EDUCATE ADVOCATE EMPOWER INTERNATIONAL STUDENT INSURANCE INFORMATION PERSONAL INSURANCE ADMINISTRATORS (PIA) SANTA MONICA COLLEGE HEALTH SERVICES by FAUZIA HASSAN RN EDUCATE ADVOCATE EMPOWER

PIA Personal Insurance Administrators What does my insurance cover? Eligibility OPT (practical training) Dependents Refunds Terms of coverage and Coverage schedule What is a referral? What is a claim and the process of filing a claim? PPO (preferred provider network) What is an emergency and what do I do in an emergency? Is there a co-pay for my Doctors visit? Who do I contact if I have any questions pertaining to my health insurance?

What Your Policy Covers Medical fees up to $250 000 per accident or sickness Covers 100% payment of all charges in PPO network (non PPO provider covered at 70% with a $100 deductible). Contains 50% reimbursement of prescription drug charges. Emergency conditions e.g. heart attack, a cut requiring stitches etc. All Doctor visits are subject to a $25 co-pay For the entire list or schedule of benefits please pick up a brochure from the Student Health Services or down load it from www.renstudent.com/smc Please visit www.renstudent.com/smc to down load ID cards and or claim forms. This Plan Does Not Cover: Dental Treatment of a non-emergency medical condition in an Emergency Care facility

ELIGIBILITY Eligibility: International students, visiting faculty, scholars or other persons with a current passport or student visa (F-1, J-1 or M-1 visa) Students who have paid their required premium (insurance fee) and their name, student number and date of birth must have been included in the declaration made by the college or the Administrative Agent to the insurer. Covered students must actively attend classes for at least the first 31 days of the period for which coverage is purchased, except in the case of medical withdrawal. For questions, please contact Ascension at 1-800-537-1777

PRACTICAL TRAINING STUDENTS OPT STUDENTS (PRACTICAL TRAINING) Must submit to Ascension the following: An enrollment form and payment (by mail) within 30 days of the termination date of the immediately preceding term; and Proof of Practical Training (either a copy of their Employment Authorization Card or an official letter from the college stating their OPT dates). Please note, students engaged in OPT are not eligible to use the Students Health Services, therefore, the Deductible can not be waived under any circumstances. For questions please call Ascension at 1-800-537-1777

DEPENDENTS DEPENDENTS: Spouse (husband or wife) living with the covered student; or unmarried children under the age of 26 years. Eligible dependents must be enrolled by the Deadline Date or within 31 days of birth, adoption, marriage, or arrival in the U.S. or termination of other insurance coverage. Coverage for eligible dependents will not be effective prior to that of the covered student or extend beyond that of the covered student. A newly acquired dependent child will be covered under Policy for the first 31 days after birth; or the earlier of: effective date of adoption of the child; or the date of placement of the child for adoption. Benefits will be the same as any other covered person who is the child’s parent. To continue the coverage the covered student must within 31 days after the birth, adoption or placement for adoption: Apply to the company in writing Pay the required additional premium. If not coverage ends at day 31.

REFUNDS REFUNDS: No refunds for insurance will be permitted unless: You are withdrawing from Santa Monica College and returning to your home country---airline ticket must be presented You are transferring to a different U.S. university or college----documentation may be requested You are a covered student entering the armed forces. Refunds will be pro rated and issued upon request from the school. No refunds will be given if you purchase other insurance after the semester begins.

TERMS OF COVERAGE TERMS OF COVERAGE: Coverage begins at 12:01 a.m. if the eligibility requirements are met. The effective date of the policy The effective date of the term of coverage for which premium has been paid. The day immediately following the date that full premium is received by the Administrative Agent or the College Please note: (PIA) Personal Insurance Administrators does not send termination or renewal notices. It is the covered persons responsibility to renew coverage in a timely manner, subject to continuing eligibility.

