Brigham Young University–Hawaii
Student Medical Benefit 2024–2025

Summary of Benefits

This summary of benefits provides a brief review of benefits. For complete details of coverage, including limitations and exclusions, please read this entire Student Medical Benefit handbook.

Who to Contact

Enrollment and Coverage Information

Addresses

To contact DMBA online, go to: https://demo.dmba.com/sc/dmba/SecureMessage.aspx

DMBA’s Preferred Provider Network

You must preauthorize all care outside the Student Health Center by calling 808-466-4077.

Find a contracted medical provider:

Access the Student Medical Benefit handbook: demo.dmba.com/nsc/Student/Handbooks.aspx

Introduction

Having good health is important for you to achieve your goals at BYU–Hawaii. And having adequate medical coverage is important to your good health. Without adequate coverage, unexpected expenses could alter your future dramatically. An accident, illness, or hospitalization could result in a financial burden to you, your family, and the community. For this reason, BYU–Hawaii covers all full-time (matriculating) students while in Hawaii.

Good health is vital for you to be successful in your university studies. If you’re currently being evaluated or receiving care or treatment for a medical condition, please discuss your plans with your physician before coming to BYU–Hawaii. It’s important to resolve any problems that may prevent you from maintaining full-time student status or require you to miss classes or assignments.

The BYU–Hawaii Student Medical Benefit was designed to offer a wide range of benefits for students, spouses, and their children. It is administered by BYU–Hawaii and DMBA, based in Salt Lake City. For your convenience, DMBA has a Hawaii office to serve you locally.

This handbook will provide you with a summary of benefits, as well as information about how the Student Medical Benefit works. Please review this information carefully. To receive the benefits available to you, it’s your responsibility to become familiar with the provisions and guidelines. Exceptions to contractual provisions cannot be granted.

The BYU–Hawaii Student Medical Benefit

You are enrolled in the BYU–Hawaii Student Medical Benefit while you are enrolled as a full-time (matriculating) student on campus attending class. BYU–Hawaii maintains the right to revoke a student’s full-time status because of academic, Honor Code, or other infractions. When you end full-time enrollment, you are no longer covered by the Student Medical Benefit. Students who graduate will end coverage on the last day of their enrollment span (that is, the coverage term date for the semester, and not the day of graduation). International students must enroll all eligible dependents that reside with them while attending BYU–Hawaii.

A student is eligible for the Student Medical Benefit when enrolled in and attending classes of 12 or more credit hours, with at least one face-to-face class on campus. If a student is enrolled in fewer than 12 credit hours, he or she must be approved for a reduced load to be eligible for the Student Medical Benefit. A domestic student who is covered by a qualifying plan may opt out of the Student Medical Benefit.

If you are married, your non-student spouse and children will not be enrolled automatically. Domestic students may enroll dependents by completing a Dependent Coverage Enrollment Form. All international students are required to enroll their dependents and non-student spouse. International students must also enroll newborn dependents in the Family Student Medical Benefit. If your spouse is also a full-time student, he/she will be enrolled automatically.

Enrolling Your Family

To enroll your eligible dependents, you may change your enrollment from individual to family coverage at the beginning of your first semester, or at the beginning of each fall semester thereafter.

Their enrollment will remain in effect until you graduate or lose your coverage from BYU–Hawaii. BYU–Hawaii will renew enrollment for your family at the beginning of each fall semester based on their enrollment for the previous semester. If you want to change your family’s enrollment, remember to notify the Student Medical Benefit Office.

To enroll your family, complete an enrollment form and return it to the Student Medical Benefit Office. Enrollment forms are due during the first week of classes. If you are a new student, you must return the form during the first week of your first semester.

Remember, if you don’t enroll your dependents at the beginning of your first semester or at the beginning of the fall semester, you can’t add them to your coverage midyear. You must wait until the next fall semester unless you meet one of the special circumstances outlined below.

Changing Enrollment Midyear

If you acquire a new dependent through marriage, birth, or adoption, you may enroll or change your enrollment to include coverage for your new spouse and/or child as long as you apply within 30 days. If this changes your coverage option, you will be assessed the appropriate premium prorated to the enrolled date. Remember, you must formally enroll a newborn or adopted child; it isn’t done automatically for you when the child is born or placed in your care. If you do not add your dependent within 30 days of the qualifying event, the university may impose a penalty.

Newborn and adopted newborn dependents with medically diagnosed congenital defects and birth abnormalities will be covered for care and treatment from the date of birth for 30 days. To receive this coverage, you must add the newborn to your Student Medical Benefit. Adopted dependents who are not newborns will be covered automatically from the date of placement for 30 days (with premium payment).

In the case of an adopted child, “placed” means physical placement in the care of the adoptive subscriber or other member of the covered group. When physical placement is prevented because the child requires care in a medical facility, “placed” means when the adoptive subscriber or other member of the covered group signs agreements for adoption and assumes financial responsibility for the child.

Eligibility

The following individuals may be enrolled in the Student Medical Benefit.

Students: For a student to be eligible for the Student Medical Benefit, he or she must be considered “full time.” Usually at BYU–Hawaii, a student is considered full time when enrolled in 12 or more credit hours with at least one face-to-face class on campus, or 8 or more credit hours for spring semester. Please be aware, if you are registered for fewer than 12 credit hours, you must get approval for the reduced load to be eligible for the Student Medical Benefit.

The following do not count toward minimum credit hour requirements:

• Credits earned through testing (for example, language credits, Advanced Placement exams, etc.)
• Credits earned by auditing a course (that is, taking a course but not receiving a grade or academic progress)
• Credits earned for coursework taken at an institution other than BYU–Hawaii

Dependents who are eligible to be enrolled include:

• Your legal spouse
• Your eligible children. Eligible children are your unmarried children who are younger than 26 and must reside full time in your household, including:
  
  • Natural children (including infants from date of birth), legally adopted children, and children appointed by a court of law to your custody or your spouse’s custody. In the case of a child who is committed by a court of law to your custody or your spouse’s custody, you must submit a copy of the certified court order granting the adoption, custody, or guardianship authenticated in the United States.
  • A child placed with you under the direction of a licensed child placement agency and for which you are the legal guardian.
  • Your unmarried child who is 26 or older and incapable of self-support because of mental or physical disability that existed before the child reached 26, and who is primarily dependent upon you for support. You must submit proof of the incapacity within 30 days of your child’s 26th birthday. This exception is subject to approval of the Student Medical Benefit Committee.
  • Your stepchild (child of your spouse) younger than 26. If the stepchild is younger than 18, your spouse must have a court order granting full or partial custody.

