INTERNATIONAL STUDENT HEALTH INSURANCE NACEL OPEN DOOR

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1 INTERNATIONAL STUDENT HEALTH INSURANCE Students currently on program in the United States are covered by multiple insurance plans. Most Nacel Open Door (NOD) students are covered by Mutuaide Insurance. However, students from certain countries arrive with alternate insurance coverage. Each student has been provided an insurance card, which lists the appropriate information. Information listed in this document is for Mutuaide Insurance only. Please check your student s card to verify the insurance carrier and make sure you follow the proper procedures for handling claims. Insurance Company Name: Mutuaide Group Policy Number: 3924 OR 3926 (French students only) (Students do not have an individual group number.) CONTACT INFORMATION: For questions or concerns, please contact: option 1 DIRECT PHONE: (9:00am 4:00pm CST, M-Fr) FAX: Please remit claim forms & other correspondence to: Nacel Open Door ATTN: Student Health Insurance th Street East, Suite 1900 St. Paul, MN IMPORTANT: Host families are advised to list Nacel Open Door as the guarantor or responsible party on any medical forms submitted during a visit to a doctor s office, clinic, hospital, or emergency room. Equally, they should give NOD s billing address, telephone, and fax numbers to the medical provider. Families are encouraged to bring along the Authorization for the Release of Protected Health Information signed by the natural parents, (part of the student dossier), and student ID card, as proof of their relationship with the student and NOD. Whenever possible, host families should register their student with medical provider(s) prior to the occurrence of an illness or accident, so that there is adequate time to validate insurance coverage in their system. POLICY DESCRIPTION Nacel Open Door s insurance policy for its students is an Accident and Emergency Illness Policy. All medical visits need to be pre-authorized before the time of the visit. Please contact for pre-authorization. This number is available 24 hours a day. At the time of the call, you will be given a file number. If you have questions, or are unable to contact the assistance number, please contact Nacel Open Door during business hours at , option 1. Any visit without pre-authorization will not be covered by insurance. *Note that the prerecorded message will be in French. Wait for the live person and request to speak in English. Guaranteed Accidents are covered by this policy. These include accidents that occur during the life of the students policy (while they are on our program). Examples of Guaranteed Accidents include hurting a knee while playing sports, slamming a finger in a door, getting burned while helping in the kitchen, etc. Emergency Illness means illness that occurs during the life of the students policy. For example, the student develops a headache or cough that won t go away, has the flu, or as the insurance certificate describes it, [has] Any deterioration in health recorded by a qualified medical authority. Dental Coverage The dental coverage for urgent needs (e.g. toothache that doesn t allow the student to eat) is limited, unless the dental care is the result of a guaranteed accident. Please refer to the policy for coverage limits. Prescriptions Prescription drugs are covered, if prescribed for a covered injury or accident, and only if the student has been seen by a physician. Mutuaide does not offer online billing for prescriptions, so prescriptions must be paid for by the

2 student. For prescription claim reimbursement, save the original PHARMACY PRESCRIPTION receipt (usually stapled to the bag or attached to the medication information) showing the student s name and address, doctor s name, NDC code, price, prescription description, and date. This original pharmacy receipt (Fig. 1) must be sent with a completed claim form to the NOD national office for reimbursement. Proof of PAYMENT receipts (credit card slips, cash register receipts) are also required in addition to the Pharmacy Prescription receipt. EXAMPLES OF HEALTH ISSUES NOT COVERED BY THE POLICY Periodic medical examinations (physicals, annual exams, etc.). If needed, these are the responsibility of the student. Immunizations, vaccinations, and tests required by school, should the student need them for registration or sports participation (these are the student s responsibility and are not covered by the insurance policy). Routine dental check-ups, cleanings, and any procedures that are not emergencies, or the direct result of a Guaranteed Accident (dental prosthesis and comparable items are also excluded from emergency dental care). Any non-emergency related to the eye (e.g., eye exams, glasses/contact replacement, etc.). Any non-emergency related to the ear (auditory prosthesis, hearing, etc.). Psychological illnesses (eating disorders, therapy, depression, stress-related illness, etc.). Anything related to the back (chiropractor, backaches, etc.) that is not the direct result of an accident. Prior conditions (anything relating to an accident/illness that occurred prior to the student s arrival). Physical Therapy *For a comprehensive list of the exclusions of coverage please consult the Insurance Certificate. SUBMITTING A CLAIM (FOR STUDENTS ON MUTUAIDE INSURANCE ONLY) Student needs medical assistance Student/host family calls insurance to get file number before going to the doctor, clinic, urgent care, or hospital Student gives Mutuaide insurance card from Nacel Open Door (NOD) as evidence of insurance Student requests copy of their medical records Service provider sends insurance claim (bill) directly to NOD Student/host family sends Insurance Claim Form, student medical records, and any additional documents to NOD NOD Receives forms, reviews, and submits them to Mutuaide for claims-processing NOTE: Some service providers/doctors do not send the bill directly to NOD, but rather to the host family. In these cases, the host family should immediately forward the bill to NOD for processing. It is also possible that the provider will not recognize our insurance. The family or student will be marked as having no insurance and will be written as the guarantor. The host family should request that a HCFA 1500, UB-04 or UB-92 be sent to them, and then forward to NOD. The student claim form is only necessary if host family or student paid for the visit or the prescription.

