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2017–2018 Student Injury and Sickness Insurance Plan for


The Colorado School of Mines


Who is eligible to enroll?


Al degree-seeking U.S. citizens and permanent resident students and al international students regardless of degree-seeking
status are automatical y enrol ed in this insurance plan at registration, unless proof of comparable coverage is furnished.

Accident coverage for Intercollegiate Sports injuries is provided under a separate policy number 2017-4059-8. Contact the
school for information on the Intercollegiate Sports plan. Plan information is also available at www.uhcsr.com/csm.

Students must actively attend classes for at least the first 31 days after the date for which coverage is purchased. Home study,
correspondence, and online courses do not fulfil the eligibility requirements that the student actively attend classes. The
Company maintains its right to investigate eligibility or student status and attendance records to verify that the Policy eligibility
requirements have been met. If and whenever the Company discovers that the Policy eligibility requirements have not been met,
its only obligation is refund of premium.
Coverage Dates and Plan Cost
Rates
Annual
Spring/Summer
Summer 1
Summer 2
8-18-17 to
1-9-18 to
5-14-18 to
6-25-18 to
8-19-18
8-19-18
8-19-18
8-19-18
Student
$1,990.00
$1,215.00
$534.00
$305.00


NOTE: The amounts stated above include certain fees charged by the school you are receiving coverage through. Such fees may include
amounts which are retained by your school (to, for example, cover your school’s administrative costs associated with offering this health plan)
as well as amounts which are paid to certain non-insurer vendors or consultants by, or at the direction of, your school.

The Insured Person must meet the eligibility requirements each time a premium payment is made. To avoid a lapse in coverage,
the Insured Person’s premium must be received within 14 days after the coverage expiration date. It is the Insured Person’s
responsibility to make timely premium payments to avoid a lapse in coverage.




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UnitedHealthcare StudentResources

Where can I get more information about the benefits available?
Please read the certificate of coverage to determine whether this plan is right for you before you enroll. The certificate of
coverage provides details of the coverage including costs, benefits, exclusions, and reductions or limitations and the terms
under which the coverage may be continued in force. Copies of the certificate of coverage are available from the College and
may be viewed at www.uhcsr.com/csm. This plan is underwritten by UnitedHealthcare Insurance Company and is based on
policy number 2017-4059-1. The Policy is a Non-Renewable One-Year Term Policy.
Who can answer questions I have about the plan?
If you have questions please contact Customer Service at 1-866-458-4954 or customerservice@uhcsr.com.



Highlights of Coverage offered by UnitedHealthcare StudentResources



Other Coverage
Accident coverage for Intercollegiate sports injury is available under a separate policy, 2017-4059-8.
Student Health Center Message
Coulter Student Health Center Benefits: The Deductible wil be waived and benefits wil be paid at 100% for Covered Medical
Expenses incurred when treatment is rendered at or referred by the Coulter Student Health Center for the fol owing services:

Certain laboratory services

Travel Clinic

Immunizations – as indicated on the approved SHC Fee Schedule.

Highlights of the Student Injury and Sickness Insurance Plan Benefits
METALLIC LEVEL – GOLD WITH ACTUARIAL VALUE OF 86.68%
Preferred Providers: The Preferred Provider Network for this plan is UnitedHealthcare Choice Plus. Preferred Providers can
be found using the following link: http://www.uhcsr.com/lookupredirect.aspx?delsys=52
Student Health Center Benefits: The Deductible wil be waived and benefits wil be paid at 100% for Covered Medical
Expenses incurred when treatment is rendered at or referred by the Coulter Student Health Center for the fol owing services:
 Certain laboratory services
 Travel Clinic
 Immunizations – as indicated on the approved SHC Fee Schedule