Coverage

While You’re Away from BYU–Hawaii

• Internships: International students who’ve been approved for an internship within the United States must enroll in the Student Medical Benefit. Domestic students may show proof of other coverage to waive enrollment. Single coverage is $80 per month and couple or family coverage is $205 per month. Your career services program manager will provide you with more information. You must complete an enrollment form and pay for coverage before leaving the university.
• Approved Leave of Absence: Beginning Fall Semester 2017, all students taking a leave of absence will no longer be eligible for enrollment in the Student Medical Benefit. International students staying in the United States while on leave of absence will need to work with the International Student Services department to make sure they meet all medical coverage requirements. Domestic students on leave of absence must secure their own appropriate medical coverage.
• Vacations or Short Breaks from School: You are eligible for coverage within the United States for the academic year unless you lose your status as a full-time student. I-Work students must be current on all financial obligations or have a payment plan in place before traveling.
• Performing Groups: If you are away on school business (sports team, performing group on tour, etc.) and are enrolled as a full-time student, you will have coverage within the United States.
• Missions: Missionaries are not covered by the Student Medical Benefit.

All care is subject to the guidelines and limitations of the Student Medical Benefit.

Coverage Periods

* You must formally enroll your new spouse within 30 days of marriage.

** You must formally enroll your dependent within 30 days of birth or placement. You will be charged a premium retroactive to the baby’s birth date.

You are covered while you are traveling to school and during on-campus activities before the first day of classes. This coverage is effective for up to 14 days before the first day of class. You must be checked-in with the University.

You are enrolled as long as you are a full-time (matriculating) student. The participation level you choose (either individual or family) will generally remain in effect as long as you don’t lose full-time student status. (If you drop below full-time status through administrative action, Regular On-Campus Coverage will end on the day your status changes.)

After your coverage ends, you may request a document, similar to a Certificate of Creditable Coverage, certifying the length of time you were enrolled in the Student Medical Benefit by calling DMBA.

Coverage at Other Church Universities

If you receive services at the SHC of another Church university, you must pay a $10 copayment and you will be covered at 100% for eligible services. You do not need to preauthorize your care between campus Health Centers.

Payment is required upfront at the time of your visit. A claim form will be provided to you to submit a reimbursement request from DMBA.

Opting Out of the Student Medical Benefit

Upon approval, a domestic student may choose to opt out of the Student Medical Benefit and use his or her own private insurance plan after the student provides adequate proof of other coverage.

As of July 27, 2015, the Student Medical Benefit will no longer qualify as minimum essential coverage that meets Affordable Care Act guidelines. If you are not enrolled in qualifying minimum essential coverage, you may incur a tax penalty. For more information, please contact the Student Medical Benefit Office.

Premiums for Dependents

For additional dependent premiums, see the table below. International students must enroll all eligible dependents that reside with them while attending BYU–Hawaii. Domestic students are strongly advised to add their dependents, but are not required to do so.

If you change enrollment midyear, your premium (or additional premium, if necessary) will be due immediately when you enroll for the semester in which the change becomes effective.

How the Student Medical Benefit Works

Overview

You must receive or coordinate all your medical care at the SHC. When you receive services at the SHC, you pay an upfront copayment of $10. If the SHC cannot treat you, at their discretion they will refer you to a contracted medical provider.

If you receive authorized services outside the SHC, you pay an upfront copayment to the medical provider. A copayment is a fixed dollar amount (usually $25) that you owe at the time services are received. Also, your provider may require you to pay the additional 20% patient responsibility when you receive services. Any payments you make will be credited to your account.

After you pay your copayment, the amount DMBA pays on behalf of the Student Medical Benefit is your benefit (for example, 80%). The amount you pay (the remaining 20%) is your co-share.

Services received outside of the SHC that have not been referred or authorized may not be covered and are subject to review.

In some cases, the medical provider may bill more than the Student Medical Benefit’s allowable limit for the services you received. If so, your EOB statement will also itemize how much of the bill is over the allowable limit.

• If you receive your care from one of DMBA’s contracted providers, you don’t have to pay any amount over the allowable limit. When healthcare providers contract with DMBA, they agree not to bill you for more than the allowable limit.
• If you receive your care from a provider who is not contracted with DMBA, you are responsible to pay any charges over the allowable limit.

You are also responsible to pay your medical provider for any services that aren’t paid for by DMBA on behalf of the Student Medical Benefit. For example, medical tax charges are not eligible for reimbursement and are your responsibility.

Student Medical Benefit Identification Card

To obtain a copy of your Student Medical Benefit card, please contact the local DMBA office.

Copayments

You must receive or coordinate all your medical care at the SHC. Your office visit fees and copayments are as follows:

Benefits and Your Co-share

After you have paid your copayment, benefits for the remainder of eligible expenses are:

Maximum Benefit

Expenses that exceed $250,000 per benefit year are not covered.

Preauthorization

All services received outside the SHC, other than emergency care, must be preauthorized by DMBA. You must preauthorize before you receive the medical care. To preauthorize all care outside the SHC, you must obtain a referral from the SHC first. The SHC will obtain a preauthorization on your behalf if services are approved.

If your referred provider recommends care that is not specified in the referral from the SHC (such as additional office visits, tests at another facility, or consultation with another healthcare provider), you must contact the SHC for approval before you receive the additional care. Remember, care beyond the scope of the original SHC referral must also be authorized in advance by DMBA. If you don’t preauthorize services you receive outside the SHC, you may not be eligible for coverage or you may pay an additional $200 copayment per service.

Even if you have preauthorization from DMBA to see an outside provider, that does not guarantee payment for any treatment you may receive. The guidelines, benefits, and exclusions of the Student Medical Benefit will determine claims payment.

Student Health Center

The Student Health Center (SHC) provides or coordinates all medical care that is paid for by the Student Medical Benefit. It is open to all students, spouses, and dependents who are enrolled in the Student Medical Benefit. If you need eligible services that the SHC can’t provide, you may be referred to contracted medical providers in the community. These providers have contracted with DMBA to offer care at a reduced cost to participants. The discounts will be reflected in the portion of charges that you are responsible to pay.

The SHC provides some limited durable medical equipment and medical supplies. Some routine services available at the SHC are not eligible for benefits.

Operating Hours

SHC hours are as follows (last appointment available one-half hour before closing):

Services Outside the SHC

The Student Medical Benefit covers hospitalization and many other specialized medical services that the SHC does not provide. If you need such services, you may be referred to a contracted medical provider in the community. You must be referred by the SHC and preauthorize all care you receive outside the SHC, except for emergency care. If you do not obtain a referral from the SHC and a preauthorization from DMBA, you may be responsible for all costs incurred.

