program to communicate with all student health program entities

at Colorado School of Mines, including many of our affiliated

external service companies. Students may subscribe using their

CSM email addresses by visiting our secure web site at

https://csm.wordsecure.com. Students may, subject to

conditions established by their counselor, use the secure

messaging system. Appointments, however, must be scheduled

by telephone or by visiting the Counseling Center.

Professional Staff

The professional staff includes licensed professional

counselors, psychologists, and social workers. All professional

staff have experience and specialized training in meeting the

counseling needs of college students.

CSM Counseling Center

(continued)

Confidentiality

Student Development and Academic Services complies with

both the Health Insurance Portability and Accountability Act of

1996 (HIPAA) and applicable State of Colorado laws and

regulations pertaining to confidentiality of health records. In

some instances, certain educational records and other personal

information is governed by the Family Educational Rights and

Privacy Act (FERPA) rather than HIPAA. Please review the

complete Notice of Privacy Practices statement in this brochure.

Your health records and medical information will be kept

confidential by Student Development and Academic Services,

except as specifically provided for in our privacy polices

and/or as pursuant to a valid release of health records and

medical information.

CSM has one of the nation’s best values for a student health insurance program.

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Good health is essential to academic success, and adequate

health insurance is essential to receive high quality health care.

Unexpected medical bills can also threaten the ability to complete

an education if students are uninsured or have inadequate

coverage. Health insurance is particularly important as primary

care and mental health care services provided by CSM are limited

as explained in this brochure.

●

The CSM Student Health Insurance Plan (SHIP) provides out-

standing coverage at a cost well below many comparable indi-

vidual health insurance policies. The SHIP is less expensive

than dependent coverage provided under many employer-

sponsored group health insurance plans.

●

Many employer-sponsored group health insurance plans do not

cover part-time students, or contain upper age limits. Also,

students who have declared financial independence from their

parents are no longer eligible to be covered as dependents

under employer-sponsored health insurance plans.

●

Students covered under a managed care type of health

insurance may not have full access to health care providers

while in the Denver area. This is a particularly important

consideration for students needing access to mental health

care providers.

●

For UnitedHealthcare preferred providers, the SHIP features

copayments rather than deductibles. Copayments are a

convenient way to pay your share of health care expenses.

●

NCAA intercollegiate athletes may be taking significant financial

risk if they do not enroll in the Student Health Insurance Plan.

They must confirm that their personal health insurance will cover

injuries resulting from the practice or play of intercollegiate

sports. See page 12 for more details.

●

The SHIP includes an annual vision exam benefit. See page 13

for details.

●

The SHIP includes special medical evacuation and repatriation

coverage for all international students. The SHIP also includes

special medical evacuation and repatriation coverage for SHIP

participants who travel abroad.

SHIP Overview

The Colorado School of Mines is pleased to offer a student

health insurance plan that is one of the best in the country for

scope of coverage and program value. This program provides

world-wide coverage for injury and sickness, on- or off-campus.

This fully insured plan is underwritten by UnitedHealthcare

Insurance Company and administered by UnitedHealthcare

StudentResources.*

SHIP Student Eligibility

Unless otherwise specified in this brochure, all degree-seeking

students who are United States Citizens or permanent residents

must have health insurance that meets or exceeds CSM’s

coverage requirements. International students and INTERLINK

students are only allowed to waive enrollment in the SHIP if they

have coverage that has been pre-approved by CSM for waiver

of SHIP coverage.

Upon a student’s bona fide request and submission of

appropriate documentation, the School may grant a waiver of

the insurance based on the student’s sincerely-held religious

belief which prevents the student from buying or having health

insurance. All waiver requests must be submitted in writing and

will be reviewed by the Student Health Insurance Coordinator.

All eligible students must meet the following additional

requirements:

1. Students must be enrolled in the SHIP prior to the

enrollment/waiver deadline for each coverage period, which

is the last day of any coverage period to drop a class without

a “W”. Students who waive coverage for the fall semester

will not be allowed to change this decision for the

spring/summer or summer coverage periods except as

specifically allowed for Qualified Late Enrollees (refer to

Voluntary SHIP Participation). Requests for rescission of a

SHIP waiver request will not be considered after the

enrollment/waiver deadline.

2. Students must attend regularly scheduled classes for the

first 31 days of each coverage period unless the student has

an approved medical withdrawal from CSM.

3. The student has not been enrolled in the SHIP for more than

nine years while in a single degree program.

4. Students may be required to establish that they are pursuing

a degree and making normal progress toward degree

completion.

5. Refer to the page 12 for special insurance requirements for

students who participate in NCAA-sanctioned intercollegiate

sports.

STUDENT HEALTH

INSURANCE PLAN (SHIP)

*Some components of the program (such as limited dental care benefits at the Coulter Student Health Center) are self-funded by CSM. This means a portion of

the cost of the plan is retained by CSM to provide certain benefits through special arrangements on a direct funding basis. CSM also retains funds to pay for

administrative costs associated with providing the SHIP.

Annual Open Enrollment

Students who waive enrollment in the SHIP are not eligible

for enrollment until the next annual open enrollment period,

except for provisions established for Qualified Late Enrollees.

For example, a student who waives enrollment in the SHIP for

the fall semester is not eligible to enroll in the subsequent

Spring/Summer coverage period. Note that students who are

covered by the SHIP for the spring semester automatically

have coverage through the summer, including students who

are graduating in May. Students not participating in

intercollegiate sports may withdraw from the SHIP at the

beginning of the spring/summer coverage period (not

applicable to summer) if they acquire health insurance that

qualifies for waiving SHIP enrollment. This option is not

available to students who participate in NCAA-sanctioned

sports.

Voluntary SHIP Eligibility Classes

Spouses and children of SHIP-covered students are also

eligible for participation in the SHIP. Eligible dependents are

the spouse (except in the event of divorce or annulment) and

unmarried children younger than 19 years of age. There are

also certain rules that apply for newborn coverage and adding

dependents that can be found at www.UHCSR.com/csm.

Pro-rated costs are available for newly acquired dependents.

Students who are in good academic standing and take an

approved leave of absence from CSM, including Cooperative

Education students and students enrolled in the International

Student Exchange Program, may request continuation in the

SHIP for a period not exceeding two academic semesters.

Such students must be enrolled in the SHIP in the period of

coverage immediately preceding the period of absence.

Spouses and dependents of such students are similarly

eligible for coverage.

Qualified Late Enrollees

An eligible student will only be allowed to enroll in the SHIP

after the applicable enrollment/waiver period if proof is

furnished that the student became involuntarily ineligible for

coverage under another group’s insurance plan during the 30

days immediately preceding the date of the request for late

enrollment in the SHIP. In such cases, the student’s effective

date of coverage under the SHIP will be the first day of the

month in which the student involuntarily loses coverage. The

30-day period in the provision may be extended if the student

can establish that he or she was unaware of the involuntary

loss of coverage. Refunds of premiums are allowed only upon

entry into the armed forces.

UnitedHealthcare StudentResources maintains its right to

investigate student status and attendance records to verify

that the policy eligibility requirements have been met. If

UnitedHealthcare StudentResources discovers the eligibility

requirements have not been met, its only obligation is to

refund premiums. Dependent eligibility expires concurrently

with that of the insured student.

