Berkeley Ship Waiver Request Form Worksheet, Exams of Surgical Pathology

Download Berkeley Ship Waiver Request Form Worksheet and more Exams Surgical Pathology in PDF only on Docsity! BERKELEY SHIP WAIVER REQUEST FORM WORKSHEET 2017-18 Academic Year 1 THE BERKELEY SHIP WAIVER FORM WILL REQUEST THE FOLLOWING INFORMATION NOTES 1 Select one of the following to describe your health insurance plan: Covered California Plan; Medicare; Medi-Cal; Military/TRICARE; University of California employee plan or another Employer Group Health Insurance Plan ? (Select "Other" if your plan is not one of these.) 2 Provide your name, student ID number issued by your campus, current address, email address and phone number. 3 Provide the name, address and phone number of your health insurance plan. You will also be asked to provide your insurance plan member subscriber identification number or your medical record number, if you have Kaiser. This information is printed on your insurance ID card. The Waiver Form will have a drop-down menu with a list of insurance companies from which to select. If you select "Other," you will be asked to provide the name, address and phone number of your health insurance company. 4 What is the name of the Primary Enrollee or Subscriber on your health plan? 5 Does your health insurance plan provide unrestricted access to an in-network primary care provider and hospital providing full non-emergency medical and behavioral health care within 50 miles of campus or the student's place of residence while attending school for the entire SHIP term? (Plans with an assigned PCP must have one assigned within 50 miles of campus or the student's place of residence while attending school prior to the start of the semester- January 9, 2018.) (YES or NO) PERSONAL AND HEALTH PLAN INFORMATION IMPORTANT POP-UP Alert: Disable your POP-UP Blocker when you enter the online Waiver Form to receive important pop-up options. DEAR STUDENT: Complete the waiver form easily and quickly by preparing your answers ahead of time. This worksheet can help you gather needed insurance information BEFORE you start the online Waiver Form. You may not be required to answer all these questions, depending on your health plan type. Have your health plan booklet, benefits summary, or contract/policy handy to answer the questions listed below. Call the customer service number listed on your insurance card; or check online health plan information to find the details of your plan if you have questions. NOTE: Insurance terminology in bold italics is defined in the GLOSSARY of Medical Insurance Terminology. YOUR HEALTH INSURANCE PLAN ANSWERS FROM PLAN BOOKLET, SUMMARY OF BENEFITS, OR CONTRACT/POLICY This is just a guide to help you get the answers for your waiver. Actual waivers must be submitted using the online form and submitted by January 1, 2018. The final deadline is January 15 with a $75 late fee. The questions may be worded slightly differently on the waiver application itself. BERKELEY SHIP WAIVER REQUEST FORM WORKSHEET 2017-18 Academic Year 2 THE BERKELEY SHIP WAIVER FORM WILL REQUEST THE FOLLOWING INFORMATION NOTES 6 Please indicate the type of health insurance plan you have: (select one) 7 Does your health insurance plan have unlimited annual and lifetime in-network benefits? 8 Does your health insurance plan cover inpatient and outpatient hospital services for medical and surgical care? 9 Does your health insurance plan cover hospital stays for mental health care and substance abuse disorder conditions the same as any other medical condition? 10 Does your health insurance plan cover office visits for medical, including mental health and substance abuse conditions? 11 Does your health plan provide coverage for emergency room services and emergency transport/ambulance services? 12 Does your health plan cover medications prescribed by a doctor? 13 If your Annual Out-of-Pocket Maximum limit is more than $7,350 (or more than $14,700 for a family), do you have a Health Savings Account (HSA) or Health Reimbusement Account (HRA) funded sufficiently to reduce the total out-of- pocket expenses to $7,350 for an individual, or $14,700 for a family, or less? 14 Is your health plan based on reimbursement of your expenses paid at the time of service for medical care? Under this type of plan, you pay for medical and behavioral health services out of your own pocket and obtain reimbursement afterwards from your home government or from another party. 15 Is your health plan based on reimbursement of your expenses paid at the time of service for prescription drugs? Under this type of plan, you pay for pharmacy services out of your own pocket and obtain reimbursement afterwards from your home government or from another party. 16 Does your health insurance company have a complete master policy written in Standard English with benefits expressed in U.S. dollars? 17 Does your medical insurance plan have a claims payment office with an address and phone number in the United States? 18 Does your health insurance plan have a maximum benefit limit per-medical or per mental health/substance use disorder-condition per year? 19 Does your health plan cover services related to suicidal conditions, including attempted suicide or suicidal thoughts? 20 Does your health insurance plan have a Pre-existing Condition Exclusion or waiting period (or limitation) ? IF YOU ARE AN INTERNATIONAL STUDENT, YOU WILL BE ASKED TO ANSWER THESE ADDITIONAL QUESTIONS (YES or NO) (YES or NO) (YES or NO) (YES or NO) (YES or NO) (YES or NO) HMO (Health Maintenance Organization) EPO (Exclusive Provider Organization) PPO (preferred provider organization) POS (Point-of-Service) I don't know (YES or NO) (YES or NO) ANSWERS FROM PLAN BOOKLET, SUMMARY OF BENEFITS, OR CONTRACT/POLICY (YES or NO) QUESTIONS ABOUT YOUR HEALTH PLAN BENEFITS (YES or NO) (YES or NO) (YES or NO) (YES or NO) NOTE: The Exclusions and Limitations section(s) in your health plan booklet or contract/policy may contain information requested in the questions below. (YES or NO)