Dartmouth Student Group Health Plan Summary Brochure

Dartmouth Student Group

Health Plan

(DSGHP)

Summary Brochure

2023

2024

Important Health Resources at

Dartmouth College

______________________________

Dartmouth Health Service

dartgo.org/healthservice

______________________________

Dartmouth Counseling Services

dartgo.org/chd

______________________________

Dick Hall’s House Pharmacy

dartgo.org/dickshousepharmacy

______________________________

Photo: Je Woodward

For full details of the DSGHP, or the Dartmouth College

annual waiver process, please visit our website:

dartgo.org/studennsurance

Dartmouth College Insurance Requirement

By College policy, all students (Undergraduate, Graduate, and Professional) including those on leave

or not taking classes, on or o campus, are automacally enrolled in the DSGHP and charged the

premium each year unless a waiver is submied and approved. This premium charge will appear on

the student’s tuion account.

*Exchange students will be enrolled and charged for the terms they aend Dartmouth, unless a waiver is submied and approved.

J1 Visa holding students are not permied to waive the DSGHP coverage.

Why Choose the DSGHP?

• DSGHP is primary over all other plans for students.

• Lower deducbles, copayments, out-of-pocket maximums, and

premiums as compared to the lower cost opons oered

through the Exchanges/Marketplaces.

• Unlimited lifeme maximum.

• Worldwide coverage for care including medical evacuaon and

repatriaon.

• Complies with a general provision of the Paent Protecon and

Aordable Care Act (PPACA).

• Emergency medical assistance through ISOS while traveling

abroad.

• Dental Savings program through Basix.

• Prescripon drug benets for the campus pharmacy and

naonwide parcipang pharmacies.

• Oponal addional coverage for a student’s spouse, domesc

partner, and/or children.

• In most cases, Financial Aid and loans can be used to pay for

part or all of the DSGHP premium.

• Coverage for injuries sustained in NCAA sanconed and club

sports.

• The DSGHP is purchased through Dartmouth College at

preferred pricing. Though there is no premium tax credit

(subsidy) available, there are also no tax implicaons.

• On-campus assistance for eligibility, claim submission, and

coverage details.

Dental Savings Program

The cost of dental care is a major concern to nearly everyone! The

DSGHP has incorporated the Basix Dental Savings Program. As part

of your membership in the DSGHP, you automacally have access to

the Basix Dental Savings Program. Basix contracts with densts

who agree to charge a reduced fee to individuals enrolled in the

DSGHP. You must pay the dental fees at the me of service to

receive the negoated rates.

It is important to understand that the Dental Savings Program is not

a dental insurance. Because it is a discount program and not an

insurance, there are no lifeme maximums, exclusions, or claim

forms to ll out.

Savings vary depending upon the type of service received and the

contracted denst providing the service, but can be as high as 50%!

Full details of the program can be viewed at:

hp://www.basixstudent.com

Are You Parcipang in Sports?

Students parcipang in athlecs should note the College provides

separate catastrophic insurance coverage with unlimited coverage

for injuries sustained in a sanconed intercollegiate or club sport,

pracce or game, for expenses incurred within two years of injury.

The policy has a $90,000 deducble for intercollegiate and $30,000

deducble for club sport injuries, which the DSGHP will process as

any other medical condion. This coverage is subject to DSGHP

deducbles, co-insurance, and out-of-pocket maximums.

Are You Traveling or Studying Abroad?

The DSGHP covers you during breaks, vacaons, traveling, or

studying abroad.

• When outside of the United States, you will likely be asked to

pay for your medical care rst and will then need to seek

reimbursement. Covered expenses will be reimbursed at the

out-of-network level.

As an added benet the College provides a comprehensive program

that provides emergency medical assistance with Internaonal SOS

(ISOS). Services range from consultaon by telephone, medical

referrals, and legal aide, to full-scale evacuaon by private air

ambulance. The ISOS network of 5,000 employees, including

mullingual crical care and aero-medical specialists, operate 24

hours a day, 365 days a year from over 26 ISOS Alarm Call-In

Centers around the world. Contact informaon may be found at:

hp://www.internaonalsos.com &

hp://www.dartmouth.edu/~rmi/rmstravel/.

Please note: ISOS guarantees medical payment but expects reimbursement

from your insurer.

Thinking of Waiving DSGHP Coverage? Before You Do,

Consider the Following

Before assuming that you are covered adequately by another policy,

evaluate its eligibility rules and levels of coverage in the Hanover,

NH area.

• Will your current plan cover medical care beyond emergency

services (i.e. doctor’s oce visits, x-rays, prescripon drugs,

mental health, etc.) on and o campus?

• Does your plan cover you if you are studying abroad?

• Does your plan have doctors and hospitals near campus?

• Check the cost. Is the annual cost of the DSGHP less expensive

than the cost of your plan? Be sure to compare deducbles

and total out-of-pocket costs, not just the annual premium.

• Are there administrave pre-requirements, pre-cercaon, or

Primary Care Physician referrals required under your current

plan that may delay receipt of care?

