Dear Student, Parent, or Guardian:

We are pleased to provide you with this overview of the UW-Stout Domestic Student Health Insurance Plan (SHIP). This SHIP is underwritten by Nationwide Life Insurance Company and administered by Consolidated Health Plans, Inc. (CHP).

This ACA-compliant plan includes:

Coverage while at school and at home

Comprehensive coverage both for emergency and non-emergency situations

Access to the First Health PPO network

BENEFIT SUMMARY*

Benefit Maximum Unlimited

IN-NETWORK OUT-OF- NETWORK

Annual Deductible Per Person

$500 $1,000

Coinsurance 80% of PA 60% of R&C

Out-of-Pocket Maximum

$6,350 per person $12,700 family

No maximum

Preventive Care 100% of PA

(No Cost Sharing) Not Covered

Inpatient Hospital Expense

80% of PA after $500 copay

60% of R&C after $500 copay

Physician’s Office Visit

100% of PA after $35 copay

60% of R&C after $35 copay

Emergency Room Expense (Copay Waived if admitted)

80% of PA after $225 copay

80% of R&C after $225 copay

Surgeon Expense 80% of PA 60% of R&C

X-Ray and Laboratory 80% of PA 60% of R&C

Mental Health/ Substance Abuse

Paid the Same as any other Sickness

Paid the Same as any other Sickness

Prescription Drug Benefits Retail Prescription Drugs are subject to exclusions and other limitations of the Policy. Deductible does NOT apply to prescriptions.

Prescriptions will be reimbursed at 80% of R&C after applicable copay:

$20 copay for Generic Drugs

$50 copay for Preferred Brand Drugs

$50 copay for Non-Preferred Brand Drugs

$50 copay for Specialty Drugs One copayment per thirty (30) Day Supply. No cost sharing applies to Generic Contraceptives or other Preventative Services

PA= Preferred Allowance R&C = Reasonable & Customary

*This summary is provided as a courtesy and is not meant to replace or override the terms and conditions detailed in the insurance policy/brochure. Please refer to the policy/brochure to verify medical coverage, eligibility, exclusions, limitations, and for more detailed information.

Insurance Requirements If you are a domestic student taking 5 or more credit hours or graduate student, you are eligible to enroll in the insurance. To enroll, you must complete an online enrollment form on the website listed below by the enrollment period deadline dates.

2016/2017 Enrollment Period Deadline Dates for:

Annual/First Semester: October 15, 2016

Second Semester: March 15, 2017

Summer: July, 1, 2017

I need to: Visit:

Enroll in the insurance plan:

Consolidated Health Plans www.chpstudent.com

Learn about:

Insurance Benefits

Preferred Provider Listings

Claims Processing

ID Card

Consolidated Health Plans

2077 Roosevelt Avenue Springfield, MA 01104

(800) 633-7867 www.chpstudent.com

Find a Provider:

Consolidated Health Plans or www.firsthealthlbp.com

(800) 226-5116

Contact Agent

Jeatran Associates

1321 Stout Road Menomonie, WI 54751

(715) 235-6133

Cost and Period of Coverage

Annual* 9/1//16-8/31/17

First Semester*

9/1/16-1/31/17

Second Semester*

2/1//17-8/31/17

Summer* 6/1/17-8/31/17

New Students

$1,814 $760 $1,054 $457

Per Dependent

$1,814 $760 $1,054 $457

*The Rates above include an Administrative Fee

This plan also offers the following value-added services:

Vision Discount Program through Davis Vision

Phone Based Nurse line through Ask Mayo Clinic

Medical Travel Assistance services through Travel Guard

UW-Stout 2016 – 2017

Domestic Student Health

Insurance Plan