3 STEP-BY-STEP INSURANCE DIRECTIONS GENERAL INFORMATION FOR ALL MEDICAL AND DENTAL VISITS: Call Mutuaide to obtain pre-authorization and a file number. o You will need to provide information about the student in order to open a case, such as the student s name (not an American nickname), date of birth, name and contact information for the medical care facility, details about the injury/illness, etc. o The pre-recorded message will be in French. Wait until the end of the message for the live person. Request to speak English. o After pre-authorization has been acquired and a case number has been assigned to the student, the insurance company will set up direct billing with the medical care provider. In this case, bills may go directly to the insurance company, bypassing Nacel Open Door. For Doctor/Dentist appointments: Bring the following any time a student needs medical/dental care: -Student insurance envelope (insurance card, insurance policy, insurance information) -Host Family Agreement (shows relationship between student, host family, and Nacel Open Door) -Authorization for the Release of Protected Health Information Form (back of Student Application) Note: There are no co-pays required for any medical visits under this policy. Nacel Open Door insurance contact: , option 1 OR direct line: When contacting NOD about insurance issues, please be prepared to provide the following information: Name of student (not American nickname) Student ID Date and time of the medical appointment (non-emergency) or the nature of medical emergency Name and telephone number of the medical care provider Prescriptions If a student receives a prescription, it will need to be paid for out of pocket. A claim form needs to be filled out and mailed to NOD along with the original pharmacy prescription receipts (the ones that are stapled to the bag or information sheet when you pick up the prescription) in order to receive reimbursement. SCENARIOS Non-emergency illness or injury (e.g. cold, flu, sinus infection, bronchitis, stomach pain, pulled muscle, etc.): 1. Wait a few days to see if the condition improves. 2. If there are no signs of improvement, call Mutuaide to open a case, and schedule an appointment with a doctor. If you cannot get an appointment at a clinic, you may go to an urgent care (NOT an emergency room). The hospital or emergency room should only be used for true emergencies. 3. Go to the appointment (be sure to bring all necessary documents, as listed in General Information ). List Nacel Open Door as the guarantor or responsible party on any medical forms submitted. NOD does not advise host families to list themselves as the guarantor. 4. The medical care provider will submit a special insurance claim form (CMS-1500, UB-04, or UB-92) to Nacel Open Door for processing.