Not all services are eligible for benefits. To see which services are not covered, please carefully read the exclusions.

The following are examples of services outside the SHC that may be eligible for benefits:

Allergy services

• Contracted provider: The benefit pays 80% after your $25 copayment; you pay 20%.
• Non-contracted provider: The benefit pays 50% after your $25 copayment; you pay 50%.
• You must preauthorize.

Ambulance (land and air)

• When medically necessary, the benefit covers licensed ambulance services to the nearest medical facility equipped to provide the appropriate care.
• The benefit pays 80% after your $25 copayment; you pay 20%.
• Air ambulance must be preauthorized.

Anesthesia

• The benefit pays 80%; you pay 20%.

Chemotherapy

• Contracted provider: The benefit pays 80%; you pay 20%.
• Non-contracted provider: The benefit pays 50%; you pay 50%.
• You must preauthorize.

COVID vaccine

• Effective begins May 12, 2023.
• Contracted providers: The plan pays 100%; you pay 0%.
• All other providers: The plan pays 50%; you pay 50%.
• For more information about getting your COVID vaccine, call the SHC.

Dental accident benefit

• The benefit pays 80% after your $25 copayment; you pay 20%.
• The maximum benefit is $3,000 per benefit year.
• Benefits apply only to services made necessary as a direct result of a traumatic accidental injury to a permanent, sound tooth that occurs while you are enrolled in the Student Medical Benefit.
• Benefits apply only to services received while you are enrolled in the Student Medical Benefit and within two years of the accident.
• You must preauthorize.

Diabetes education

• Contracted provider: The benefit pays 80% after your $25 copayment; you pay 20%.
• Non-contracted provider: The benefit pays 50% after your $25 copayment; you pay 50%.
• The maximum benefit is $300 per benefit year.
• You must preauthorize.

Diabetic supplies

• The benefit pays 80%; you pay 20%.

Dialysis

• Contracted provider: The benefit pays 80%; you pay 20%.
• Non-contracted provider: The benefit pays 50%; you pay 50%.
• You must preauthorize.

Emergency room

• The benefit pays 80% after your $50 copayment; you pay 20%.
• You don’t need to authorize the initial visit, but you must preauthorize any follow-up care outside the SHC with DMBA.

Eye exams

• Contracted provider: The benefit pays 80% after your $25 copayment; you pay 20%.
• Non-contracted provider: The benefit pays 50% after your $25 copayment; you pay 50%.
• One routine eye exam per person is eligible for benefits each benefit year with no preauthorization.
• Eye exams for medical conditions, such as glaucoma, may be eligible for benefits more often, but you must preauthorize.

Food supplements

• Contracted provider: The benefit pays 80%; you pay 20%.
• Non-contracted provider: The benefit pays 50%; you pay 50%.
• Only food supplements for treatment of inborn errors of metabolism, such as phenylketonuria (PKU), are covered.
• You must preauthorize.

Home healthcare

• Contracted provider: The benefit pays 80% after your $25 copayment; you pay 20%.
• Non-contracted provider: The benefit pays 50% after your $25 copayment; you pay 50%.
• To be eligible for benefits, services must be performed by a licensed Registered Nurse or a Licensed Practical Nurse.
• Custodial care, such as maintaining someone beyond the acute phase of injury or illness, including room, meals, bathing, dressing, and home health aides, is not eligible for benefits.
• You must preauthorize.

Immunizations for children

At the SHC:

• The benefit pays 100% for children younger than 6.

Outside the SHC:

• All immunizations for children younger than 6 must be preauthorized to be eligible for coverage.

In vitro fertilization

• Contracted provider: The benefit pays 80% after your $25 copayment; you pay 20%.
• Non-contracted provider: The benefit pays 50%; you pay 50%.
• In vitro fertilization is eligible for benefits for one time only.
• You must have at least a five-year history of infertility or endometriosis, diethylstilbestrol (DES), blockage or removal of fallopian tube, or abnormal male factors.
• You must have been married for the entire duration of your five-year history.
• You must have exhausted other methods of covered infertility treatment.
• The patient’s spouse must be the sperm donor.
• Procedures must be performed at medical facilities that conform to the American College of Obstetricians and Gynecologists guidelines for in vitro fertilization clinics, or to the American Fertility Society minimal standards for programs of in vitro fertilization.
• You must preauthorize.
• For information about covered prescriptions drugs related to in vitro fertilization, call DMBA at 808-466-4077.

Injections (allergy, intramuscular, etc.)

• Contracted provider: The benefit pays 80%; you pay 20%.
• Non-contracted provider: The benefit pays 50%; you pay 50%.

Inpatient hospital services

• Contracted provider: The benefit pays 80%; you pay 20%.
• Non-contracted provider: The benefit pays 50%; you pay 50%.
• You pay a $200 copayment per admission and $50 for newborn infants.
• You must preauthorize. If you don’t preauthorize your hospital stay, you will be charged an additional $300 copayment.
• For more information, please see Maternity—Hospitalization.

Inpatient physician services

• Contracted provider: The benefit pays 80%; you pay 20%.
• Non-contracted provider: The benefit pays 50%; you pay 50%.
• You must preauthorize.

Laboratory services

• Contracted provider: The benefit pays 80%; you pay 20%.
• Non-contracted provider: The benefit pays 50%; you pay 50%.
• You must preauthorize genetic testing services. Services will only be preauthorized after consultation with a contracted genetic counselor.

Maternity

• Contracted provider: The benefit pays 80%; you pay 20%.
• Non-contracted provider: The benefit pays 50%; you pay 50%.
• To be eligible for benefits, you must maintain maternity coverage continuously from the date of your last menstrual period to the date of delivery.
• The SHC provides pregnancy tests, but you’ll be referred to a contracted provider for ongoing maternity care.
• You will receive separate bills for the newborn baby’s medical care. If you want to add your newborn child to your Student Medical Benefit coverage and receive benefits for the baby’s expenses, you must enroll the child within 30 days of the birth. All international students are required to add their newborns. You will be charged a premium retroactive to the date of the baby’s birth.

