Graduate Assistant Health Insurance Plan Highlights

Eligibility Criteria for enrollment into the Graduate Assistant Health Insurance: • Work at least 10 hours per week for a full academic semester (.25 FTE) in a Graduate Assistant position. • Be a full-time graduate student enrolled in at least 9 graded credits from NMSU • Be in good academic standing

Enrollment Deadlines: Coverage Period Regular Enrollment Late Enrollment Fall or Academic Year August 31st September 15th Spring/Summer January 31st February 15th
Once coverage is elected, it cannot be cancelled unless the Graduate Assistantship is terminated.

Coverage Dates: Coverage Period Start Date End Date Fall August 16th January 15th Spring/Summer January 16th August 15th Academic Year August 16th August 15th

Summary of Medical Expense Benefits: (please refer to the Student Injury and Sickness Insurance Plan booklet for details and maximum benefits paid for each service)

• No Overall Maximum Dollar Limit per insured person per plan year • $50 Deductible for each injury or sickness, per insured person for in-network services • $150 Deductible for each injury or sickness, per insured person for out-of-network services • Out of Pocket Maximum Preferred Provider $6,350 per insured person per policy year ($12,700 for all insureds in a Family per policy year) • The Campus Health Center (CHC) is a preferred provider for out-patient services. Deductibles are excluded at CHC.

New Mexico State University Campus Health Center is located on the corner of Breland Drive and Stewart Street on campus, just south of Zuhl Library. The facility is open for outpatient health care services Monday-Friday from 7:30 am - 4:30 pm. You may contact the CHC at 575-646-1512 during normal business hours or you can visit their website at http://wellness.nmsu.edu/shc/index.html

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The benefits payable are as defined in and subject to all provisions of the policy and any endorsements thereto. Benefits are calculated on a Policy Year basis unless otherwise specifically stated. When benefit limits apply, benefits will be paid up to the maximum benefit for each service as scheduled below. All benefit maximums are combined Preferred Provider and Out-of-Network unless otherwise specifically stated.

PA = Preferred Allowance U&C = Usual & Customary Charges
|Service |Preferred Provider |Out of Network Provider |
|In-Patient | | |
|Hospital Expense |90% of PA |60% of U&C |
|Routine Newborn Care, Psychotherapy |Paid as any other Sickness |Paid as any other Sickness |
|Surgeon’s Fees, Registered Nurse Services, |90% of PA |60% of U&C |
|Physician Visits, Pre-admission Testing | | |
|Anesthetist |25% of Surgery Allowance |25% of Surgery Allowance |
|Out-Patient | | |
|Surgeons Fees, Day Surgery Miscellaneous, |90% of PA |60% of U&C |
|Anesthetist |90% of PA |60% of U&C |
|Physician Visits, Physiotherapy, Diagnostic X-rays|90% of PA |60% of U&C |
|& Labs, Tests & Procedures, Chemotherapy & | | |
|Radiation Therapy | | |
|Medical Emergency Expenses – |90% of PA |90% of U&C |
|$100 co-pay per visit | | |
|Prescription Drugs |Campus Health Center 80% of PA or |No Benefits |
| |UHC Network Pharmacy | |
| |$10 Copay Tier 1 | |
| |$20 Copay Tier 2 | |
| |Up to 31-day supply per prescription | |
|Other | | |
|Ambulance, Dental Treatment |90% of U&C |90% of U&C |
|Maternity & Complications of Pregnancy |Paid as any other Sickness |Paid as any other Sickness |
|Mental Illness/Substance Abuse |Paid as any other Sickness |Paid as any other Sickness |