UO Student Health Benefits Plan
Student Guide
Group No.: G0033725
Comprehensive Medical - Domestic
Effective: 08/10/2019
With Third Party Administrative Services Provided By:
Student Guide_2019_Student Plan _Medical_Domestic
,Introduction
Welcome to your Student Health Benefits Plan. The University of Oregon established
the UO Student Health Benefits Plan (referred to as the “Student Plan”) to provide
health coverage to help you stay well and assist you in case of illness, injury, or
disease. We encourage you to familiarize yourself with the wide range of benefits and
services offered by this Student Plan.
Any words or phrases used in this student guide that appear with an initial capital letter,
or which are in italics, are defined terms. All such words or phrases are defined in the
Definitions Section (see the Table of Contents for exact location). The University of
Oregon highly encourages you to read this student guide in its entirety and to ask any
questions you may have to ensure you understand your rights, responsibilities, and the
benefits available to you under the terms of this Student Plan.
Using this Student Guide
This student guide will help you understand how this Student Plan works and how to
use it. Please read it carefully and thoroughly.
Within this guide you will find Member Benefit Summaries for your medical plan and any
other health benefits provided under the University of Oregon’s Student Plan. The
summaries work with this guide to explain this Student Plan. The guide explains the
services covered by this Student Plan; the benefit summaries tell you how much this
Student Plan pays toward expenses and the amount for which you will be responsible.
The UO Student Health Benefits Plan team is available to answer your questions about
eligibility, general plan design, and enrollment/termination (call 541-346-2832 or stop by
the University Health Center). The customer service team at PacificSource is also
available to answer questions about providers, benefits, prior authorizations, and
specific claims questions. To contact PacificSource Customer Service, call 1-855-274-
9814.
Nature of this Student Plan
This Student Plan is not an employee welfare benefit plan or an employer-sponsored
plan. This Student Plan is not governed by the Employee Retirement Income Security
Act (“ERISA”).
This Student Plan is "self-insured," which means benefits are paid by the University of
Oregon and are not guaranteed by a separate insurance company. The University of
Oregon, which is also the Plan Administrator, has contracted with the Third Party
Administrator to perform certain administrative services related to this Student Plan.
PacificSource Health Plans (“PacificSource”) is the Third Party Administrator and will
process Claims, manage its network of Health Care Providers, answer medical benefit
and Claim questions, and generally provide administrative services to this Student Plan.
As used in this student guide, the word ‘year’ refers to the Student Plan’s contract year,
as follows: UO law students – August 10, 2019 to August 9, 2020 and UO students
(undergraduate/non-law graduate students) – September 15, 2019 to September 14,
2020. The word ‘lifetime’ as used in this student guide refers to the period of time you
participate in this Student Plan or any other student plan offered by the University of
Oregon.
Student Guide_2019_Student Plan _Medical_Domestic
,Representations not warranties: In the absence of fraud, all statements made by the
University of Oregon with respect to this Student Plan will be considered
representations and not warranties. No statement made for the purpose of effecting
coverage will void the coverage or reduce benefits unless it is contained in a written
document signed by the University of Oregon and a provided to a student.
Retention of Fiduciary Duties
The University of Oregon has retained all fiduciary duties under this Student Plan,
including all interpretations of this Student Plan and the eligibility, benefits, and
exclusions it contains. This means that the University of Oregon is solely responsible for
all final decisions regarding what benefits are or will be covered, both now and in the
future. The University of Oregon is solely responsible for the design of this Student
Plan. The University of Oregon is solely responsible for setting any and all criteria used
to determine enrollment and eligibility.
Governing Law
This Student Plan must comply with both state and federal law, including required
changes occurring after this Student Plan’s effective date. Therefore, coverage is
subject to change as required by law.
Questions?
If you have any questions, please contact the Student Health Benefits Team or
PacificSource Customer Service staff. Please give them a call, visit them on the
Internet, or stop by their offices.