Maternity—hospitalization

• Contracted provider: The benefit pays 80%; you pay 20%.
• Non-contracted provider: The benefit pays 50%; you pay 50%.
• You pay a $200 copayment per admission ($50 for newborn infants).
• You must preauthorize medically necessary hospital stays of more than two days for a vaginal delivery or four days for a cesarean section delivery. If you do not preauthorize your extended hospital stay, additional days will be subject to medical review and you will be charged an additional $200 copayment. For preauthorization, contact DMBA before your stay is extended.
• Some maternity-related expenses, such as expenses for miscarriage or false labor, are not considered in the contracted hospital rates. In such cases, the hospital will charge its regular fees, and regular benefits and hospitalization copayments will apply to these charges.

Maternity—physician/nurse-midwife services

• Contracted provider: The benefit pays 80%; you pay 20%.
• Non-contracted provider: The benefit pays 50%; you pay 50%.
• You pay a $25 copayment per visit (maximum total copayment of $150 for routine care).
• The contracted rate covers prenatal care and delivery provided by one physician through the term of pregnancy.
• Additional services, such as ultrasounds and amniocentesis, are billed separately and normal benefits and copayments apply to the additional charges.
• Other physicians involved in the medical care for you and your baby, such as anesthesiologists or pediatricians, will bill you separately. Regular benefits and copayments will apply to these charges.
• A maximum of two ultrasounds per pregnancy are covered by the BYU–Hawaii Student Medical Benefit.

Medical equipment (durable)

• Durable medical equipment is a device that is durable, primarily serves a medical purpose, generally is not useful to people in the absence of illness, injury, or congenital defect, and is appropriate for use in the home. Not all equipment that meets these requirements is eligible for benefits.
• Contracted provider: The benefit pays 80% after your $25 copayment; you pay 20%.
• Non-contracted provider: The benefit pays 50% after your $25 copayment; you pay 50%.
• To be eligible for benefits, you must have a prescription from your physician.
• You must preauthorize certain medical equipment. For information about equipment requiring preauthorization, please refer to the table that follows. If you do not, the purchase or rental of the equipment will be reviewed retrospectively (after the fact) to determine if it is eligible for coverage.
• Time limitations apply to replacing some equipment.
• You are responsible for expenses associated with the maintenance and upkeep of your medical equipment.

Medical Equipment

This table is not intended to be all-inclusive.

* Preauthorization is required after 30 days

Medical supplies

• Medical supplies are disposable, one-use-only medical items for immediate use. These include dressings, gauze, tape, ace bandages, etc.
• Contracted provider: The benefit pays 80%; you pay 20%.
• Non-contracted provider: The benefit pays 50%; you pay 50%.
• To be eligible for benefits, you must have a prescription from your physician.

Mental health therapy

• Contracted provider: The benefit pays 80% after your $25 copayment; you pay 20%.
• Non-contracted provider: The benefit pays 50% after your $25 copayment; you pay 50%.
• Your Student Medical Benefit covers mental and behavioral health counseling visits performed via telehealth.
• Residential treatment is not covered.
• To be eligible for benefits, services must be provided by a physician, psychologist, clinical social worker, or advanced practice registered nurse.
• You must preauthorize all mental health services outside the SHC or the campus counseling center.

Office visits outside the SHC

• Contracted provider: The benefit pays 80% after your $25 copayment; you pay 20%.
• Non-contracted provider: The benefit pays 50% after your $25 copayment; you pay 50%.
• The benefit covers medical office visits performed via telehealth (CPT codes 99201-99215)
• Telehealth services performed via “convenient care” or other typically app-based platforms are excluded from the Student Medical Benefit.
• You must preauthorize services outside the SHC.

Pain management

• Contracted provider: The benefit pays 80%; you pay 20%.
• Non-contracted provider: The benefit pays 50%; you pay 50%.
• The benefit is for either inpatient or outpatient care.
• Outpatient services have a five-visit or $1,500 benefit limit per benefit year. Each visit is subject to the contracted and non-contracted rates after your $25 copayment.
• You must preauthorize.

Physical therapy—outpatient

• Contracted provider in Hawaii: The benefit pays 100% after your $10 copayment.
• Contracted provider outside of Hawaii: The benefit pays 80% after your $25 copayment.
• Non-contracted provider: The benefit pays 50% after your $25 copayment; you pay 50%.
• The benefit covers up to 20 visits per person per benefit year.
• Inpatient visits do not count toward your annual outpatient visit limit.
• Physical therapy outside of Hawaii must be referred by the SHC and preauthorized by DMBA. If you do not preauthorize, you will be charged an additional $200 copayment per visit.

Prescription drugs

At network retail pharmacies:

• High-cost and specialty drugs are excluded.
• Covered Brand and Generic Drugs: The benefit pays 70%; you pay 30%.
• Non-covered Brand and Generic Drugs: You pay 100%.
• Some items that can be prescribed but are not eligible for benefits include:
  
  • Dietary or nutritional products, including special diets for medical problems
  • Hair-loss treatments
  • Medications for sexual dysfunction
  • Vitamins, except prescribed prenatal vitamins and prescribed infant vitamins
  • Weight-reduction aids
• Benefits are limited to a 30-day supply at a retail pharmacy.
• Prescription drugs are not included in Catastrophe Protection. If you qualify for Catastrophe Protection, standard prescription benefits will remain in effect.

For more information about covered drugs and retail pharmacy locations, call DMBA at 808-466-4077 or 800-777-3622.

Prosthetics

• This benefit includes prosthetics such as artificial arms or legs.
• Contracted provider: The benefit pays 80% after your $25 copayment; you pay 20%.
• Non-contracted provider: The benefit pays 50% after your $25 copayment; you pay 50%.
• To be eligible for benefits, you must have a prescription from your physician.
• This benefit is limited to a new diagnosis requiring prosthetic. Replacements of old, less technical, or lost prosthetics are not eligible for benefits.
• You must preauthorize.

Radiation therapy

• Contracted provider: The benefit pays 80%; you pay 20%.
• Non-contracted provider: The benefit pays 50%; you pay 50%.
• You must preauthorize.

Radiology services (mammograms, X-rays, CT scans, MRIs, etc.)

• The benefit pays 80% after your $25 copayment; you pay 20%.
• Routine mammograms are covered once every benefit year. For a woman with a personal or family history of breast cancer, a mammogram is covered upon the recommendation of her physician.
• You must preauthorize some services, like PET and SPECT scans.

Skilled nursing benefit

• Contracted provider: The benefit pays 80% after your $25 copayment; you pay 20%.
• Non-contracted provider: The benefit pays 50% after your $25 copayment; you pay 50%.
• You must preauthorize.
• Time in an extended-care facility must occur after an inpatient hospitalization.
• If the care is for recuperating or convalescing from an acute injury or illness, the maximum benefit is 50 days per benefit year.
• Custodial care (such as maintaining someone beyond the acute phase of injury or illness, including room, meals, bathing, and dressing) is not covered.