Unqualified Late Enrollees

Any eligible student who is subject to the Colorado School of Mines’

insurance requirement and is found to be uninsured during the Plan

Year (and is not a Qualified Late Enrollee) or their plan

coverage does not meet CSM’s requirements will be required to enroll

in the SHIP under policy #2009-4059-2. Unqualified Late Enrollees

cannot purchase dependent cov-

erage under the SHIP until the next

Annual Open Enrollment Period.

Unqualified Late Enrollees will be

subject to a pre-existing condition

limitation that includes a six-month

look-back period for diagnosis or

treatment and a six-month waiting

period for benefits for any pre-exist-

ing condition to begin. The cost of

the SHIP is not pro-rated for

Unqualified Late Enrollees.

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2009

Fall Semester

August 25, 2009

January 12, 2010

2010

Spring/Summer

January 13, 2010

August 24, 2010

2010

Spring/Summer*

January 13, 2010

August 24, 2010

Only for students and

dependents not enrolled in the

SHIP in the Fall Semester.

2010

Field Session

May17, 2010

August 24, 2010

Only for students first

enrolling at CSM

2010

Summer Only

June 21, 2010

August 24, 2010

Only for students first

enrolling at CSM

Student/NCAA Student Athlete $780 $780 $1,037 $662 $467

Spouse $2,456 $2,456 $3,271 $1,774 $1,252

Child(ren) $1,660 $1,660 $2,216 $1,346 $951

Spouse and Child(ren) $4,116 $4,116 $5,487 $3,120 $2,203

2009/2010 SHIP Costs and Coverage Dates

Effective dates may be earlier for NCAA-intercollegiate athletes or other students required to be at CSM prior to start of school.

*These rates are calculated using similar average monthly costs as charged to students/dependents who are enrolled for both fall and spring/summer coverage periods.

NCAA Student Athletes

Students who will be participating in NCAA-sanctioned

intercollegiate sports at the Colorado School of Mines are

subject to additional insurance requirements as specified

below. The requirements apply even if the student is only

trying out for a team or is only engaged in a single day of

intercollegiate sports practice activities.

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To enroll in or waive SHIP coverage, athletes engaged in

NCAA-sanctioned intercollegiate sports must complete a

special enrollment/waiver form and submit it to the Athletic

Department. You will not be allowed to participate in

intercollegiate practice or play until this form is completed and

submitted to the Athletic Department.

Please make note of the following.

●

If you waive participation in the SHIP, you and your

parent/guardian accept financial responsibility for any

expenses or illnesses resulting from the practice or play of

NCAA-sanctioned intercollegiate sports. This liability

includes: (1) any expense limited or excluded by the NCAA

catastrophic insurance and (2) the $75,000 deductible

under the policy. The NCAA catastrophic insurance policy

is available for review at the CSM Athletic Department.

●

If you enroll in the SHIP and you comply with the

preauthorization for care requirements, you will be

responsible only for the copayments, deductibles, and any

ineligible charges under the program.

●

The cost of the SHIP for students who are engaged in the

practice or play of intercollegiate sports will no longer be

subject to a surcharge. The cost for students who

participate in NCAA-sanctioned intercollegiate sports will

be the same as for all other students who participate in the

SHIP.

●

If you waive participation in the SHIP and will be relying on

employer-sponsored health plan coverage, you must

confirm that your plan will cover injuries resulting from the

practice or play of intercollegiate sports. Students and

parents should use caution in relying on employer-

sponsored health coverage as some plans have adopted

exclusions for professional sports or organized sports such

as intercollegiate athletics

NCAA Coverage for Catastrophic Intercollegiate

Athletic Injury

NCAA catastrophic coverage is provided, without charge, to

all CSM students who participate in NCAA-sanctioned

intercollegiate athletics, regardless of participation in the

SHIP. This coverage is provided through the National

Collegiate Athletic Association. The NCAA coverage has two

levels of financial liability for students: (1) any expense limited

or excluded by the NCAA catastrophic insurance and (2) the

$75,000 deductible under the policy. This coverage also

includes important benefits other than reimbursement of

medical expenses (e.g., college education benefits and

assimilation/rehabilitation benefits).

STUDENTS WHO PARTICIPATE IN NCAA-

SANCTIONED INTERCOLLEGIATE SPORTS

Preferred Plan

The school has selected a Preferred health plan that gives you

the opportunity to save by offering a higher benefit level when

you see preferred providers. This plan offers the typical health

plan benefits, plus many services that you may not expect

from a PPO — including some preventive care and

prescription drugs. When you see preferred providers, they

will take care of all the necessary paperwork for you. With this

plan, you may select any doctor or hospital you wish. You will

receive benefits for most covered services even if you choose

to receive care from an out-of-network provider — but you will

pay a greater share of the cost. Please note that out-of-

network care is not covered for certain specialized services.

Refunds

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rated refund will be returned to such person upon request.

Students who withdraw from CSM for non-medical reasons

prior to the last day of any semester to drop a class without a

“W” are not eligible for the SHIP coverage for that semester.

Students must notify the Registrar’s Office of such withdrawal

and the entire cost of the coverage for that semester will be

refunded, including dependent coverage.

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Identification Cards

Students and dependents covered by the SHIP may request

Identification Cards using the Internet. Students may log on

to the UnitedHealthcare StudentResources website at

www.UHCSR.com on or after the following dates for the

2009-2010 academic year.

Fall Semester: October 1, 2009

Spring Semester: February 15, 2010*

Summer Session: July 15, 2010*

*Students enrolling for the fall semester do not have to re-

order identification cards for the spring/summer coverage

periods. These dates are only for new students first enrolling

at CSM during these periods.

Understanding the Network

The SHIP is a PPO plan provided through UnitedHealthcare

Insurance Company – the largest insurance company in the

country. UnitedHealthcare has negotiated discounted service

rates in order to provide the best healthcare value to you.

The plan encourages you to use preferred providers to

maximize your healthcare dollars. Using preferred providers

results in a lower deductible and a lower out-of-pocket

maximum. Out-of-network service charges by physicians and

facilities are also higher since they have not agreed to

provide a discount on their services.

Want to see if your doctor is in the UnitedHealthcare Choice Plus

PPO network? Go to www.UHCSR.com/CSM to search for

participating providers. You can also call Customer Service at

866-458-4954. Customer Service Representatives are available

from 7 a.m. to 7 p.m., Central Time, Monday through Friday.

Pharmacy Benefits

The SHIP includes benefits for outpatient prescription drugs

when dispensed by UnitedHealthcare Network Pharmacy

(UHPS). Please refer to the Schedule of Medical Expense

Benefits, page 15, for information. For a full description of

pharmacy benefits, including the terms, limitations, and

additional pharmacy specific exclusions, please refer to the

plan brochure available on-line at www.UHCSR.com/CSM.

Vision Benefits

The SHIP includes a vision exam once per policy year and the

benefit is available from either a preferred provider or out-of-

network provider. Please refer to the Schedule of Medical

Expense Benefits, page 14, for additional information.