You can also use the following tools provided on our website, to

help you decide:

• Summary of Benets and Coverage (SBC)

• Glossary of Health Coverage and Medical Terms

www.dartgo.org/studennsurance

2023-2024 Dartmouth Student Group Health Plan Benet Chart

Deducbles & Out-of-Pocket Maximums In-Network Out-of-Network

Medical Deducble

$100 Individual

$200 Family

$500 Individual

$1,000 Family

Prescripon Deducble

(Does not apply to Dick Hall’s House Pharmacy, Dartmouth-Hitchcock Pharmacy, Dartmouth-

$100 Individual / $200 Family

Medical and Prescripon Out-of-Pocket Maximum

$2,500 Individual

$5,000 Family

$6,000 Individual

$10,000 Family

(of usual and customary charges)

Benet Descripon In-Network Out-of-Network

Prevenve Care Services

(If in Hanover, NH area: Services received at Dartmouth College Health Service, or with referral if

services are not available at Dartmouth College Health Service. If no referral is obtained, services will

automacally fall under Out-of-Network)

100% Not Covered

Services at Dartmouth College Health Service

100% N/A

Emergency Room Services

100% aer $100 co-payment

Ambulance (Emergency Ground) 100% aer $100 co-payment

Outpaent Mental/Nervous, Outpaent Substance Abuse

Treatment & Outpaent Biologically Based Mental Health Care

Services

(Includes telemedicine)

90%; no deducble

80% of usual and

customary charges; no

deducble

Inpaent Mental/Nervous and Substance Abuse Treatment

90% aer deducble

70% of Usual and

Customary charges aer

deducble

In & Outpaent Services for Physician Expenses

(Includes oce visits, telemedicine, hospital visits, surgery, diagnosc, X-rays, and laboratory tests.)

Inpaent Hospital Services

Home Health Care Services

Vision/Eyecare

(One roune vision/eye exam every twelve (12) months)

100% Not Covered

Vision/Eyecare - Correcve Lens Hardware

$110 Allowance

(No coverage aer allowance)

$110 Allowance

(No coverage aer allowance)

Dick Hall’s House Pharmacy, Dartmouth-Hitchcock Pharmacy,

Dartmouth-Hitchcock Pharmacy at Centerra & Cheshire Medical

Center Pharmacy

(Not subject to prescripon plan year deducble. $10 Generic drug copayment per 30-day

prescripon, $20 preferred brand name drug copayment per thirty (30) day prescripon, $50

non-preferred and/or specialty drug copayment per thirty (30) day prescripon, 100% coverage for

generic contracepon medicaon and medically necessary brand name and/or specialty

contracepon medicaon. If receiving a ninety (90) day supply, there will be a $20 copayment for

generic drugs, a $40 copayment for preferred brand name drugs, and a $100 copayment for

N/A N/A

All Other Pharmacies

80% Express Scripts parcipang

pharmacies aer deducble,

100% coverage (not subject to pre-

scripon plan year deducble) for

generic contracepon medicaon and

medically necessary brand name

80% of usual and

customary charges aer

deducble

Dispensing Limits: The amount of drug which may be dispensed per prescripon or rell (regardless of dosage form) is limited to a 90

The DSGHP Assistance Group

Claims Administrator/Health Care Management

Program

Welleet

P.O. Box 15369

Springeld, MA 01115-5369

Phone: 833-443-5338

Website: Welleetstudent.com

Email: customerservice@weleensurance.com

Pharmacy Network

Welleet Rx

Phone: 888-265-7884

Email: pharmacy@welleensurance.com

Network

Cigna OAP

PO Box 188061

Chaanooga, TN 37422-8061

Website: www.cigna.com

Confidentiality

DSGHP and Dartmouth College Health Service are commied to protecng your privacy. In accordance with the Health Insurance Portability and

Accountability Act (HIPAA), medical informaon is gathered solely for the purpose of fullling our obligaons to you under the terms of your policy. This

informaon is kept private and condenal. We do not share or distribute this informaon unless required to do so under the law; or to facilitate or

coordinate medical treatment for you, in which case informaon would be shared on a strict “need to know” basis.

This brochure does not constute a promise of benets on behalf of Dartmouth College, and is intended to provide an overview of the plan benets. A

complete descripon of benets, limitaons, exclusions, and special provisions is provided in the Plan Document which is posted on the Dartmouth

Student Group Health Plan website located at:

dartgo.org/studennsurance

MLM 031422

Dartmouth College Health Service

5-7 Rope Ferry Road

(603) 646-9400

dartgo.org/healthservice

Dick Hall’s House Pharmacy

5-7 Rope Ferry Road

(603) 646-9456

dartgo.org/dickshousepharmacy

Dartmouth Counseling Services

5-7 Rope Ferry Road

(603) 646-9442

dartgo.org/chd

Health Care Locaons on Campus

Benets for Services from Dartmouth Health Service

For services received from Dartmouth College Health Service, the DSGHP pays 100 percent of Covered Expenses/Services and the plan year deducble does not apply.

These services are for covered immunizaons, inpaent services, and clinic & physical exam visits.

~ General Assistance ~

The DSGHP Oce is available remotely only. Give us a call at 603-646-9438 or 603-646-9449, or send us an email at Dartmouth.Student.Health.Pla[email protected]. We

assist with claim submission, enrollments, terminaons, proof of coverage and general coverage quesons.

Office Hours: 8:00 a.m.—4:00 p.m.

(Limited availability during the lunch hour)