Substance abuse

• Contracted provider: The benefit pays 80% after your $25 copayment (for outpatient services); you pay 20%.
• Non-contracted provider: The benefit pays 50%; you pay 50%.
• Residential treatment is not covered.
• You must preauthorize.

Surgery—inpatient hospital services

• Contracted provider: The benefit pays 80%; you pay 20% after your $200 copayment.
• Non-contracted provider: The benefit pays 50%; you pay 50%.
• You must preauthorize.

Surgery—outpatient hospital services

• Contracted provider: The benefit pays 80% after your $25 copayment; you pay 20%.
• Non-contracted provider: The benefit pays 50% after your $25 copayment; you pay 50%.
• You must preauthorize.

Surgery—physician services

• Contracted provider: The benefit pays 80% after your $25 copayment; you pay 20%.
• Non-contracted provider: The benefit pays 50% after your $25 copayment; you pay 50%.
• You must preauthorize.

DMBA’s Preferred Provider Network

If you are away from Oahu while you’re enrolled in the Student Medical Benefit, you may obtain care from any qualified, appropriately licensed medical provider. However, it’s to your advantage to make sure the physicians and hospitals providing your care are part of DMBA’s Preferred Provider Network. Your benefits will be higher, and the providers will not bill you for fees that exceed the Student Medical Benefit’s maximum allowable amounts.

This network extends throughout most areas of the United States and includes physicians and hospitals that provide quality care at substantially discounted rates.

For information about contracted providers in your area, please see the following networks. (Remember, you must obtain an SHC referral by calling 808-675-3510 and preauthorize all care outside the Student Health Center by calling 808-466-4077.)

Find a Contracted Medical Provider:

Hawaii: MDX Contracted Providers
808-466-4077

Utah and Southeast Idaho: DMBA Contracted Providers
800-777-3622 or demo.dmba.com (click on Find a Provider)

All other states: UnitedHealthcare Options PPO
www.uhc.com

Remember, eligible expenses for services from contracted providers are covered at 80% while eligible expenses from non-contracted providers are covered at 50%.

Emergencies

In an emergency, you should always get the appropriate care immediately. For non-life threatening situations, you’ll pay $10 at the SHC. At an urgent care facility, you’ll pay a $25 copayment plus 20%. At a hospital emergency room, you’ll pay a $50 copayment plus 20%.

Life-threatening Emergencies

If you are faced with a life-threatening emergency, you should seek immediate medical treatment from a qualified, accessible provider. Benefits for treatment outside the SHC will apply.

Life-threatening emergencies are those in connection with a sudden and unexpected onset of a condition requiring immediate medical or surgical care to safeguard the patient’s life. This includes heart attack, severe bleeding, loss of consciousness, convulsions, or temperature of more than 104° Fahrenheit.

Other Medical Emergencies

Other medical emergencies are those that are not life-threatening, but the onset of symptoms is so sudden and severe that immediate medical or surgical treatment is required to prevent serious impairment of bodily functions.

In the case of an emergency that is not life-threatening while the SHC is open, you should obtain care from the SHC.

If such an emergency occurs when the SHC is closed, call the after-hours telephone number. If you are directed to seek care from another qualified, accessible provider, contact the SHC within two working days to coordinate care.

If you receive services in an emergency room and you are subsequently admitted to the hospital, you must call DMBA to preauthorize the admission within two business days. If you receive emergency care in a physician’s office after business hours, you must also call DMBA for preauthorization.

Follow-up to Emergency Care

For all emergencies, contact DMBA at 808-466-4077 before you receive any follow-up care. If you need to receive follow-up care outside the SHC, you must preauthorize with DMBA before you receive the care.

Submitting Claims for Payment

Most providers in Hawaii will submit your claim to DMBA directly. If you pay for services, please bring your receipts to the Hawaii DMBA office.

If you receive services outside of Hawaii, Utah, or Southeast Idaho, your provider should send claims directly to UnitedHealthcare. The address is on the back of your Student Medical Benefit ID card.

To be eligible for coverage, claims must be submitted within 12 months of the date of service.

Catastrophe Protection

If your share of eligible expense reaches a certain limit per benefit year (your annual maximum co-share), your benefits for the remainder of the benefit year are paid according to the catastrophe protection of the Student Medical Benefit, up to your $250,000 annual maximum benefit.

For individuals (students and/or dependents) enrolled in the Student Medical Benefit, after your share of eligible expenses reaches $2,000, benefits increase to 100% for eligible charges (up to $250,000), based on the Student Medical Benefit’s maximum allowable limits. You continue to be responsible for copayments and co-shares on these benefits; catastrophe protection does not apply to:

• Hospital emergency room
• Mental health—outpatient care
• Office visits
• Therapy (such as physical therapy)
• Urgent care facility

Expenses for the following services do not apply to your annual maximum co-share and are not paid for by catastrophe protection:

• Infusion therapy drugs purchased through your physician’s office
• Prescription drugs

These expenses don’t apply to your annual maximum co-share and aren’t paid for by catastrophe protection:

• Amounts that exceed the allowable limits
• Ineligible amounts
• Premium payments
• Any other expenses not covered by the Student Medical Benefit

Repatriation of Remains

If a covered accident or illness causes the death of an enrolled student while he or she is in a foreign country (that is, the student is not a citizen of the country), or if the student is a resident of the continental United States, the Student Medical Benefit will pay expenses for returning the body to the country of citizenship or the continental United States, up to a maximum benefit of $25,000. To be eligible for coverage, expenses must be approved in advance. For more information, call DMBA at 808-466-4077.

Medical Evacuation for Sponsored Visitors

In compliance with U.S. State Department requirements, BYU–Hawaii will cover up to $50,000 of expenses associated with the medical evacuation of a sponsored exchange visitor to his or her home country. For eligibility requirements and other information, please contact the office of the Vice President of Student Services & Development at 808-675-3799.

Exclusions

Services that do not meet the definitions of eligible, as previously defined, are not eligible for coverage by any coverage option. In addition, the following services and their associated costs are excluded from coverage:

Alternative care

1.1. Holistic, homeopathic, ecological, or environmental treatment.
1.2. Acupuncture.
1.3. Vertebral column rehabilitation (chiropractic care) or massage therapy.