4 Emergency illness or injury (e.g. broken bone, deep laceration, severe stomach pain, etc.): 1. Call Mutuaide to open a case, and go to an urgent care, emergency room, or to any physician that is able to provide appropriate medical care. Be sure to bring all necessary documents. 2. Contact Nacel Open Door as soon as possible afterwards to report the visit. ( , option 1.) 3. After receiving billing and insurance information, the medical care provider will submit an insurance claim form to Nacel Open Door or Mutuaide for processing. Hospitalization or surgery: 1. Please notify Nacel Open Door of any hospitalization and surgery cases so our insurance staff can monitor the claims process. 2. Elective or optional surgeries are not covered by Mutuaide insurance. Dental (e.g. cavity, tooth infection, broken filling): If a student has a toothache that is causing considerable pain and discomfort, call Mutuaide to open a case, and make an appointment with a dentist. Go to the appointment (be sure to bring all necessary documents, as listed in General Information ). List Nacel Open Door as the guarantor or responsible party on any medical forms submitted during a visit to a doctor s/dentist s office, clinic, hospital, or emergency room. The dental care clinic will submit a special insurance claim to Nacel Open Door for processing. Maximum coverage of dental care is 300 Euro, unless it is the result of a guaranteed accident. **Please note: General exam and cleaning, as well as any type of cosmetic or restoration dentistry, unless the dental care is a result of a guaranteed accident (see the definitions section of the insurance certificate), are not covered under this insurance policy. NOTES AND OTHER INFORMATION If a student, for any reason, paid out of pocket for a medical bill, a claim form must be submitted to Nacel Open Door, along with all receipts and statements from the medical care facility. o Claim forms and other insurance information can be accessed at: No referrals are needed to see a specialist. Over-the-counter medications are not covered by this insurance policy. Medical equipment (e.g. brace, boot, crutches) may or may not be covered by this insurance policy. MRI and CAT scans may or may not be covered by this insurance policy. Physical Therapy and Chiropractic care are not covered by this insurance policy.

5 MUTUAIDE INSURANCE FAQs Do I need to call insurance for every medical visit? Even just to the dentist or eye doctor? YES. All medical visits need to be pre-authorized before the time of the visit. You must contact for pre-authorization. This number is available 24 hours a day. At the time of the call, you will be given a file number. If you have questions, or are unable to contact the assistance number, please contact Nacel Open Door during business hours at , option 1. Any visit without pre-authorization will not be covered by insurance. *Note that the prerecorded message will be in French. Wait for the live person and request to speak in English. Are routine or sports physicals covered? No, they are not covered. Student insurance only covers sudden illness and accidents/injuries. Students must pay for any physical examinations on the date of service. We do not recommend that host parents pay for the service, or sign as guarantor for payment. Students often need immunizations before starting school. If a student has not received all required vaccinations and immunizations, would the student be covered by the insurance policy? No, student insurance does not cover immunizations. We inform students about the immunizations most schools require; however, we cannot predict the requirements of every school. If a student has not received the immunizations their school requires, it is the student s responsibility to cover the cost associated with obtaining them. If a student is ill, should I take the student to a family doctor or the emergency room? If a student s condition is not life threatening, we suggest bringing the student to a family doctor or clinic. If this is not an option, then an urgent care facility should be considered. The emergency room should only be utilized for critical conditions. When I take a student to the doctor, how should we handle payment of the bill? The student must present their insurance card, which has the billing address on the back. We prefer to have the medical facility bill Nacel Open Door directly by sending an insurance claim form to the address on the insurance card. Some medical facilities do not recognize the insurance and will demand pre-payment. If you or the student pays for medical treatment and/or prescription medications, please complete the Nacel Open Door claim form and mail it to the address on the form. Where do I find a Nacel Open Door claim form? A claim form is included in the Host Family Handbook and in the insurance info packet. Students also have a copy of the claim form in their Student Handbook and the insurance packet mailed to them. Copies of the form can be made for future use. If you cannot locate a claim form, please visit the document center on our website at Are prescriptions covered? Prescriptions might be covered, but only if they were prescribed by a licensed physician from whom we receive a corresponding insurance claim. Over-the-counter medications, such as aspirin, cold medicine, etc., are not covered. Prescriptions for pre-existing conditions or psychological medications are not covered. What should I do if a student needs dental attention or eye care? The insurance certificate states that routine eye care and routine dental care are not covered. If a student needs dental care (e.g. sudden toothache,) that exceeds the maximum coverage amount on the insurance certificate, the student is responsible for the additional cost. If a student needs eye care (unless it is the result of illness or a covered accident), the student is responsible for the cost of the eye care. *Dental work, eye care, and back problems are only considered if they are the result of illness or a covered accident. What are some things NOT COVERED by the illness and accident insurance policy? Some examples of other perils NOT COVERED include: mental health care, plastic surgery for cosmetic purposes, back pain (unless the result of a covered accident), chiropractic care, physical therapy, medical care or prescriptions for pre-existing conditions (allergies, acne, etc.). The insurance company reserves the right to determine whether or not any claim is covered at the time it is reviewed. The insurance company reserves the right to determine whether or not any claim is covered at the time it is reviewed. If you have any remaining questions, please feel free to call your coordinator/local representative or the national office ( ) for clarification.