Discount Vision benefits through UnitedHealth Allies

SHIP participants will also have access to a discount program

from UnitedHealth Allies that provides point of service discounts

on vision care including optometry, mail order vision products and

laser vision correction. Vision discounts range from 10% to 50%

on vision services. This is a discount program, not insurance.

Your UnitedHealth Allies I.D. card will be delivered in the same

envelope as your SHIP I.D. card. Simply register at

sr.unitedhealthallies.com using the member number on the

UnitedHealth Allies I.D. card to search for vision providers in the

area and secure your guaranteed discount.

Maximum Lifetime Benefit $2,000,000

Deductible, Preferred Provider: $0

Deductible, Out-of-Network: $1,000

(Per Insured Person) (Per Policy Year)

Deductible, Out-of-Network: $3,000

(Aggregate) (Per Family) (Per Policy Year)

Coinsurance, Preferred Provider:

90% except as noted

Coinsurance, Out-of-Network:

70% except as noted

Max = Maximum

PA = Preferred Allowance

U&C = Usual & Customary Charges

INPATIENT Preferred Provider Out-of-Network

Hospital Expense, daily semi-private room rate; general nursing care provided by the Hospital;

Hospital Miscellaneous Expenses, such as the cost of the operating room, laboratory tests, x-ray

examinations, anesthesia, drugs (excluding take home drugs) or medicines, therapeutic services,

and supplies. In computing the number of days payable under this benefit, the date of admission

will be counted, but not the date of discharge.

90% of PA / $250 copay

per admission

70% of U&C /

$750 Deductible

per admission

Routine Newborn Care, while Hospital Confined; and routine nursery care provided

immediately after birth. 4 days Hospital Confinement expense maximum.

Paid as any other Sickness

Physiotherapy, (Includes occupational and speech therapy. 30 non-acute days maximum Per

Policy Year.)

Paid under Hospital Expense

Surgeon’s Fees, in accordance with data provided by Ingenix. If two or more procedures are

performed through the same incision or in immediate succession at the same operative session,

the maximum amount paid will not exceed 50% of the second procedure and 50% of all

subsequent procedures.

90% of PA 70% of U&C

Assistant Surgeon

90% of PA 70% of U&C

Anesthetist, professional services in connection with inpatient surgery.

90% of PA 70% of U&C

Registered Nurse’s Services, private duty nursing care. 90% of PA 70% of U&C

Physician’s Visits, benefits do not apply when related to surgery.

90% of PA 70% of U&C

Pre-Admission Testing, payable within 3 working days prior to admission. Paid under Hospital Miscellaneous Expenses

Psychotherapy (other than for Biologically-Based Mental Illness.)

See Benefits for Psychotherapy

Biologically-Based Mental Illness

See Benefits for Biologically Based Mental Illness

OUTPATIENT Preferred Provider Out-of-Network

Surgeon’s Fees, in accordance with data provided by Ingenix. If two or more procedures are

performed through the same incision or in immediate succession at the same operative session,

the maximum amount paid will not exceed 50% of the second procedure and 50% of all

subsequent procedures.

90% of PA 70% of U&C

Day Surgery Miscellaneous, related to scheduled surgery performed in a Hospital, including

the cost of the operating room; laboratory tests and x-ray examinations, including professional

fees; anesthesia; drugs or medicines; and supplies. Usual and Customary Charges for Day

Surgery Miscellaneous are based on the Outpatient Surgical Facility Charge Index.

90% of PA /

$250 copay

70% of U&C /

$750 Deductible

Assistant Surgeon

90% of PA 70% of U&C

Anesthetist, professional services administered in connection with outpatient surgery.

90% of PA 70% of U&C

Physician’s Visits, benefits for Physician’s Visits do not apply when related to surgery or

Physiotherapy.

100% of PA / $25 copay per

visit

70% of U&C / $25

Deductible per visit

The Policy provides benefits for the Usual and Customary Charges incurred by an Insured Person for loss due

to a covered Injury or Sickness up to the Maximum Lifetime Benefit of $2,000,000.

The Preferred Provider for this plan is UnitedHealthcare Choice Plus PPO.

If care is received from a Preferred Provider any Covered Medical Expenses will be paid at the Preferred

Provider level of benefits. In all other situations, reduced or lower benefits will be provided when an Out-of-

Network provider is used.

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The Company will pay 90% of Preferred Allowance for Preferred

Providers up to $1,000 Per Insured Person Per Policy Year or $3,000 Aggregate Maximum Per Insured Family,

Per Policy Year. Once the Insured or Family out-of-pocket maximum has been satisfied, additional Covered

Medical Expenses will be paid at 100% of Preferred Allowance, up to a Lifetime Maximum Benefit of

$2,000,000 Per Insured Person. Copayments do not apply to the Preferred Provider out-of-pocket maximum.

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After the Deductible has been satisfied, the Company will pay 70%

of Usual & Customary Charges up to $3,000 Per Insured Person, Per Policy Year or $9,000 Aggregate

Maximum Per Insured Family, Per Policy Year. Once the Insured or Family out-of-pocket maximum has been

satisfied, additional Covered Medical Expenses will be paid at 100% of Usual & Customary Charges, up to a

Lifetime Maximum Benefit of $2,000,000 Per Insured Person. Copayments and per service Deductibles do

not apply to the Out-of-Network out-of-pocket maximum.

All maximums are combined Preferred Provider and Out-of-Network, unless noted below.

Benefits will be paid up

to the Maximum Benefit for each service as scheduled below. Covered Medical Expenses include:

SHIP SCHEDULE OF

COVERAGE

OUTPATIENT continued Preferred Provider Out-of-Network

Physiotherapy, Benefits are limited to one visit per day. (Includes occupational and speech

therapy. 20 visits maximum Per Policy Year.) (For children up to age 5, benefits are limited to

20 therapy visits each per policy year each for physiotherapy, occupational, and speech

therapy.)

90% of PA / $25

copay per visit

70% of U&C

Medical Emergency, attending Physician’s charges and the use of the emergency room and

supplies. Treatment must be rendered within 72 hours from time of Injury or first onset of

Sickness. Copay/Deductible waived if admitted.

90% of PA / $100 copay per

visit

90% of U&C / $100

Deductible per visit

(Includes all ancillary charges)

Diagnostic X-ray Services

90% of PA 70% of U&C

Laboratory Services

90% of PA 70% of U&C

Radiation Therapy & Chemotherapy

90% of PA 70% of U&C

Tests & Procedures, diagnostic services and medical procedures performed by a Physician,

other than Physician’s Visits, Physiotherapy, X-Rays and Lab Procedures.

90% of PA 70% of U&C

Psychotherapy (other than for Biologically-Based Mental Illness.) See Benefits for Psychotherapy page 17

Prescription Drugs, Prescription medications are categorized within three tiers. Each tier is

assigned a copay, which is an amount you pay when you fill a prescription at a participating retail

pharmacy or refill your ongoing prescription through the network mail-order pharmacy service.

Tier 4 prescriptions are for self-administered injectables only.

Mail order is available through UHPS at 2.5 times the retail copay up to a 90 day supply. The

maximum copay for mail-order Tier 4 self-administered injectables is $500 maximum.