Preferred Providers
Out-of-Network Providers
Overall Plan Maximum
There is no overal maximum dollar limit on the policy
Plan Deductible
$0
$1,000 (Per Insured Person, Per Policy
Year)
Out-of-Pocket Maximum
$2,000 (Per Insured Person, Per
$4,000 (Per Insured Person, Per Policy
After the Out-of-Pocket Maximum has been
Policy Year)
Year)
satisfied, Covered Medical Expenses will be
paid at 100% for the remainder of the Policy
Year subject to any applicable benefit
maximums. Refer to the plan certificate for
details about how the Out-of-Pocket
Maximum applies.
Coinsurance
80% of Preferred Al owance for
60% of Usual and Customary Charges
All benefits are subject to satisfaction of the
Covered Medical Expenses
for Covered Medical Expenses
Deductible, specific benefit limitations,
maximums and Copays as described in the
plan certificate.
Prescription Drugs
$15 Copay for Tier 1
No Benefits
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UnitedHealthcare StudentResources

Prescriptions must be filled at a UHCP
$30 Copay for Tier 2
network pharmacy. Mail order through UHCP $60 Copay for Tier 3
at 2.5 times the retail Copay up to a 90 day
Up to a 31-day supply per
supply.
prescription fil ed at a
UnitedHealthcare Pharmacy (UHCP)
Preventive Care Services
100% of Preferred Al owance
No Benefits
Including but not limited to: annual physicals,
GYN exams, routine screenings and
immunizations. No Deductible, Copays, or
Coinsurance will be applied when the
services are received from a Preferred
Provider. Please visit
www.healthcare.gov/preventive-care-benefits/
for a complete list of the services provided for
specific age and risk groups.
The following services have per Service
Room and Board: $250
Room and Board: $750
Copays
Day Surgery Miscellaneous: $250
Day Surgery Miscellaneous: $750
This list is not all inclusive. Please read the
Physician’s Visits: $25
Physician’s Visits: $25
plan certificate for complete listing of Copays. Medical Emergency: $100
Medical Emergency: $100
(Waived if admitted to the Hospital)
(Waived if admitted to the Hospital)
Ambulance: $200
Ambulance: $200
Urgent Care: $35
Urgent Care: $35
Acupuncture: $25
Acupuncture: $25
Vision: $25
Vision: $25
Pediatric Dental and Vision Benefits
Refer to the plan certificate for details (age limits apply).
Exclusions and Limitations
No benefits wil 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 any of the following:
1.
Behavioral problems. Conceptual handicap. Developmental delay or disorder or mental retardation. Learning
disabilities. Milieu therapy. Parent-child problems.
This exclusion does not apply to benefits specifical y provided in the Policy.
2.
Biofeedback.
3.
Circumcision.
4.
Cosmetic procedures, except reconstructive procedures to:
 Correct an Injury or treat a Sickness.
 Treat a congenital hemangioma on the face or neck for an Insured age 18 or younger.
 Correct a congenital defect, disease or anology for which benefits are otherwise payable under the Policy. The
primary result of the procedure is not a changed or improved physical appearance.
5.
Custodial Care.
 Care provided in: rest homes, health resorts, homes for the aged, halfway houses, college infirmaries or places
mainly for domiciliary or Custodial Care.
 Extended care in treatment or substance abuse facilities for domiciliary or Custodial Care.
6.
Dental treatment, except:
 For accidental Injury to Sound, Natural Teeth.
This exclusion does not apply to benefits specifical y provided in Pediatric Dental Services.
7.
Elective Surgery or Elective Treatment.
8.
Elective abortion.
9.
Health spa or similar facilities. Strengthening programs.
10.
Hearing examinations. Hearing aids. Other treatment for hearing defects and hearing loss. "Hearing defects" means
any physical defect of the ear which does or can impair normal hearing, apart from the disease process.
This exclusion does not apply to:
 Hearing defects or hearing loss as a result of an infection or Injury.
 Hearing Aids specifical y provided for in Benefits for Hearing Aids for Minor Children.
 Hearing exams and tests to determine the need for hearing correction.
11.
Hypnosis.
12.
Immunizations, except as specifical y provided in the Policy. Preventive medicines or vaccines, except where required
for treatment of a covered Injury or as specifical y provided in the Policy.
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UnitedHealthcare StudentResources