Congenital anomalies

2.1. Ineligible unless necessary to preserve life.
2.2. Care, treatment, or operations provided outside the SHC in connection with congenital anomalies when such services are performed to restore normal body form or appearance, the conditions are not immediately life-threatening, and/or the timing is subject to the choice or decision of the patient and physician. This exclusion does not apply to care, treatment, or operations to treat congenital anomalies in children who have been enrolled since birth.

Convenience/cosmetic services

3.1. Care, treatment, supplies, or other services incurred primarily for convenience, contentment, or other non-therapeutic purposes.
3.2. Care, treatment, or operations that are performed primarily for cosmetic purposes (non-suspicious mole removal, normal or abnormal hair loss, etc.), except for expenses incurred as a result of injury suffered while enrolled in the Student Medical Benefit.
3.3. Care, treatment, diagnostic procedures, or other expenses for an abdominoplasty, breast reduction, lipectomy, panniculectomy, skin furrow removal, or diastasis rectus repair.

Custodial care

4.1. Hospice care, custodial care, education, training, or rest cures.
4.2. Inpatient hospitalization or residential treatment for the primary purpose of providing shelter and/or safe residence.

Dental care

5.1. Dental treatment, except that made necessary by accidental injury to sound natural teeth, as provided for by the Student Medical Benefit.

Diagnostic and experimental services

6.1. Care, treatment, diagnostic procedures, or operations that are:

• Considered medical research
• Investigative/experimental technology
• Not recognized by the U.S. medical profession as usual and/or common
• Determined by the Student Medical Benefit not to be usual and/or common medical practice
• Illegal

That a physician might prescribe, order, recommend, or approve services or medical equipment does not, of itself, make it an allowable expense, even though it is not specifically listed as an exclusion.

Investigative/experimental technology means treatment, procedure, facility, equipment, drug, device, or supply that does not, as determined on a case-by-case basis, meet all of the following criteria:

• The technology must have final approval from all appropriate governmental regulatory bodies, if applicable.
• The technology must be available in significant number outside the clinical trial or research setting.
• The available research about the technology must be substantial. For Student Medical Benefit purposes, substantial means sufficient to allow the Student Medical Benefit to conclude the technology is:
  
  • Both medically necessary and appropriate for the covered person’s treatment
  • Safe and efficacious
  • More likely than not will be beneficial to the covered person’s health
  • Must be generally recognized as appropriate by the regional medical community as a whole

Procedures, care, treatment, or operations falling in these categories described herein continue to be excluded until actual experience clearly defines them as non-experimental and they are specifically included in the medical benefit.

Educational programs

7.1. Educational programs (except for diabetes education) provided outside the SHC (PMS clinics, etc.).

Fertility/family planning/home delivery

8.1. Reproductive organ prostheses.
8.2. Care, treatment, or operations provided in connection with sexual dysfunction.
8.3. Abortions, except in cases of rape or incest or when the life of the mother would be seriously endangered if the fetus were carried to term.
8.4. Sterilization procedures.
8.5. Planned home delivery for childbirth and all associated costs.
8.6. Services related to the evaluation and treatment of the cause(s) of multiple miscarriages (the miscarriage itself is covered) or infertility.
8.7. All services and expenses related to a surrogate pregnancy including but not limited to care, treatment, delivery, diagnostic procedures, or operations, as well as maternity care and prenatal/postnatal care for the newborn child are excluded. All services and expenses for complications related to a surrogate pregnancy are also excluded. All services and expenses related to a pregnancy resulting in an adoption including but not limited to care, treatment, delivery, diagnostic procedures, or operations, as well as maternity care for the surrogate mother and prenatal/postnatal care for the newborn child are excluded. All services and expenses for complications related to a pregnancy resulting in adoption are also excluded.

Government/war

9.1. Services furnished by a hospital or facility owned or operated by the United States Government or any agency thereof; any charges for services, treatments, or supplies furnished by or for the United States Government or any agency thereof.
9.2. Services covered, or which could have been covered, by any governmental plans (including, but not limited to, Medicare or Medicaid).
9.3. Conditions caused by or resulting from war or act of war or service in the military forces of any country at war, declared or undeclared. War includes hostilities conducted by force or arms by one country against another country, or between countries or factions within a country, either with or without a formal declaration of war.

Hearing

10.1. The purchase or fitting of hearing devices.

Legal exclusions

11.1. Services provided before coverage begins and services after coverage ends.
11.2. Accidents sustained as a result of participation in the ROTC program, professional contests, or vehicular contests.
11.3. Care, treatment, diagnostic procedures, or any other expenses when it has been determined by the Student Medical Benefit that brain death has occurred.
11.4. Services incurred in connection with injury arising from participation in or attempt at committing an assault or felony, participation in illegal acts of violence, or services provided as a result of a court order, or for other legal proceedings.
11.5. Services for which the covered person has no legal obligation to pay.
11.6. Conditions resulting from catastrophic events defined as an earthquake, fire, terrorist attack, any other accidental occurrence or series of one event, or a group of related events within seven days or less resulting in the death or serious injury of 20 or more covered students.
11.7. Complications resulting from excluded services.
11.8. Services not specified as covered.

Medical equipment

12.1. Learning devices.
12.2. Multipurpose equipment or facilities, such as those listed in the Medical Equipment chart.
12.3. Modifications to homes, other structures, or motor vehicles to accommodate activities of daily living.

Medical necessity

13.1. Care, treatment, or operations that are not clearly a medical necessity.
13.2. Wart removal, treatment of toenails, corns, calluses, or bunions provided outside the SHC.
13.3 Special formulas, food supplements, or special diets except in cases of inborn metabolic disorders.
13.4. Cardiopulmonary fitness training or conditioning (meaning reimbursement for gym, health, or fitness club memberships or fees), either as a preventive or therapeutic measure.

Mental health/counseling/chemical dependency

14.1. Marriage and family counseling, recreational therapy, or therapy over the telephone provided outside the SHC.
14.2. Care or treatment provided outside the SHC or campus counseling center in connection with anorexia, bulimia, or other eating disorders.
14.3. Care of treatment for mental health, counseling, or substance abuse received in a residential treatment center.
14.4. Evaluation and/or treatment for autism.

Miscellaneous

15.1. Care, treatment, diagnostic procedures, equipment, or any other services for sleep disorders, chronic fatigue, or fibromyalgia provided outside the SHC.
15.2. Sex change operations and all associated procedures and services (medical, psychological, pharmaceutical, surgical, etc.).
15.3. Aviation-related accidents (including but not limited to parachuting, hang gliding, or ballooning events), other than to passengers on scheduled commercial airlines.
15.4. Services of any practitioner of the healing arts who ordinarily resides in the same household with you or your dependents, or has legal responsibility for financial support and maintenance of you or your dependents.
15.5. Injuries sustained as a result of cliff jumping/diving.
15.6. All services performed outside of DMBA’s domestic national provider network area.