COVERAGE SCHEDULE BEGIN END DEPENDENT ENROLLMENT DEADLINE FALL 08-25-16 02-12-17 09-25-16 WINTER 01-02-17 02-02-17 SPRING 08-25-17 03-12-17 SUMMER 06-16-17 07-16-17

STUDENT HEALTH SERVICES REFERRAL REQUIREMENT DOCTORS OFFICE ACU PUNCTURE PHYSIO THERAPIST Students covered by the insurance must first get a referral/claim form from the Student Health Services. The covered student must visit the Student Health Services for care prior to seeing a Doctor or receiving care off-campus unless its an Emergency.

Referral and Claim forms This is a sheet of paper documenting medical need that you the individual will take with you to see the doctor. It is obtained by visiting the student health office. Claim form: This is a sheet of paper that can be downloaded from www.4studenthealth.com It is also a part of the referral form. The back side of the referral form is the claim form.

REFERRAL’S WAIVED UNDER THESE CIRCUMSTANCES/SITUATIONS REFERRAL WAIVED DUE TO: Medical emergency. The covered student must return to Student Health Services for referral and follow up care. When Student Health Services is closed. When service is given at another facility during school break or vacation periods. Medical care received when the covered student is more than 50 miles from campus.

PREFERRED PROVIDER ORGANIZATION PPO: Preferred Provider Organization This is a network of Doctors and hospitals approved by the covered student’s insurance to provide care to the covered student. Covered student using the PPO network/panel of Medical Professionals will only be responsible for any deductibles, co-pays or co-insurance as shown in the schedule of benefits. Covered students not using the PPO provider network will be responsible for 30% of the eligible expenses. However, if treatment is received in a non PPO facility due to an emergency medical condition, benefits for eligible expenses are payable at the PPO level. For a complete listing of PPO provider network Hospital and Doctor facilities visit www.myfirsthealth.com or call 1-800-226-5116

OBTAINING/GETTING MEDICAL TREATMENT. Get the Referral and Claim form from the RN in the Student Health Services. Please bring your student ID card to receive service. Select a Doctor within the PPO network by either calling 1-800-226-5116 or going to the website www.myfirsthealth.com. Call the Doctor and make an appointment. Verify coverage with the doctor or primary care provider and with your insurance company by calling 1-800-226-5116. When going to the Doctor’s office present your insurance card, $25 and the dual sided referral/claim form. Make sure to get the referral form/claim form back from the Doctor’s office when the visit it done. It is mandatory that the referral/claim form is mailed by the covered student to the claims department for the Doctor to be paid and for the expenses incurred to be covered.

Filing A Claim After Receiving Treatment After receiving treatment complete the claim form side by: Answering all the questions, sign and date the form prior to submitting it. Attach medication bill’s, lab fees etc to this form. Make copies of all forms and receipts and keep for your own records. Submit all copies of forms as one package. If you need help feeling informs contact International Student Center. Have all your bills and the forms sent as one package to: Personal Insurance Administrators, Inc. P O Box 6040, Agoura Hills, CA 91376

IMPORTANT NOTICE For More In depth and Up To Date Information check out PIA’s website at: www.4studenthealth.com/smc or call Denise or Sharif at 1 310 394 0440. You can down load claim forms, ID cards and or brochures from www.4studenthealth.com/smc if needed. For questions regarding eligibility, benefits or claims: Personal Insurance Administrators, Inc. P.O.Box 6040 Agoura Hills, CA 91376 1-800-468-4343 www.piaclaims.com Plan Underwritten by: National Union Fire Insurance Company of Pittsburgh, Pa. Policy Number CHH0058772 NO COST LANGUAGE ASSISTANCE SERVICES You can get an interpreter and get documents read to you in your language. For help call the number listed on your insurance card or 1-800-468-4343

SMC STUDENT HEALTH SERVICES Office Hours (subject to change): 8:00am-6:00pm Monday–Thursday 8:00am-2:00pm Friday Telephone 1 310 434 4262 To Receive service at the health office you need to have paid your health fee of $18 spring and Fall, $15 summer and winter; and have your student ID card. ADMINISTRATIVE AGENT: Ascension Benefits & Insurance Solutions Phone: 1-800-537-1777 Monday-Friday, 8:00 a.m. to 5:00 p.m. Available on campus at International Education Counseling by appointment.