13.
Injury or Sickness for which benefits are paid or payable under any Workers' Compensation or Occupational Disease
Law or Act, or similar legislation.
14.
Injury or Sickness outside the United States and its possessions.
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.
Injury sustained while:
 Participating in any intercollegiate or professional sport, contest or competition.
 Traveling to or from such sport, contest or competition as a participant.
 Participating in any practice or conditioning program for such sport, contest or competition.
17.
Investigational services.
18.
Lipectomy.
19.
Marital or family counseling.
20.
Nuclear, chemical or biological Contamination, whether direct or indirect. “Contamination” means the contamination or
poisoning of people by nuclear and/or chemical and/or biological substances which cause Sickness and/or death.
21.
Participation in a riot or civil disorder. Commission of or attempt to commit a felony. Fighting.
22.
Prescription Drugs, services or supplies as fol ows:
 Therapeutic devices or appliances, including: hypodermic needles, syringes, support garments and other non-
medical substances, regardless of intended use, except as specifical y provided in the Policy.
 Immunization agents, except as specifical y provided in the Policy.
 Drugs labeled, “Caution - limited by federal law to investigational use” or experimental drugs.
 Products used for cosmetic purposes.
 Drugs used to treat or cure baldness. Anabolic steroids used for body building.
 Anorectics - drugs used for the purpose of weight control.
 Fertility agents or sexual enhancement drugs, such as Parlodel, Pergonal, Clomid, Profasi, Metrodin, Serophene, or
Viagra.
 Refil s in excess of the number specified or dispensed after one (1) year of date of the prescription.
23.
Reproductive/Infertility services including but not limited to the fol owing:
 Genetic counseling and genetic testing.
 Cryopreservation of reproductive materials. Storage of reproductive materials.
 Fertility tests.
 Infertility treatment (male or female), including any services or supplies rendered for the purpose or with the intent
of inducing conception, except as specifical y provided in the Policy.
 Premarital examinations.
 Impotence, organic or otherwise.
 Reversal of sterilization procedures.
24.
Research or examinations relating to research studies, or any treatment for which the patient or the patient’s
representative must sign an informed consent document identifying the treatment in which the patient is to participate
as a research study or clinical research study, except as specifical y provided in the Policy.
25.
Routine eye examinations. Eye refractions. Eyeglasses. Contact lenses. Prescriptions or fitting of eyeglasses or contact
lenses. Vision correction surgery. Treatment for visual defects and problems.
This exclusion does not apply as follows:
 When due to a covered Injury or disease process.
 To benefits specifical y provided in Pediatric Vision Services.
 To benefits specifical y provided in the Policy.
26.
Routine Newborn Infant Care and well-baby nursery and related Physician charge, except as specifical y provided in
the Policy.
27.
Services provided normal y without charge by the Health Service of the Policyholder. Services covered or provided by
the student health fee.
28.
Skeletal irregularities of one or both jaws, including orthognathia and mandibular retrognathia. Temporomandibular joint
dysfunction, except as specifical y provided in the Policy. Deviated nasal septum, including submucous resection
and/or other surgical correction thereof. Nasal and sinus surgery, except for treatment of a covered Injury or treatment
of chronic sinusitis.
29.
Supplies, except as specifical y provided in the Policy.
30.
Surgical breast reduction, breast augmentation, breast implants or breast prosthetic devices, or gynecomastia, except
as specifical y provided in the Policy.
31.
Treatment in a Government hospital, unless there is a legal obligation for the Insured Person to pay for such treatment.
32.
War or any act of war, declared or undeclared; or while in the armed forces of any country (a pro-rata premium wil be
refunded upon request for such period not covered).
33.
Weight management. Weight reduction programs. Nutrition programs Treatment for obesity (except surgery for morbid
obesity). This exclusion does not apply to benefits specifical y provided in the Policy.

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UnitedHealthcare StudentResources



Highlights of Services offered by UnitedHealthcare StudentResources

Healthiest You: National Telehealth Service
Starting on the effective date of your policy, you have 24/7 access to medical advice through HealthiestYou, a national
telehealth service. By cal ing the tol -free number listed on the front of your medical ID card or visiting
www.telehealth4students.com, you have access to board-certified physicians via phone and/or video, where permitted. This
service is especial y helpful for minor il nesses, such as al ergies, sore throat, earache, pink eye, etc. Based on the condition
being treated, the doctor can also prescribe certain medications, saving you a trip to the doctor’s office. Using HealthiestYou
can save you money and time, while avoiding costly trips to a doctor’s office, urgent care facility, or emergency room. As an
insured with StudentResources, there is no consultation fee for this service.* Every cal with a HealthiestYou doctor is covered
100% during your policy period.