Benefits are also available for smoking cessation Prescription Drugs when enrolled in an

approved UHPS smoking cessation counseling program up to a $250 per insured Per Policy

Year / $500 Maximum Lifetime Benefit.

UnitedHealthcare Network

Pharmacy (UHPS) up to a 31-day

supply per prescription.

Tier 1: $15 copay per prescription.

Tier 2: $40 copay per prescription.

Tier 3: $60 copay per prescription.

Tier 4: 30% copay per prescription

not to exceed $250 maximum

copay per prescription.

No Benefits

Biologically-Based Mental Illness

See Benefits for Biologically Based Mental Illness page 17

OTHER Preferred Provider Out-of-Network

Ambulance Services, (Copay/Deductible is per trip.)

100% of PA / $200 copay

100% of U&C / $200

Deductible

Air Ambulance

90% of PA /

$5,000 maximum per trip

90% of U&C /

$5,000 maximum per trip

Durable Medical Equipment, a written prescription must accompany the claim when

submitted. Replacement equipment is not covered. Exception: See Benefits for Prosthetic

Devices

90% of PA / $1000 maximum

Per Policy Year

No Benefits

Consultant Physician Fees, when requested and approved by the attending

Physician.

Paid as a Physician’s Visit

Alcoholism/Drug Abuse

Paid as any other Sickness

See Benefits for Biologically Based Mental Illness

Maternity

Paid as any other Sickness

Complications of Pregnancy

Paid as any other Sickness

Organ Transplants

90% of PA / $250 copay per

admission

No Benefits

Voluntary Termination of Pregnancy

No Benefits

NCAA Sanctioned Intercollegiate Sports Benefit, $75,000 max Per Injury

Paid as any other Injury

Annual Gynecological Exam, (This benefit is not subject to the Policy Deductible.)

90% of PA / $25 copay per visit 70% of U&C

Acupuncture, (12 visits maximum Per Policy Year.)

90% of PA / $25 copay per visit 70% of U&C

Vision, (One exam Per Policy Year) (The eye exam exclusion will be waived and benefits will

be paid as specified not to exceed one exam Per Policy Year.)

100% of PA / $20 copay

100% of U&C / $20

Deductible

Skilled Nursing Care, (Limited to 30 days Per Policy Year in and out-of-network combined.

Copayment waived if admitted directly to a skilled nursing facility from an inpatient acute

facility.)

90% of PA / $250 copay

per admission

70% of U&C / $750

Deductible per admission

Home Health Care, (Limited to 60 visits Per Policy Year.)

90% of PA / $25 copay per visit No Benefits

Hospice Care, (30 inpatient days maximum Per Policy Year/91 outpatient days maximum Per

Policy Year. Visit maximums are in and out-of-network combined.)

90% of PA 70% of U&C

Urgent Care

90% of PA / $35 copay per visit 70% of U&C

Dental, (Injury to Sound, Natural teeth only.)

90% of U&C 90% of U&C

STATE MANDATES

Benefits for Prosthetic Devices

Benefits will be paid for the Usual and Customary Charges for the

purchase of Prosthetic Devices.

Prosthetic device means an artificial device to replace, in whole or in part,

an arm or leg.

Benefits are limited to the most appropriate model that adequately meets

the medical needs of the Insured as determined by a Physician. Repairs

and replacements of Prosthetic Devices are also covered unless

necessitated by misuse or loss.

Benefits shall be subject to all Deductible, copayment, coinsurance,

limitations, or any other provisions of the policy.

Benefits for Telemedicine Services

Benefits will be paid for Covered Medical Expenses on the same basis as

services provided through a face-to-face consultation for services

provided through Telemedicine for an Insured residing in a county with

one hundred fifty thousand or fewer residents. “Telemedicine” means the

use of interactive audio, video, or other electronic media to deliver health

care. The term includes the use of electronic media for diagnosis,

consultation, treatment, transfer of medical data and medical education.

The term does not include services performed using a telephone or

facsimile machine.

Nothing in this provision shall require the use of Telemedicine when in-

person care by a participating provider is available to an Insured Person

within the Company’s network and within the Insured’s geographic area.

Benefits shall be subject to all Deductible, copayment, coinsurance,

limitations, or any other provisions of the policy.

Benefits for Mammography

Benefits will be paid for the actual expense incurred up to $90.00 for

low-dose screening mammography for the presence of occult breast

cancer. Benefits will be provided according to the following guidelines:

1. A single baseline mammogram for women thirty-five to thirty-nine years

of age.

2. A mammogram not less than once every two years for women forty

years of age and under fifty years of age or more often for women with

risk factors to breast cancer if recommended by her Physician.

3. A mammogram every year for women fifty to sixty-five years of age.

“Low-dose mammography” means the x-ray examination of the breast,

using equipment dedicated specifically for mammography including but

not limited to the x-ray tube, filter, compression device, screens, films, and

cassettes, with an average radiation exposure delivery of less than one rad

mid-breast, with two views for each breast.

The policy Deductible will not be applied to this benefit.

Benefits shall be subject to all copayment, coinsurance, limitations or any

other provisions of the policy.

Benefits for Diabetes

Benefits will be paid for the Usual and Customary Charges for all

medically appropriate and necessary equipment, supplies, and outpatient

diabetes self-management training and educational services including

nutritional therapy if prescribed by a Physician.

Diabetes outpatient self-management training and education shall be

provided by a Physician with expertise in diabetes.

Benefits shall be subject to all Deductible, copayment, coinsurance,

limitations, or any other provisions of the policy.

Benefits for Cervical Cancer Vaccines

Benefits are payable for the cost of cervical cancer vaccinations for all

female Insured Persons under the age of 20 for whom a vaccination is

recommended by the Advisory Committee on Immunization practices of

the United States Department of Health and Human Services.

Benefits for Medical Foods

Benefits are payable for Medical Foods needed to treat inherited

enzymatic disorders caused by single gene defects involved in the

metabolism of amino, organic, and fatty acids as specified below.

If the policy provides benefits for Prescription Drugs, benefits will be paid

the same as any other Sickness for Medical Foods, to the extent medically

necessary, for home use for which a Physician has issued a written, oral

or electronic prescription. Benefits will not be provided for alternative

medicine.

Coverage includes but is not limited to the following diagnosed

conditions: phenylketonuria; maternal phenylketonuria; maple syrup urine

disease; tyrosinemia; homocystinuria; histidinemia; urea cycle disorders;

hyperlysinemia; glutaric acidemias; methylmalonic acidemia; and

propionic acidemia. Benefits do not apply to cystic fibrosis patients or

lactose- or soy-intolerant patients.

There is no age limit on the benefits provided for inherited enzymatic

disorders except for phenylketonuria. The maximum age to receive

benefits for phenylketonuria is twenty-one years of age; except that the

maximum age to receive benefits for phenylketonuria for women who are

of child-bearing age is thirty-five years of age.