6 MEDICAL/DENTAL INSURANCE CLAIM FORM TO BE FILLED OUT BY MEDICAL PROVIDER AT THE TIME OF VISIT: File #: (from pre-authorization phone call) Policy # (Refer to card): # Nacel Open Door Student ID Number: OR #3926 French Students (from Insurance Card) Name of Student: Name of Host Family: Street Address: City: State & Zip: Address: Phone number Home Cell Work Facility Information: Hospital ER Physician/Medical Clinic Dental Office Hospital Stay Name of Facility: Name of Provider: Street Address: City: State & Zip: Phone Number: Reason for Claim: Illness Accident Dental Date of Injury/Accident or Onset of Illness: Short description of injury, accident, or illness: *ANY CLAIM SUBMITTED WITHOUT PRE-AUTHORIZATION AND FILE NUMBER WILL NOT BE COVERED. PROVIDERS: To expedite claim payment, please complete this form and attach medical records, progress notes, or any supporting documentation along with one of the following paper forms: 1500 Health Insurance Claim; UB-04/UB-92; or ADA Claim. Mail invoice and completed claim form to: Nacel Open Door, Inc Attn: Student Insurance th Street East, Suite 1900 St. Paul, MN P: x608 F: All preventative services excluded from coverage and should be paid at the time of service (i.e. physicals, immunizations, dental cleanings, exams, etc.).

7 MEDICAL/DENTAL REIMBURSEMENT FORM To be used for upfront out-of-pocket expenses incurred by student or host family. File #: (from pre-authorization phone call) Policy # (Refer to card): # Nacel Open Door Student ID Number: OR #3926 French Students (from Insurance Card) Personal Accident Illness Last Name: First Name: Date of Birth (MM/DD/YYYY): Home Country: Area Code & Phone No. of Host Family: Host Family Name and Address: PERSONAL ACCIDENT Type of injury: ILLNESS Diagnosis of illness: Date of occurrence: Date symptoms first noticed: Have you previously suffered from the same illness or injury? YES NO Date of service rendered: If injury Describe how and where the injury occurred: If illness- Describe onset symptoms: Name of Medical Facility including address: Name of Doctor consulted: To be completed by the person who incurred the out-of-pocket expense: Dental paper ADA claim form and copy of Dentists progress notes must be included for reimbursement. Pharmacy original labels and receipts stapled to bag with price of medication and NDC code. EXPLANATION OF COSTS: Payment to dental or medical provider receipt(s) MUST be attached for reimbursement. TYPE OF COST INCURRED (medicine, doctor, hospital, clinic, etc.) AMOUNT OF CLAIM REFUND PAYABLE TO: Total *ANY CLAIM SUBMITTED WITHOUT PRE-AUTHORIZATION AND FILE NUMBER WILL NOT BE COVERED. CLAIM FORM MUST BE COMPLETED IN FULL To make a claim, please return this form to: Nacel Open Door, Inc. Attn: Student Health Insurance th Street East, Suite 1900 St. Paul, MN 55101

8 ASSISTANCE PROCESS In case of Illness, Accident, or Injury: BEFORE THE FIRST CONSULTATION CONTACT MUTUAIDE ASSISTANCE (Available 24/7/365) Policy Number (refer to card): 3924 Nacel Open Door 3926 French students CALL: **Any visit without pre-authorization will not be covered by insurance. Note that the prerecorded message will be in French. Wait for the live person and request to speak in English. MUTUAIDE ASSISTANCE File Number Will Be Given MEDICAL PROVIDER WILL FILE CLAIMS WITH MUTUAIDE PAYS COSTS IN ADVANCE: Only in certified establishments by Mutuaide Assistance MUTUAIDE REFUNDS COSTS AFTER: Nacel Open Door sends provider receipts.