This service is meant to compliment your Student Health Center. If possible, we encourage you to visit your SHC first before
using this service.

HealthiestYou is not health insurance. HealthiestYou is designed to complement, and not replace, the care you receive from
your primary care physician. HealthiestYou physicians are an independent network of doctors who advise, diagnose, and
prescribe at their own discretion. HealthiestYou physicians provide cross coverage and operate subject to state regulations.
Physicians in the independent network do not prescribe DEA control ed substances, non-therapeutic drugs and certain other
drugs which may be harmful because of their potential for abuse. HealthiestYou does not guarantee that a prescription wil be
written. Not available in Arkansas; limited services in Idaho and Texas.

*If you are an Insured under this insurance Plan, and you cal prior to the plan effective date, you wil be charged a $40 service
fee before being connected to a board-certified physician.
BetterHelp

Starting on the effective date of your policy, you have access to Psychologists (PhD / PsyD), Marriage and family therapists
(LMFT), Clinical Social Workers (LCSW) and Licensed Professional Counselors (LPC) through BetterHelp, a national virtual
counseling service. These professional licensed counselors wil be available to you via ongoing text communications, live chat,
phone, video or groupinars.

When you first visit the counseling website, you wil be asked to complete a questionnaire that wil request your UHCSR
insurance information on your ID card, emergency contacts and your goals for accessing the service. The questionnaire wil
also ask you for counselor preferences (gender, specialty, etc.) to ensure you are matched with a practitioner that can help you
meet your goals. Within 24 hours after completing the questionnaire, you wil be contacted by a counselor to schedule an
appointment and decide on a communication method that best suits your needs.

As an insured with StudentResources, there is no consultation fee for this service. Every communication with a BetterHelp counselor is
covered 100% during your policy period.
Student Assistance
Insureds have immediate access to the Student Assistance Program, a service that coordinates care using a network of
resources. Services available include counseling, financial and legal advice, as wel as mediation. Counseling services are
offered by Licensed Clinicians who can provide insureds with someone to talk to when everyday issues become
overwhelming. Financial services, provided by licensed CPA’s and Certified Financial Planners offer consultations on issues
such as financial planning, credit and col ection issues, home buying and renting and more. Legal Services are provided by
fully credentialed attorneys with at least 5 years of experience practicing law. Mediation services are available to help resolve
family-related disputes. Translation services are available in over 170 languages for most services. Insureds also have access
to LiveAndWorkWell.com where they can take health risk assessments, use health estimators to calculate things like their
target heart rate and BMI, and participate in personalized self-help programs. More information about these services is
available by logging into My Account at www.uhcsr.com/MyAccount.
UnitedHealthcare Global: Global Emergency Services
If you are a member insured with this insurance plan, you are eligible for UnitedHealthcare Global Emergency Services. The
requirements to receive these services are as fol ows:
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UnitedHealthcare StudentResources


International Students: you are eligible to receive UnitedHealthcare Global services worldwide, except in your home country.

Domestic Students: you are eligible for UnitedHealthcare Global services when 100 miles or more away from your campus
address and 100 miles or more away from your permanent home address or while participating in a Study Abroad program.

The Emergency Medical Evacuation services are not meant to be used in lieu of or replace local emergency services such as an
ambulance requested through emergency 911 telephone assistance. Al services must be arranged and provided by
UnitedHealthcare Global; any services not arranged by UnitedHealthcare Global wil not be considered for payment. If the
condition is an emergency, you should go immediately to the nearest physician or hospital without delay and then contact the
24-hour Emergency Response Center. UnitedHealthcare Global wil then take the appropriate action to assist you and monitor
your care until the situation is resolved.
Key Services include:
 Transfer of Insurance Information to Medical Providers
 Monitoring of Treatment
 Transfer of Medical Records
 Medication, Vaccine
 Worldwide Medical and Dental Referrals
 Dispatch of Doctors/Specialists
 Emergency Medical Evacuation
 Facilitation of Hospital Admittance up to $5,000.00 payment
 Transportation to Join a Hospitalized Participant
 Transportation After Stabilization
 Coordinate the replacement of Corrective Lenses and Medical Devices
 Emergency Travel Arrangements
 Hotel Arrangements for Convalescence
 Continuous Updates to Family and Home Physician
 Return of Dependent Children
 Replacement of Lost or Stolen Travel Documents
 Repatriation of Mortal Remains
 Worldwide Destination Intelligence Destination Profiles
 Legal Referral
 Transfer of Funds
 Message Transmittals
 Translation Services
 Security and Political Evacuation Services
 Natural Disaster Evacuation Services