Medical foods means prescription metabolic formulas and their modular

counterparts, obtained through a pharmacy that are specifically designed

and manufactured for the treatment of inherited enzymatic disorders

caused by single gene defects involved in the metabolism of amino,

organic, and fatty acids and for which medically standard methods of

diagnosis, treatment, and monitoring exist. Such formulas are specifically

processed or formulated to be deficient in one or more nutrients and are

to be consumed or administered enterally either via tube or oral route

under the direction of a Physician.

Benefits shall be subject to all Deductible, copayment, coinsurance,

limitations, or any other provisions of the policy

Benefits for Prostate Cancer Screening

Benefits will be paid for actual charges incurred up to $65 for an annual

screening by a Physician for the early detection of prostate cancer.

Benefits will be payable for one screening per year for any male Insured

50 years of age or older. One screening per year shall be covered for any

male Insured 40 to 50 years of age who is at risk of developing prostate

cancer as determined by the Insured’s Physician. The screening shall

consist of the following tests:

1) A prostate-specific antigen (PSA) blood test; and

2) Digital rectal examination.

The policy Deductible will not be applied to this benefit and this benefit

will not reduce any diagnostic benefits otherwise allowable under the

policy.

Benefits shall be subject to all copayment, coinsurance, limitations, or any

other provisions of the policy.

Benefits for Biologically Based Mental Illness

Benefits will be paid the same as any other Sickness for the

treatment of Biologically Based Mental Illness. The benefit provided

will not duplicate any other benefits provided in this policy.

“Biologically Based Mental Illness” means schizophrenia,

schizoaffective disorder, bipolar affective disorder, major depressive

disorder, specific obsessive-compulsive disorder, and panic

disorder.

“Mental Disorder” means posttraumatic stress disorder, drug and

alcohol disorders, dysthymia, cyclothymia, social phobia,

agoraphobia with panic disorder, and general anxiety disorder.

Mental Disorder also includes anorexia nervosa and bulimia nervosa

to the extent those diagnoses are treated on an out-patient, day

treatment, and in-patient basis, exclusive of residential treatment.

Benefits shall be subject to all Deductible, copayment, coinsurance,

limitations, or any other provisions of the policy.

Benefits for Psychotherapy

Benefits will be paid the same as any other Sickness at a

coinsurance percentage of 50% for Psychotherapy treatment

subject to the following provisions:

Inpatient or Partial Hospitalization Benefits:

Benefits are limited to 45 days for inpatient care or 90 days for

Partial Hospitalization care in any 12-month period. For the purpose

of computing the period for which benefits are payable, the following

will apply:

1) Two days of Partial Hospitalization shall reduce by one day the 45

days for inpatient care. One day of inpatient care shall reduce by

two days the 90 days available for Partial Hospitalization.

2) Each day of inpatient confinement under this benefit or each two

days of Partial Hospitalization shall reduce by one day, the total

days available for all Sicknesses for any one 12-month period.

Partial Hospitalization, for the purposes of this benefit, means

continuous treatment for at least three hours, but not more than 12

hours during a 24-hour period.

Outpatient Benefits:

Treatment will be provided for outpatient services furnished by 1) a

comprehensive health care service corporation; or 2) a Hospital, a

community mental health center; or 3) other mental health clinic

approved by the Colorado Department of Human Services to provide

such care; or 4) a registered professional nurse; or 5) a licensed

clinical social worker, acting within the scope of license; or 6)

furnished by or under the supervision of a licensed Physician or

psychologist.

Except as stated below, all such services must be provided by or

under the supervision of a licensed Physician or licensed

psychologist; and records must show that the licensed Physician or

psychologist, saw the patient or had a written summary of

consultations or a personal consultation with the therapist at least

once each 90 days.

Covered services under this benefit, which can legally be furnished

by a registered professional nurse or licensed clinical social worker,

acting within the scope of his or her license, will not require the

supervision of a Physician or psychologist. Reimbursement may be

made directly to such provider.

Outpatient Benefits are limited to $5,000 in any 12-month period.

Benefits shall be subject to all Deductible, copayment, coinsurance,

limitations, or any other provisions of the policy.

Benefits for Child Health Supervision Services

Benefits will be paid for the Usual and Customary charges for Child

Health Supervision Services from birth up to the age of 13. Benefits are

payable on a per visit basis to one health care provider per visit.

Child Health Supervision Services rendered during a periodic review are

covered only to the extent such services are provided during the course

of one visit by, or under the supervision of a single Physician, Physician’s

assistant or Registered Nurse.

Child Health Supervision Services means the periodic review of a child’s

physical and emotional status by a Physician or other provider as above.

A review shall include but not be limited to a history, complete physical

examination, developmental assessment, anticipatory guidance, appropri-

ate immunizations, preventative services, and laboratory tests in keeping

with prevailing medical standards.

Immunizations are based on the recommended childhood immunization

schedule and the recommended immunization schedule for children who

start late or who are more than 1 month behind published by the CDC.

Recommended schedules are available from:

Advisory Committee on Immunization Practices,

www.cdc.aov/nip/acip;

American Academy of Pediatrics, www.aap.org;

American Academy of Family Physicians, www.aafp.org.

The policy Deductible and dollar limits will not be applied to this benefit.

Benefits shall be subject to all copayment, coinsurance, limitations, or any

other provisions of the policy.

Benefits for Therapies for Congenital Defects and Birth

Abnormalities

Benefits will be paid the same as any other Sickness for physical,

occupational and speech therapy for congenital defects and birth

abnormalities for covered Dependent children beginning after the first 31

days of life to five years of age.

Benefits will be paid for the greater of the number of such visits provided

under the policy or twenty visits per year for each therapy. Benefits will be

provided without regard to whether the condition is acute or chronic and

without regard to whether the purpose of the therapy is to maintain or to

improve functional capacity.

Benefits shall be subject to all Deductible, copayment, coinsurance,

limitations, or any other provisions of the policy.

Benefits for Cleft Lip or Cleft Palate

Benefits will be paid the same as any other Sickness for treatment of

newborn children born with cleft lip or cleft palate or both. Benefits shall

include the medically necessary care and treatment including oral and

facial surgery; surgical management; the medically necessary care by a

plastic or oral surgeon; prosthetic treatment such as obturators, speech

appliances, feeding appliances; medically necessary orthodontic and

prosthodontic treatment; habilitative speech therapy, otolaryngology

treatment; and audiological assessments and treatment.

Benefits shall be subject to all Deductible, copayment, coinsurance,

limitations, or any other provisions of the policy.

Benefits for Hospitalization and General Anesthesia for

Dental Procedures for Dependent Children

Benefits will be paid the same as any other Sickness for general

anesthesia, when rendered in a Hospital, outpatient surgical facility, or

other facility licensed pursuant to Colorado Statute Section 25-3-101,

and for associated Hospital or facility charges for dental care provided to

a Dependent child. Such Dependent child shall, in the treating Physician’s

opinion, meet one or more of the following criteria:

1. The child has a physical, mental, or medically compromising condition;

2. The child has dental needs for which local anesthesia is ineffective

because of acute infection, anatomic variations, or allergy;

3. The child is an extremely uncooperative, unmanageable, anxious, or

uncommunicative child or adolescent with dental needs deemed

sufficiently important that dental care cannot be deferred; or

4. The child has sustained extensive orofacial and dental trauma.

Benefits shall be subject to all Deductible, copayment, coinsurance,

limitations, or any other provisions of the policy.