Obesity

16.1. Care, treatment, or operations provided outside the SHC in connection with obesity or weight loss (including bariatric surgery).

Other insurance/workers’ compensation

17.1. Services covered or that could have been covered by applicable workers’ compensation statutes.
17.2. Services or materials covered or that could have been covered by insurance required or provided by any statute had the participant complied with the statutory requirements, including but not limited to no-fault insurance.
17.3. Services that a third party, the liability insurance of a third party, or the uninsured and/or underinsured motorist insurance pays or is obligated to pay.

Prescription drugs, specialty pharmacy medications, formulas, and supplements

18.1. Preventive medicine or vaccines, including immunizations except for children younger than 6.
18.2. Dietary products, nutritional or food supplements, and special diets except to the extent specifically provided in the plan (including any requirements regarding preauthorization).
18.3. Specialty pharmacy medications for conditions including but not limited to: hemophilia (i.e., Factor Products, Benefix); multiple sclerosis (Avonex or Copaxone); HIV/AIDS; hepatitis C (Peg-Intron); oral or self-administered chemotherapy agents (Gleevec, Procrit, or Epogen); drugs administered to treat infertility (Clomid); Crohn’s disease (Remicade); rheumatoid arthritis (Raptiva or Enbrel); growth hormone deficiencies (Humatrope or Nutropin); asthma (Xolair); diabetes (Byetta); or RSV (Synagis).
18.4. Excluded medications such as dietary or nutritional products and/or supplements (including special diets for medical problems), herbal remedies, homeopathic treatments, products used to stimulate hair growth, medications used for sexual dysfunction, medications whose use is for cosmetic purposes, over-the-counter products, vitamins, weight reduction-aids, and non-federal legend status drugs.

Routine services

19.1. Routine physical exams for adults 18 years and older.
19.2. Physical examination for the purpose of obtaining insurance, employment, government licensing (including immigration), or as needed for volunteer work unless otherwise provided for by the terms of the Student Medical Benefit.

Speech therapy

20.1. Speech therapy and evaluation.

TMJ dysfunction

21.1. Services and materials in connection with disturbances of the temporomandibular joint (TMJ).
21.2. Jaw surgery (osteotomy).

Testing

22.1. Diagnostic services that are not related to an injury or illness, unless otherwise provided for by the Student Medical Benefit.
22.2. Some allergy tests including but not limited to ALCAT testing/food intolerance testing, cytotoxic food testing (Bryan’s Test, ACT), Conjunctival Challenge Test (electro-acupuncture), Leukocyte Histamine Release Test (LHRT), Passive Transfer (PX) or Prausnitz-Kustner (PK) Test, Provocative Nasal Test, provocative food and chemical testing (intradermal, subcutaneous, or sublingual), Rebuck Skin Window Test, Rinkel Test, and skin endpoint titration.

Transplants

23.1. Care, treatment, diagnostic procedures, or operations in relation to transplants (donor or artificial).

Vision

24.1. Eyeglasses and contact lenses or the replacement or prescription thereof.
24.2. Care, treatment, diagnostic procedures, or other expenses for elective surgeries to correct vision including radial keratotomy or LASIK surgery, unless otherwise provided for by the terms of the Student Medical Benefit.

Claims Review Procedures

If you have questions, concerns, or complaints, please bring them to our attention. This includes complaints about the SHC, contracted and non-contracted physicians and facilities, administrative procedures, claims payments, or preauthorization procedures.

If you have concerns about the Student Medical Benefit, the SHC, its staff, or services you receive there, contact the SHC director at 808-675-3510 or 808-675-3487, or visit or write to 55-220 Kulanui St. #1916, Laie, HI 96762.

If you have concerns about services you received outside the SHC, please contact the DMBA Hawaii manager at 808-466-4077.

To file a complaint about claims for services received outside the SHC, or concerning administrative or preauthorization procedures, please follow these steps:

• Come to the Hawaii DMBA office to discuss your complaint
• If your complaint is not resolved, prepare a written statement explaining the nature of your complaint and request a formal review by the Student Medical Benefit committee.

Coordination of Benefits

The Student Medical Benefit adheres to appropriate coordination of benefits guidelines and regulations. Many commercial plans do not coordinate with the Student Medical Benefit and will take the primary payor position. Coordination of benefits must be determined before receiving any services outside of the SHC. If you are enrolled in another plan that provides medical coverage, it is imperative that you provide a copy of that plan’s medical coverage card (front and back), the cardholder’s name and birthdate, and the plan’s effective date to the Student Medical Benefit Office. Failure to do so may result in delayed or incorrect payment of your claims. Government sponsored plans (Quest in Hawaii) will always take the secondary payor position. For optimal coverage, you must follow the guidelines of your primary medical coverage carrier and Student Medical Benefit authorization requirements.

Domestic students who have other private medical coverage may want to opt out of the Student Medical Benefit. For more information about opting out of the Student Medical Benefit, contact the Student Medical Benefit office.

Subrogation

If you have an injury that is the liability of another party and you have the right to recover damages, DMBA, on behalf of the Student Medical Benefit, has the right of subrogation and will require reimbursement for any amount it has paid when damages are recovered from the third party. The Student Medical Benefit will be reimbursed:

• First
• From any recovery from a claim against a third party, the third party’s liability insurance carrier, or your uninsured and/or underinsured motorist insurance carrier
• Whether the recovery is obtained by settlement, judgment, or from any other source
• Regardless of how the settlement is allocated by the third party or insurance carrier

Your acceptance of benefits from the Student Medical Benefit for the injury constitutes subrogation. You must provide any information DMBA requests for subrogation purposes. If you fail to do so, you will be responsible for reimbursing all the costs and expenses paid by the Student Medical Benefit for the injury.

Notification of Benefit Changes

BYU–Hawaii reserves the right to amend or terminate the Student Medical Benefit at any time. If benefits change, we will notify you at least 30 days before the effective date of change.

For the most up-to-date listing of benefits and exclusions, refer to the Student Medical Benefit handbook website at demo.dmba.com/nsc/Student/Handbooks.aspx.