Please visit www.uhcsr.com/UHCGlobal for the UnitedHealthcare Global brochure which includes service descriptions and
program exclusions and limitations.

To access services please refer to the phone number on the back of your ID Card or access My Account and select Value
Added Benefits: Global Emergency Services.

When cal ing the UnitedHealthcare Global Operations Center, please be prepared to provide:

 Cal er's name, telephone and (if possible) fax number, and relationship to the patient;
 Patient's name, age, sex, and UnitedHealthcare Global ID Number as listed on your Medical ID Card
 Description of the patient's condition;
 Name, location, and telephone number of hospital, if applicable;
 Name and telephone number of the attending physician; and
 Information of where the physician can be immediately reached.

UnitedHealthcare Global is not travel or medical insurance but a service provider for emergency medical assistance services.
Al medical costs incurred should be submitted to your health plan and are subject to the policy limits of your health coverage.
Al assistance services must be arranged and provided by UnitedHealthcare Global. Claims for reimbursement of services not
provided by UnitedHealthcare Global wil not be accepted. Please refer to the UnitedHealthcare Global information in My
Account at www.uhcsr.com/MyAccount for additional information, including limitations and exclusions.



17PPOSB-4059-1
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UnitedHealthcare StudentResources

This Summary Brochure is based on Policy #2017-4059-1.
NOTE: The information contained herein is a summary of certain benefits which are offered under a student health
insurance policy issued by UnitedHealthcare. This document is a summary only and may not contain a full or complete
recitation of the benefits and restrictions/exclusions associated with the relevant policy of insurance. This document
is not an insurance policy document and your receipt of this document does not constitute the issuance or delivery of
a policy of insurance. Neither you nor UnitedHealthcare has any rights or responsibilities associated with your receipt
of this document. Changes in federal, state or other applicable legislation or regulation or changes in Plan design
required by the applicable state regulatory authority may result in differences between this summary and the actual
policy of insurance.

17PPOSB-4059-1
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UnitedHealthcare StudentResources



NON-DISCRIMINATION NOTICE

UnitedHealthcare StudentResources does not treat members differently because of sex, age, race, color, disability or national
origin.

If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint
to:


Civil Rights Coordinator

United HealthCare Civil Rights Grievance

P.O. Box 30608

Salt Lake City, UTAH 84130

UHC_Civil_Rights@uhc.com

You must send the written complaint within 60 days of when you found out about it. A decision wil be sent to you within 30
days. If you disagree with the decision, you have 15 days to ask us to look at it again.

If you need help with your complaint, please cal the toll-free member phone number listed on your health plan ID card, Monday
through Friday, 8 a.m. to 8 p.m. ET.

You can also file a complaint with the U.S. Dept. of Health and Human Services.


Online https://ocrportal.hhs.gov/ocr/portal/lobby.jsf


Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.


Phone: Toll-free 1-800-368-1019, 800-537-7697 (TDD)


Mail: U.S. Dept. of Health and Human Services. 200 Independence Avenue, SW

Room 509F, HHH Building Washington, D.C. 20201

We also provide free services to help you communicate with us. Such as, letters in other languages or large print. Or, you can
ask for free language services such as speaking with an interpreter. To ask for help, please cal the toll-free member phone
number listed on your health plan ID card, Monday through Friday, 8 a.m. to 8 p.m. ET.

NDLAP-FO-001 (1-17)



LANGUAGE ASSISTANCE PROGRAM

ATTENTION: If you speak English, language assistance services, free of charge, are available to you.
Please call 1-866-260-2723.

ATENCIÓN: Si habla español (Spanish), hay servicios de asistencia de idiomas, sin cargo, a su disposición.
Llame al 1-866-260-2723.