Benefits for Colorectal Cancer Screening

Benefits will be paid for the total costs of tests related to preventive

health care services for the early detection of colorectal cancer and

adenomatous polyps.

Benefits will be provided for an average risk adult Insured Person

who is asyptomatic and age 50 or older. Benefits will also be

provided for an Insured Person who is at high risk for colorectal

cancer and who has:

1. A family medical history of colorectal cancer;

2. A prior occurrence of cancer or precursor neoplastic polyps;

3. A prior occurrence of chronic digestive disease condition such as

inflammatory bowel disease, Crohn’s disease, or ulcerative colitis;

4. Other predisposing factors as determined by Insured Person’s

health care provider.

The policy Deductible will not be applied to this benefit.

Benefits shall be subject to all copayment, coinsurance, limitations,

or any other provisions of the policy.

Benefits for Hearing Aids for Minor Children

Benefits will be paid for Covered Medical Expenses for Hearing Aids

for a Minor Child who has a hearing loss that has been verified by a

licensed Physician and a licensed Audiologist. The Hearing Aid shall

be medically appropriate to meet the needs of the Minor Child

according to accepted professional standards.

Benefits shall include the purchase of the following:

1. Initial Hearing Aids and replacement Hearing Aids not more

frequently than every five years;

2. A new Hearing Aid when alterations to the existing Hearing Aid

cannot adequately meet the needs of the Minor Child; and

3. Services and supplies including, but not limited to, the initial

assessment, fitting, adjustments, and auditory training that is

provided according to professional standards.

“Hearing Aid” means amplification technology that optimizes

audibility and listening skills in the environments commonly

experienced by the patient, including a wearable instrument or

device designed to aid or compensate for impaired human hearing.

“Hearing Aid” shall include any parts or ear molds.

“Minor Child” means an Insured Person under the age of eighteen.

Benefits shall be subject to all Deductible, copayment, coinsurance,

limitations, or any other provisions of the policy.

Exclusions and Limitations

No benefits will be paid for: a) loss or expense caused by,

contributed to, or resulting from; or b) treatment, services or

supplies for, at, or related to:

1. Learning disabilities, behavioral problems, and Attention

Deficit Hyperactivity Disorder testing (treatment is covered),

conceptual handicap, developmental delay or disorder or

mental retardation;

2. Biofeedback;

3. Chronic pain disorders;

4. Circumcision;

5. Cosmetic procedures, except cosmetic surgery required to

correct an Injury for which benefits are otherwise payable

under this policy, removal of warts;

6. Dental treatment, except for accidental Injury to Sound,

Natural Teeth;

7. Elective Surgery or Elective Treatment;

8. Elective abortion;

9. Eye examinations, eye refractions, eyeglasses, contact

lenses, prescriptions or fitting of eyeglasses or contact

lenses, vision correction surgery, or other treatment for

visual defects and problems; except when due to a disease

process; or except as specifically provided in the policy;

10. Health spa or similar facilities; strengthening programs;

11. Hearing examinations or hearing aids, except as specifically

provided in the policy; 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;

12. Hirsutism; alopecia;

13. Hypnosis;

14. Injury or Sickness for which benefits are paid or payable

under any Workers' Compensation or Occupational

Disease Law or Act, or similar legislation;

15. Injury sustained by reason of a motor vehicle accident to the

extent that benefits are paid or payable by any other valid

and collectible insurance;

16. Inpatient convenience items such as guest meals,

telephone, televisions;

17. Investigational services;

18. Medical and non-medical self-care or self-help training,

recreation therapy, educational therapy, dance therapy, art

therapy;

19. Prescription Drugs, services or supplies as follows:

a) Therapeutic devices or appliances, including: hypoder-

mic needles, syringes, support garments and other non-

medical substances, regardless of intended use; except

as provided under Benefits for Diabetes;

b) Immunization agents, biological sera, blood or blood

products administered on an outpatient basis;

c) Drugs labeled, “Caution - limited by federal law to

investigational use” or experimental drugs;

d) Products used for cosmetic purposes;

e) Drugs used to treat or cure baldness; anabolic steroids

used for body building;

f) Anorectics - drugs used for the purpose of weight control;

g) Fertility agents or sexual enhancement drugs, such as

Parlodel, Pergonal, Clomid, Profasi, Metrodin,

Serophene, or Viagra;

h) Growth hormones; or

i) Refills in excess of the number specified or dispensed

after one (1) year of date of the prescription.

20. Reproductive/Infertility services including but not limited

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; impotence, organic or

otherwise; tubal ligation; vasectomy; sexual reassignment

surgery; reversal of sterilization procedures;

21. Routine Newborn Infant care, well-baby nursery and

related Physician charges in excess of 48 hours for

vaginal delivery or 96 hours for cesarean delivery. If forty-

eight hours following a vaginal delivery falls after 8 p.m.,

coverage shall continue until 8 a.m. the following morning.

If ninety-six hours following the cesarean section falls

after 8 p.m., coverage shall continue until 8 a.m. the

following morning;

22. 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 the policy;

23. Temporomandibular joint dysfunction; deviated nasal

septum, including submucous resection and/or other

surgical correction thereof; except for treatment of

chronic purulent sinusitis;

24. Supplies, except as specifically provided in the policy;

25. Surgical breast reduction, breast augmentation, breast

implants or breast prosthetic devices, or gynecomastia;

except as specifically provided in the policy;

26. Treatment in a Government hospital, unless there is a

legal obligation for the Insured Person to pay for such

treatment;

27. War or any act of war, declared or undeclared; or while in

the armed forces of any country other than the United

States (a pro-rata premium will be refunded upon request

for such period not covered); and

28. Weight management, weight reduction, nutrition programs,

treatment for obesity, surgery for removal of excess skin or fat.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION

ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU

CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW

IT CAREFULLY.

Explanation of Forms. The Colorado School of Mines Student

Health Program (the "SHP") handles medical information about you.

The handling of this information is regulated by law. To comply with

the applicable law, the SHP requires you to receive this notice and,

in some circumstances, to sign an authorization form.

The SHP is allowed by law to use and disclose information about

you for the purposes essential to providing care, including, but not

limited to, treatment, payment collection, and operating the SHP.

An authorization allows the SHP to use and disclose information

about you for any other reason that is listed in the authorization. The

SHP may condition enrollment or eligibility on the provision of an

authorization only if the authorization is for determining enrollment or

eligibility. Other rules about your rights regarding medical information

are described in this notice.

Types of Uses and Disclosures. Medical information about you

may be used or disclosed by the SHP for treatment, payment, and

health care operations. Treatment includes consultation, diagnosis,

provision of care and referrals. Payment includes all activities

necessary for billing and collection, such as claims processing.

Health care operations includes everything the SHP does to assess

the quality of care, teach and develop staff, and manage the SHP’s

operations. Some examples of uses and disclosures are below.

Example of Treatment Disclosure. The SHP may disclose medical

information about you to your treating physician, a hospital or other

providers to help them diagnose and treat an injury or illness.