UO Student Health Benefits Team
General Questions on Eligibility, Enrollment, Plan Design, Premiums:
1-541-346-2832
Website
Health.uoregon.edu/insurance
PacificSource Customer Service Team
Specific Questions on Claims, Provider Network, Benefits, etc.:
1-855-274-9814
PacificSource Headquarters
110 International Way, Springfield, OR 97475
PO Box 7068, Springfield, OR 97475-0068
Phone (541) 686-1242 or (800) 624-6052
Website
PacificSource.com/uo
Student Guide_2019_Student Plan _Medical_Domestic
, CONTENTS
Para asistencia en español, por favor llame al nùmero (866) 281-1464.
MEDICAL BENEFIT SUMMARY ............................................................................................... A
PHARMACY BENEFIT SUMMARY ........................................................................................... F
PEDIATRIC VISION BENEFIT SUMMARY ............................................................................... H
PEDIATRIC DENTAL BENEFIT SUMMARY ............................................................................. J
BECOMING ELIGIBLE .............................................................................................................. 1
EFFECTIVE DATE OF COVERAGE, OPEN ENROLLMENT PERIODS, PAYMENT DEADLINES....... 4
GENERAL STUDENT PLAN PROVISIONS .............................................................................. 5
HIPAA COMPLIANCE STATEMENT ...................................................................................................... 5
TERM AND TERMINATION – COVERAGE ............................................................................................ 8
USING THE PROVIDER NETWORK ......................................................................................... 9
UNIVERSITY HEALTH CENTER (UHC) AND UNIVERSITY COUNSELING CENTER (UCC) ............. 9
IN-NETWORK PROVIDERS (UO Exclusive & PacificSource Networks) ................................................ 9
OUT-OF-NETWORK PROVIDERS ....................................................................................................... 10
COVERAGE WHILE TRAVELING ......................................................................................................... 11
FINDING IN-NETWOK PROVIDER INFORMATION ............................................................................ 12
TERMINATION OF PROVIDER CONTRACTS ..................................................................................... 12
COVERED EXPENSES ............................................................................................................13
PLAN BENEFITS ................................................................................................................................... 15
PREVENTIVE CARE SERVICES .......................................................................................................... 15
PEDIATRIC DENTAL PLAN BENEFITS ............................................................................................... 18
COVERED DENTAL SERVICES ............................................................. Error! Bookmark not defined.
PEDIATRIC VISION SERVICES ........................................................................................................... 21
PROFESSIONAL SERVICES ................................................................................................................ 21
HOSPITAL AND SKILLED NURSING FACILITY SERVICES ............................................................... 23
OUTPATIENT SERVICES ..................................................................................................................... 24
EMERGENCY SERVICES..................................................................................................................... 26
MATERNITY SERVICES ....................................................................................................................... 26
MENTAL HEALTH AND SUBSTANCE USE DISORDER SERVICES ................................................. 27
HOME HEALTH AND HOSPICE SERVICES ........................................................................................ 29
DURABLE MEDICAL EQUIPMENT ...................................................................................................... 30
TRANSPLANT SERVICES .................................................................................................................... 32
OTHER COVERED SERVICES, SUPPLIES, AND TREATMENTS ..................................................... 38
EXCLUDED SERVICES ........................................................................................................................ 43
PREAUTHORIZATION .......................................................................................................................... 52
INDIVIDUAL BENEFITS MANAGEMENT ............................................................................................. 53
UTILIZATION REVIEW .......................................................................................................................... 53
NECESSITY ACCORDING TO ACCEPTABLE DENTAL PRACTICE .................................................. 55
CLAIMS PAYMENT ..................................................................................................................55
COORDINATION OF BENEFITS .......................................................................................................... 58
COMPLAINTS, GRIEVANCES, AND APPEALS ......................................................................61
GRIEVANCE PROCEDURES ............................................................................................................... 61
APPEAL PROCEDURES....................................................................................................................... 61
HOW TO SUBMIT GRIEVANCES OR APPEALS ................................................................................. 63
RESOURCES FOR INFORMATION AND ASSISTANCE ........................................................64
RIGHTS AND RESPONSIBILITIES ..........................................................................................65
PRIVACY AND CONFIDENTIALITY ..................................................................................................... 66
PLAN ADMINISTRATION ........................................................................................................67
DEFINITIONS ...........................................................................................................................69
Student Guide_2019_Student Plan _Medical_Domestic
Student Guide
Group No.: G0033725
Comprehensive Medical - Domestic
Effective: 08/10/2019
With Third Party Administrative Services Provided By:
Student Guide_2019_Student Plan _Medical_Domestic
,Introduction
Welcome to your Student Health Benefits Plan. The University of Oregon established
the UO Student Health Benefits Plan (referred to as the “Student Plan”) to provide
health coverage to help you stay well and assist you in case of illness, injury, or
disease. We encourage you to familiarize yourself with the wide range of benefits and
services offered by this Student Plan.