Fraud Policy Statement

It is unlawful to knowingly provide false, incomplete, or misleading facts or information with the intent of defrauding the Student Medical Benefit. An application for the Student Medical Benefit or statement of claim containing any materially false or misleading information may lead to reduction, denial, or termination of benefits or coverage from the benefit and recovery of any amounts DMBA may have paid on behalf of the Student Medical Benefit. Non-compliance or abuse of healthcare benefits or systems may also lead to reduction, denial, or termination of benefits or coverage from the benefit and recovery of any amounts DMBA may have paid on behalf of the Student Medical Benefit.

Important Dates

* To be eligible for the Student Medical Benefit during the summer break, you must have been enrolled in and attended spring semester classes for 8 or more credit hours, with at least one face-to-face class on campus. You must also be enrolled in the upcoming fall semester as a full-time student for 12 or more credit hours before the summer break coverage begins. Failure to meet BYU–Hawaii’s RSVP enrollment deadline may result in a penalty charge being posted to your financial account.

Definitions

Accident

An unpremeditated event of violent and external means that happens suddenly without intention or design; is unexpected, unusual, unforeseen; is identifiable as to time and place; and is not the result of illness.

Acute

Having rapid onset, severe symptoms, and a short course; opposite of chronic.

Allowable Limit

The maximum dollar amount the Student Medical Benefit will pay for a defined procedure.

Congenital Anomaly

A condition existing at or from birth that is a significant deviation from the common form or function of the body, whether caused by a hereditary or developmental defect or disease. “Significant deviation” means a deviation that impairs the function of the body. It includes but is not limited to cleft lip, cleft palate, webbed fingers or toes, sixth toes or fingers, or defects of metabolism and other conditions that are medically diagnosed to be congenital anomalies.

Continuing Student

A BYU–Hawaii student who is enrolled at least 3/4-time for the current semester.

Contracted Facilities

Hospitals, labs, and other healthcare facilities that have contracted with DMBA to provide services to participants.

Contracted Providers

Physicians, specialists, and other providers of healthcare services who have contracted with DMBA to provide services to participants.

Copayment

The initial dollar amount you pay for an eligible medical expense at the time services are rendered.

Custodial Care

Maintaining a patient beyond the acute phase of injury or illness. Custodial care includes room, meals, bed, or skilled medical care in any hospital or extended care facility, or at home to help the patient with feeding, bowel and bladder care, respiratory support, physical therapy, administration of medications, bathing, dressing, ambulation, and so on. The patient’s impairment, regardless of the severity, must require such support to continue for more than two weeks after establishing a pattern of this type of care.

Day Treatment Program for Mental Illness

An outpatient program that is staffed and managed by licensed, clinical professionals providing mental illness treatment for a portion of the day, typically eight hours.

Elective Surgery

Operations or surgical procedures for a condition that is not immediately life-threatening, and the timing is subject to the choice or decision of the patient and the physician.

Eligibility Date

The date you become eligible for benefits.

Eligible Charges/Expenses

Expenses incurred by you or a dependent for treatment of injury or illness and that are:

• Medically necessary for the care and treatment of the injury or illness and are incurred on the recommendation and while under the continuous care of a physician.
• Not in excess of the Student Medical Benefit’s maximum allowable limit for the services performed or the materials furnished.
• Not excluded from coverage by the terms of the Student Medical Benefit.
• Incurred for one or more of the services or materials specified in the Student Medical Benefit.
• Incurred during a period of active enrollment in the Student Medical Benefit Eligible charges incur on the date the service is performed or the purchase is made.

Emergency Care

The care required in connection with a sudden and unexpected onset of a condition requiring medical or surgical care necessary to safeguard the patient’s life immediately after the onset of the emergency. This includes heart attack, severe bleeding, loss of consciousness, convulsions, acute asthmatic attacks, or temperature of more than 104º Fahrenheit.

Extended Care Facility

An institution, or part of an institution, that is licensed pursuant to state or local law, and is operated primarily for the purpose of providing skilled nursing care and treatment for an individual convalescing from injury or illness as an inpatient.

Formulary Medications

A preferred list of medications that have been reviewed by an independent pharmacy and therapeutics committee for safety and efficacy only. Formulary medications are covered by the pharmacy benefit.

Full-time Student

An undergraduate degree-seeking student who is enrolled in and attending classes of 12 or more credit hours, with at least one face-to-face class on campus.

Good Academic Standing

Students are considered in good academic standing when their BYU–Hawaii CGPA is 2.0 or higher.

Good Ecclesiastical Standing

Students are considered in good ecclesiastical standing when they have a current ecclesiastical endorsement on file with the Honor Code Office and have no outstanding or pending Honor Code violations.

Good Financial Standing

Students are considered in good financial standing when they have no outstanding financial obligations to the university as determined by the Financial Services Office.

Illness

A bodily disorder, disease, mental or emotional infirmity, or all sickness that is a result of the same cause or a related cause.

Inpatient Hospital for Mental Illness

A general acute care hospital that has designated beds and is licensed by the state and certified by Medicare and/or Medicaid for the treatment of mental illness disorders, or a freestanding psychiatric hospital that is licensed by the state as a healthcare facility and is certified by Medicare and/or Medicaid for the treatment of mental illness.

Medical Equipment

A prosthesis, appliance, or device that is primarily and customarily used to serve a medical purpose and generally is not useful to a person in the absence of injury, illness, or congenital defect.

Medical Supplies

Medical items that are for immediate use, are disposable, and are not reusable.

Medical Treatment

Therapeutic measure(s), including consultations, undertaken by or under the direction of a physician in connection with an injury or illness.

Non-contracted Facilities

Hospitals, labs, and other healthcare facilities that have not contracted with DMBA to provide services to participants.

Physician

A person who has been educated, trained and licensed as a physician to practice the art and science of medicine pursuant to the laws and regulations in the locality where the services are rendered.

Preauthorization

A process of advance notification that is required for a number of benefits. When you preauthorize services with DMBA, you receive guidelines about what services are eligible for benefits before you commit to the costs.

Referral

Care directed outside the Student Health Center for continued medical services at the discretion of health center personnel.

Residential Treatment Center for Mental Illness

A facility that is licensed by the state to provide residential treatment of mental illness that has licensed, clinical professionals providing specific treatment for either mental illness or chemical dependency.

Surgical Center

Any licensed public or private establishment:

• With an organized medical staff of physicians.
• With permanent facilities equipped and operated primarily for the purpose of performing surgical procedures.
• With continuous physician services whenever a patient is in the facility.
• That does not provide services or other accommodations for patients to stay overnight.

Your Co-share

The percentage of eligible expenses you are responsible for paying after you make the applicable copayments and your benefits have been paid.