Example of Payment Disclosure. The SHP may disclose medical

information about you when health plans or insurers, Medicare,

Medicaid, or other payors require the information before paying for

your health care services.

Example of Health Care Operations Use. The SHP may use medical

information about you when it hires new staff whose education and

development requires information about the medical needs of our

patients.

Other Uses and Disclosures. The SHP may use or disclose your

medical information in the following situations without your

authorization. These situations include:

As Required By Law. The SHP may use or disclose your medical

information to the extent that the use or disclosure is required by law.

The use or disclosure will be made in compliance with the law and

will be limited to the relevant requirements of the law. You will be

notified, as required by law, of any such uses or disclosures.

Public Health. The SHP may disclose your medical information for

public health activities and purposes to a public health authority that

is permitted by law to collect or receive the information. The

disclosure will be made for the purpose of controlling disease, injury

or disability. The SHP may also disclose your medical information, if

directed by the public health authority, to another government

agency that is collaborating with the public health authority.

Communicable Diseases. The SHP may disclose your medical

information, if authorized by law, to a person who may have been

exposed to a communicable disease or may otherwise be at risk of

contracting or spreading the disease or condition.

Health Oversight. The SHP may disclose your medical information to

a health oversight agency for activities authorized by law, such as

audits, investigations, and inspections. Oversight agencies seeking

this information include government agencies that oversee the health

care system, government benefit programs, other government

regulatory programs and civil rights laws.

Abuse or Neglect. The SHP may disclose your medical information

to a public health authority that is authorized by law to receive

reports of child abuse or neglect. In addition, the SHP may disclose

your medical information to the governmental entity or agency

authorized to receive such information if the SHP believes that you

have been a victim of abuse, neglect or domestic violence. In this

case, the disclosure will be made consistent with the requirements

of applicable federal and state laws.

Food and Drug Administration. The SHP may disclose your medical

information to a person subject to the jurisdiction of the Food and

Drug Administration if that person has responsibility to report

adverse events, product defects or problems, or biologic product

deviations; to track products; to enable product recalls, repairs or

replacements; or, to conduct post marketing surveillance.

Legal Proceedings. The SHP may disclose your medical information

in the course of any judicial or administrative proceeding, in

response to an order of a court or administrative tribunal (to the

extent such disclosure is expressly authorized by such order), and,

under certain conditions, in response to a subpoena, discovery

request or other lawful process.

Law Enforcement. The SHP may also disclose your medical

information for law enforcement purposes so long as applicable legal

requirements are met. These law enforcement purposes include: (1)

disclosure pursuant to legal processes or as otherwise required by

law, (2) disclosure in response to limited information requests by a

law enforcement official for identification and location purposes, (3)

disclosure to a law enforcement official in response to information

pertaining to victims of a crime, (4) disclosure to a law enforcement

official in connection with a suspicion that death may have occurred

as a result of criminal conduct, (5) disclosure to a law enforcement

official in the event that a crime occurs on the premises of the SHP,

and (6) disclosure to a law enforcement official in connection with a

medical emergency (not on the CSM’s premises) when it is likely that

a crime has occurred.

Coroners, Funeral Directors, and Organ Donation. The SHP may

disclose your medical information to a coroner or medical examiner

for identification purposes, for determining cause of death or for the

coroner or medical examiner to perform other duties authorized by

law. The SHP may also disclose your medical information to a funeral

director, as authorized by law, in order to permit the funeral director

to carry out the director’s duties. The SHP may disclose such

information in reasonable anticipation of death. Your medical

information may also be used and disclosed to organ procurement

organizations for cadaveric organ, eye or tissue donation purposes.

THE COLORADO SCHOOL OF MINES

NOTICE OF PRIVACY PRACTICES

Research. The SHP may disclose your medical information to

researchers when the research has been approved by an institutional

review board that has reviewed the research proposal and

established protocols to ensure the privacy of your medical

information.

Criminal Activity. Consistent with applicable federal and state laws,

the SHP may disclose your medical information, if the SHP believes

that the use or disclosure is necessary to prevent or lessen a serious

and imminent threat to the health or safety of a person or the public.

The SHP may also disclose your medical information if it is

necessary for law enforcement authorities to identify or apprehend

an individual.

Military Activity and National Security. When the appropriate

conditions apply, the SHP may use or disclose the medical

information of individuals who are Armed Forces personnel (1) for

activities deemed necessary by appropriate military command

authorities; (2) for the purpose of a determination by the Department

of Veterans Affairs of eligibility for benefits, or (3) to foreign military

authority if you are a member of the foreign military services. The

SHP may also disclose your medical information to authorized

federal officials for conducting national security and intelligence

activities, including for the provision of protective services to the

President or others legally authorized.

Workers’ Compensation. Your medical information may be disclosed

by the SHP as authorized to comply with workers’ compensation

laws and other similar legally established programs.

Required Uses and Disclosures. Under the law, the SHP must make

disclosures to you when required by the Secretary of the

Department of Health and Human Services to investigate or

determine our compliance with applicable law.

Others Involved in Your Healthcare. Unless you object in

writing to the Privacy Official, the SHP may disclose to a member of

your family, a relative, a close friend or any other person whom you

identify, your medical information that directly relates to that person’s

involvement in your health care. If you are unable to agree or object

to such a disclosure, the SHP may disclose such information as

necessary if the SHP determines that it is in your best interest based

on the SHP’s professional judgment. The SHP may use or disclose

your medical information to notify or assist in notifying a family

member, personal representative or any other person that is

responsible for your care of your location, general condition or death.

Finally, the SHP may use or disclose your medical information to an

authorized public or private entity to assist in disaster relief efforts

and to coordinate uses and disclosures to family or other individuals

involved in your health care.

Authorized Uses and Disclosures. Additional uses and

disclosure may be made if you have given written authorization,

which may be revoked at any time in writing delivered to the Privacy

Official or the Privacy Official’s designee, except to the extent the

SHP acted in reliance on the authorization.

Restrictions. You have the right to request restrictions on the use

and disclosure of medical information about you; however, the SHP

will only be bound by the restrictions if the SHP notifies you that it

agrees with them. Confidentiality. You have the right to have the SHP

use only confidential means of communicating with you about

medical information. This means you may have information delivered

to you at a certain time or place, or in a manner that keeps your

information confidential. Access. You have the right to see and

receive a copy of information about you kept by the SHP under most

circumstances.

Amendment of Health Information. You have the right to have

the SHP amend its records of information about you. The SHP may

refuse to amend information that is accurate, that was created by

someone else, or is not disclosable to you.

Accounting. You have the right to request in writing a list of

disclosures of your medical information made by the SHP, which

includes the purposes and recipients of the information.

Copy. You have the right to receive a paper copy of this notice.

Amendment of Policies and Procedures. The SHP reserves its

rights to make changes to the privacy policies and procedures in

accordance with the applicable terms of such policies and

procedures with respect to changes.

Privacy Notice. The SHP is required by law to keep medical

information about you private and to give you this notice. The SHP

must abide by this notice. However, the SHP reserves the right to

amend this notice and make such change applicable to all medical

information maintained by SHP. Any revised notice will be provided

to enrollees by the SHP.