Any words or phrases used in this student guide that appear with an initial capital letter,
or which are in italics, are defined terms. All such words or phrases are defined in the
Definitions Section (see the Table of Contents for exact location). The University of
Oregon highly encourages you to read this student guide in its entirety and to ask any
questions you may have to ensure you understand your rights, responsibilities, and the
benefits available to you under the terms of this Student Plan.
Using this Student Guide
This student guide will help you understand how this Student Plan works and how to
use it. Please read it carefully and thoroughly.
Within this guide you will find Member Benefit Summaries for your medical plan and any
other health benefits provided under the University of Oregon’s Student Plan. The
summaries work with this guide to explain this Student Plan. The guide explains the
services covered by this Student Plan; the benefit summaries tell you how much this
Student Plan pays toward expenses and the amount for which you will be responsible.
The UO Student Health Benefits Plan team is available to answer your questions about
eligibility, general plan design, and enrollment/termination (call 541-346-2832 or stop by
the University Health Center). The customer service team at PacificSource is also
available to answer questions about providers, benefits, prior authorizations, and
specific claims questions. To contact PacificSource Customer Service, call 1-855-274-
9814.
Nature of this Student Plan
This Student Plan is not an employee welfare benefit plan or an employer-sponsored
plan. This Student Plan is not governed by the Employee Retirement Income Security
Act (“ERISA”).
This Student Plan is "self-insured," which means benefits are paid by the University of
Oregon and are not guaranteed by a separate insurance company. The University of
Oregon, which is also the Plan Administrator, has contracted with the Third Party
Administrator to perform certain administrative services related to this Student Plan.
PacificSource Health Plans (“PacificSource”) is the Third Party Administrator and will
process Claims, manage its network of Health Care Providers, answer medical benefit
and Claim questions, and generally provide administrative services to this Student Plan.
As used in this student guide, the word ‘year’ refers to the Student Plan’s contract year,
as follows: UO law students – August 10, 2019 to August 9, 2020 and UO students
(undergraduate/non-law graduate students) – September 15, 2019 to September 14,
2020. The word ‘lifetime’ as used in this student guide refers to the period of time you
participate in this Student Plan or any other student plan offered by the University of
Oregon.
Student Guide_2019_Student Plan _Medical_Domestic
,Representations not warranties: In the absence of fraud, all statements made by the
University of Oregon with respect to this Student Plan will be considered
representations and not warranties. No statement made for the purpose of effecting
coverage will void the coverage or reduce benefits unless it is contained in a written
document signed by the University of Oregon and a provided to a student.
Retention of Fiduciary Duties
The University of Oregon has retained all fiduciary duties under this Student Plan,
including all interpretations of this Student Plan and the eligibility, benefits, and
exclusions it contains. This means that the University of Oregon is solely responsible for
all final decisions regarding what benefits are or will be covered, both now and in the
future. The University of Oregon is solely responsible for the design of this Student
Plan. The University of Oregon is solely responsible for setting any and all criteria used
to determine enrollment and eligibility.
Governing Law
This Student Plan must comply with both state and federal law, including required
changes occurring after this Student Plan’s effective date. Therefore, coverage is
subject to change as required by law.
Questions?
If you have any questions, please contact the Student Health Benefits Team or
PacificSource Customer Service staff. Please give them a call, visit them on the
Internet, or stop by their offices.