請注意:如果您說中文 (Chinese),我們免費為您提供語言協助服務。請致電:1-866-260-2723.

XIN LƯU Ý: Nếu quý vị nói tiếng Việt (Vietnamese), quý vị sẽ được cung cấp dịch vụ trợ giúp về ngôn ngữ
miễn phí. Vui lòng gọi 1-866-260-2723.

알림: 한국어(Korean)를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-866-
260-2723번으로 전화하십시오.

PAUNAWA: Kung nagsasalita ka ng Tagalog (Tagalog), may makukuha kang mga libreng serbisyo ng tulong
sa wika. Mangyaring tumawag sa 1-866-260-2723.

ВНИМАНИЕ: бесплатные услуги перевода доступны для людей, чей родной язык является русском
(Russian). Позвоните по номеру 1-866-260-2723.

1
. -866-260-2723 ـب لاصتلأا ءاجرلا .كل ةحاتم ةيناجملا ةيوغللا ةدعاسملا تامدخ نإف ، Ar
)
abic ة

( يبرعلا ثدحتت تنك اذإ :هيبنت

ATANSYON: Si w pale Kreyòl ayisyen (Haitian Creole), ou kapab benefisye sèvis ki gratis pou ede w nan
lang pa w. Tanpri rele nan 1-866-260-2723.

ATTENTION : Si vous parlez français (French), des services d’aide linguistique vous sont proposés
gratuitement. Veuillez appeler le 1-866-260-2723.

UWAGA: Jeżeli mówisz po polsku (Polish), udostępniliśmy darmowe usługi tłumacza. Prosimy zadzwonić
pod numer 1-866-260-2723.

ATENÇÃO: Se você fala português (Portuguese), contate o serviço de assistência de idiomas gratuito. Ligue
para 1-866-260-2723.

ATTENZIONE: in caso la lingua parlata sia l’italiano (Italian), sono disponibili servizi di assistenza
linguistica gratuiti. Si prega di chiamare il numero 1-866-260-2723.

ACHTUNG: Falls Sie Deutsch (German) sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen
zur Verfügung. Rufen Sie 1-866-260-2723 an.

注意事項:日本語 (Japanese) を話される場合、無料の言語支援サービスをご利用いただけ
ます。1-866-260-2723 にお電話ください。

.دشاب یم امش رايتخا رد ناگيار روط هب ینابز دادما تامدخ ،تسا i
)
sraF ی

( سرا ام
ف ش نابز رگا :هجوت
.ديريگب سامت 1
-866-260-2723


NDLAP-FO-002 (10-16)



कृपा ध्यान दें: यदद आप ह िंदी (Hindi) भाषी हैं तो आपके लिए भाषा सहायता सेवाएं नन:शुल्क उपिब्ध हैं। कृपा पर काि
करें 1-866-260-2723

CEEB TOOM: Yog koj hais Lus Hmoob (Hmong), muaj kev pab txhais lus pub dawb rau koj. Thov hu rau 1-
866-260-2723.

ចំណាប់អារម្មណ ៍ៈ បបើសិនអ្នកនិយាយភាសាខ្មមរ(Khmer)បសវាជំនួយភាសាបោយឥតគិតថ្លៃ គឺមានសំរាប់អ្នក។ សូម្ទូរស័ព្ទ បៅបេម 1-866-260-2723។

PAKDAAR: Nu saritaem ti Ilocano (Ilocano), ti serbisyo para ti baddang ti lengguahe nga awanan bayadna,
ket sidadaan para kenyam. Maidawat nga awagan iti 1-866-260-2723.

DÍÍ BAA'ÁKONÍNÍZIN: Diné (Navajo) bizaad bee yániłti'go, saad bee áka'anída'awo'ígíí, t'áá jíík'eh, bee
ná'ahóót'i'. T'áá shoodí kohjį' 1-866-260-2723 hodíilnih.

OGOW: Haddii aad ku hadasho Soomaali (Somali), adeegyada taageerada luqadda, oo bilaash ah, ayaad heli
kartaa. Fadlan wac 1-866-260-2723.



NDLAP-FO-002 (10-16)