HIPAA and FERPA. With respect to student health information, the

SHP also complies with the requirements set forth in The Family

Educational Rights and Privacy Act (FERPA).

Complaints. If you believe your privacy rights have been violated

you may submit a written complaint to the Privacy Official, Coulter

Student Health Center, The Colorado School of Mines, Golden,

Colorado 80401. You may also complain to the Secretary of the U.S.

Department of Health and Human Services. The SHP will not

retaliate against you for making a complaint.

Effective Date. This notice is effective from April 14, 2004 until

revised by the SHP.

Participation in the SHIP provides emergency services for students who travel abroad.

Scholastic Emergency Services (SES)

International Travel Emergency Assistance, Medical

Evacuation and Repatriation Program

An International Travel Emergency Assistance, Medical

Evacuation and Repatriation Program is included for students

and dependents covered by the Student Health Insurance

Plan. The cost for this program is included in charges for the

SHIP coverage, and the service is provided by SES. SES

utilizes highly trained, multilingual coordinators and board

certified physicians in conjunction with an extensive

information and communication system to assist travelers

worldwide. SES offers prompt, professional help in any

medical or personal emergency, 24 hours a day.

SES Services

●

Worldwide 24-hour toll-free telephone assistance in

locating the nearest, most appropriate medical care.

●

Overcoming language barriers by directing the SHIP-

covered persons to English speaking doctors or

translators.

●

Monitoring progress during the course of medical

treatment and recovery, including arranging for necessary

specialists upon a doctor’s request.

●

Maintaining contact with family, personal physician, and

CSM, as appropriate.

●

Assistance in coordinating admission into hospitals or

other care facilities.

●

Coordination of direct payments or deposits to health care

providers.

●

Management, coordination, and payment of emergency

medical evacuations or repatriation.

●

Coordination of emergency blood and medication

transfers.

●

Preplanning of medical support in remote areas.

●

Emergency message transmittal services.

●

Emergency international funds transfer capabilities.

●

Travel assistance for a family member wishing to be with a

patient hospitalized for more than seven days (includes

payment of round-trip economy airfare to the place of

hospitalization).

●

Assistance for unattended dependent children (includes

payment of one-way economy airfare to the place of

residence with an escort if required).

●

Assistance in making arrangements for interrupted travel

plans resulting from an emergency situation.

●

Knowledgeable legal referral service.

●

Assistance with travel problems such as lost or stolen

passports.

Locating Medical Services

SES has a database of thousands of international providers.

These providers encompass doctors, hospitals, clinics, air

ambulance companies, and others. Providers are carefully

selected based on the medical specialty, location, language,

and office hours. In addition, SES Assistance Specialists are

multilingual and highly trained.

Payment of Medical Bills

The SHIP coverage may provide benefits for medical

expenses incurred while traveling abroad (refer to the Student

Health Insurance Plan for coverage of such expenses). SES

includes coverage for expenses associated with a medically

necessary evacuation, but all other medical bills are the

responsibility of the insured. SES will coordinate all billing

and insurance verifications, including settling any guarantee

of payment. This ensures that there is no delay or denial of

medical treatment because of an inability to make payment.

Special Information for CSM International Students

Enrolled in the SHIP

International students enrolled in the SHIP are covered by

SES (as explained in this brochure) while they are outside the

United States as part of CSM-sponsored travel. Also,

international students enrolled in the SHIP are covered by

SES for medical evacuation and repatriation while they are at

CSM.

EMERGENCY SERVICES FOR

SHIP-COVERED PERSONS

Special CSM Counseling Center

Referral Benefit

SHIP-covered persons have access to a Special CSM

Counseling Center Referral Benefit for mental health

care/chemical dependence treatment for covered students who

receive a referral to a community psychiatrist, psychologist,

certified addictions counselor, or other licensed mental health

care therapists from the CSM Counseling Center. This is a

separate benefit from the mental health care coverage shown in

the SHIP Schedule of Coverage that is administered by

UnitedHealthcare StudentResources. This means you may

obtain outpatient mental health care services, without first

receiving a referral from the CSM Counseling Center, if you

choose to use the schedule of benefits that is administered by

UnitedHealthcare StudentResources.

This Special CSM Counseling Center Referral Benefit only

applies if you receive a referral from the Counseling Center

and you obtain services from a licensed mental health care

professional who has entered into a service agreement with

the Colorado School of Mines.

The Special CSM Counseling Center Referral Benefit will pay

up to thirty (30) visits each plan year. The first visit will be paid

in full (no copayment) and the second through the 30th visits

will be subject to a $10 copayment.

Your therapist must obtain authorization for continued

services from the Director of the Counseling Center at CSM

at the 9th visit and again at the 19th visit. You will not be

required to pay any additional fee beyond the $10 copayment.

No part of this benefit is indemnified by UnitedHealthcare

Insurance Company. UnitedHealthcare Insurance Company

also has no responsibility for administration of Special CSM

Counseling Center Referral Benefit claims or covered person

eligibility determinations.

Laboratory Charges at the Coulter Student Health

Center

Except for routine physical examinations, laboratory charges

incurred by covered SHIP participants will be covered at 100

percent when laboratory specimens are obtained at the Coulter

Student Health Center. Students are not required to submit

claims. No part of this benefit is indemnified by UnitedHealthcare

Insurance Company. UnitedHealthcare StudentResources also

has no responsibility for administration of laboratory claims or

covered person eligibility determinations.

Insurance Plans, Funding, and

Indemnification of Risk

The Dental Clinic at the Coulter Student Health Center is not

a participating provider with private dental insurance plans. A

billing statement students may submit to private dental

insurance plans will be provided upon request.

Funding for construction of the Dental Clinic at the Coulter

Student Center was derived from use of reserve funds from

the Student Health Program and the Coulter Foundation

Fund. Funding for dental care benefits is derived from a

capitation payment each semester within the cost of student

only coverage.

No part of the self-funded dental benefits, laboratory charges at

the Coulter Student Health Center, or Special CSM Counseling

Center Referral Benefits, is indemnified by UnitedHealthcare

Insurance Company. UnitedHealthcare Insurance Company also

has no responsibility for administration of dental claims,

laboratory charges at the Coulter Student Health Center, or

Special CSM Counseling Center Referral Benefits.

Membership Brochure

This brochure is not a contract with UnitedHealthcare Insurance

Company. It provides a summary of the benefits and limitations

of the SHIP. If there is any difference between this brochure and

the policy, the provisions of the policy on file with the school will

govern. For a full description of coverage under the SHIP,

including benefits, exclusions, any reductions and limitations and

the terms under with the coverage may remain in force, refer to

the plan brochure which is available on-line or at the CSM

Coulter Student Health Center.

COBRA and Extension of Eligibility/Benefits

The Student Health Program is not subject to the extension of

eligibility provisions required under Consolidated Omnibus

Budget Reconciliation Act of 1986 (COBRA). Accordingly,

the Student Health Program does not provide an extension of

eligibility provision or any extension of benefit provision,

unless specifically provided for under the terms and

conditions of the program.

Student Health Program

Coulter Student Health Center

Colorado School of Mines

Golden, CO 80401