UO Student Health Benefits Team
General Questions on Eligibility, Enrollment, Plan Design, Premiums:
1-541-346-2832
Website
Health.uoregon.edu/insurance
PacificSource Customer Service Team
Specific Questions on Claims, Provider Network, Benefits, etc.:
1-855-274-9814
PacificSource Headquarters
110 International Way, Springfield, OR 97475
PO Box 7068, Springfield, OR 97475-0068
Phone (541) 686-1242 or (800) 624-6052
Website
PacificSource.com/uo
Student Guide_2019_Student Plan _Medical_Domestic
, CONTENTS
Para asistencia en español, por favor llame al nùmero (866) 281-1464.
MEDICAL BENEFIT SUMMARY ............................................................................................... A
PHARMACY BENEFIT SUMMARY ........................................................................................... F
PEDIATRIC VISION BENEFIT SUMMARY ............................................................................... H
PEDIATRIC DENTAL BENEFIT SUMMARY ............................................................................. J
BECOMING ELIGIBLE .............................................................................................................. 1
EFFECTIVE DATE OF COVERAGE, OPEN ENROLLMENT PERIODS, PAYMENT DEADLINES....... 4
GENERAL STUDENT PLAN PROVISIONS .............................................................................. 5
HIPAA COMPLIANCE STATEMENT ...................................................................................................... 5
TERM AND TERMINATION – COVERAGE ............................................................................................ 8
USING THE PROVIDER NETWORK ......................................................................................... 9
UNIVERSITY HEALTH CENTER (UHC) AND UNIVERSITY COUNSELING CENTER (UCC) ............. 9
IN-NETWORK PROVIDERS (UO Exclusive & PacificSource Networks) ................................................ 9
OUT-OF-NETWORK PROVIDERS ....................................................................................................... 10
COVERAGE WHILE TRAVELING ......................................................................................................... 11
FINDING IN-NETWOK PROVIDER INFORMATION ............................................................................ 12
TERMINATION OF PROVIDER CONTRACTS ..................................................................................... 12
COVERED EXPENSES ............................................................................................................13
PLAN BENEFITS ................................................................................................................................... 15
PREVENTIVE CARE SERVICES .......................................................................................................... 15
PEDIATRIC DENTAL PLAN BENEFITS ............................................................................................... 18
COVERED DENTAL SERVICES ............................................................. Error! Bookmark not defined.
PEDIATRIC VISION SERVICES ........................................................................................................... 21
PROFESSIONAL SERVICES ................................................................................................................ 21
HOSPITAL AND SKILLED NURSING FACILITY SERVICES ............................................................... 23
OUTPATIENT SERVICES ..................................................................................................................... 24
EMERGENCY SERVICES..................................................................................................................... 26
MATERNITY SERVICES ....................................................................................................................... 26
MENTAL HEALTH AND SUBSTANCE USE DISORDER SERVICES ................................................. 27
HOME HEALTH AND HOSPICE SERVICES ........................................................................................ 29
DURABLE MEDICAL EQUIPMENT ...................................................................................................... 30
TRANSPLANT SERVICES .................................................................................................................... 32
OTHER COVERED SERVICES, SUPPLIES, AND TREATMENTS ..................................................... 38
EXCLUDED SERVICES ........................................................................................................................ 43
PREAUTHORIZATION .......................................................................................................................... 52
INDIVIDUAL BENEFITS MANAGEMENT ............................................................................................. 53
UTILIZATION REVIEW .......................................................................................................................... 53
NECESSITY ACCORDING TO ACCEPTABLE DENTAL PRACTICE .................................................. 55
CLAIMS PAYMENT ..................................................................................................................55
COORDINATION OF BENEFITS .......................................................................................................... 58
COMPLAINTS, GRIEVANCES, AND APPEALS ......................................................................61
GRIEVANCE PROCEDURES ............................................................................................................... 61
APPEAL PROCEDURES....................................................................................................................... 61
HOW TO SUBMIT GRIEVANCES OR APPEALS ................................................................................. 63
RESOURCES FOR INFORMATION AND ASSISTANCE ........................................................64
RIGHTS AND RESPONSIBILITIES ..........................................................................................65
PRIVACY AND CONFIDENTIALITY ..................................................................................................... 66
PLAN ADMINISTRATION ........................................................................................................67
DEFINITIONS ...........................................................................................................................69
Student Guide_2019_Student Plan _Medical_Domestic
