Washington Square Students

Manhattan
726 Broadway, 2nd, 3rd, and 4th Floors
New York, NY 10003
(212) 443-1000

Brooklyn
6 MetroTech Center, ROG-B020
Brooklyn, NY 11201
(646) 997-3456

Your privacy is our priority. The Student Health Center (SHC) is legally and ethically obligated to protect the privacy of a student’s health information.

Treatment of student health information is governed by the Family Educational Rights and Privacy Act (FERPA) and the requirements of applicable New York State law. The SHC will only disclose this information in limited circumstances in accordance with applicable law.

The SHC will not release medical information to anyone, including family, parents/legal guardians, NYU faculty/staff, or outside agencies, without the written authorization of the student, except in emergency situations or to comply with a subpoena or judicial order. In the case of a minor, the authorization of a parent or legal guardian is required to release medical records. In a medical emergency, only relevant health information will be released to another healthcare provider.

The underwriter and administrator of the NYU-sponsored student health insurance plans also handle student health information in connection with the operation of those plans. Treatment of such information is governed by the Health Insurance Portability and Accountability Act (HIPAA) and the requirements of applicable New York State law.

The Affordable Care Act (ACA) was enacted to increase the availability of health insurance coverage to more Americans. There are a multitude of medical coverage requirements and it is important for you to know that the NYU sponsored student health insurance plans are fully ACA compliant.

Here’s additional information about the ACA to assist you in making coverage decisions:

Students are eligible to remain on a parent’s plan until age 26. However, you should compare the cost and benefits of coverage under a parent’s plan to those of the NYU plans.

Employer plans held by you or your parents may be local HMO’s that are not appropriate for a student attending school out of state.

The ACA created health insurance marketplaces for individuals to obtain coverage. However, you should carefully review the terms of the coverage to compare with any other alternatives including in terms of: Deductibles, Copayments, Coinsurance, and limited provider networks. If you are interested in exploring this option, the web site is www.healthcare.gov. You will be directed to the appropriate online marketplace for your home state of residence.

Generally, international students holding an F-1 or J-1 visa are not eligible to purchase insurance through the marketplaces because they must show permanent residency.

The NYU sponsored student health insurance plans, administered by Wellfleet Group, LLC, are designed to provide reasonably priced healthcare coverage. The student health insurance plans supplement the free services (as does any other health insurance) provided at the SHC. The plans cover most medical treatments and procedures provided at the SHC, for which there is a fee, as well as national coverage for medically necessary healthcare services.

All matriculated students are eligible for enrollment in the Insurance Plans sponsored by NYU. See Voluntary Enrollment section for more information about dependents and other eligible enrollees.

The NYU sponsored student health insurance has two plans designed to provide reasonably priced healthcare coverage:

1. Basic Plan
2. Comprehensive Plan

The Basic and Comprehensive Plans cover the same medical and mental health services. However, they have different:

• reimbursement levels,
  
• coinsurance,
  
• out-of-pocket expenses,
  
• and premiums

Both plans offer coverage for services rendered by healthcare providers who participate in the Cigna PPO network. To search for Cigna PPO providers visit the Cigna website. Out-of-network providers are also covered but at a lower reimbursement level.  

Please note: The SHC is in-network under the NYU sponsored student health insurance plan underwritten by Wellfleet New York Insurance Company as well as United Healthcare commercial products and the Oxford Freedom and Liberty networks for medical/surgical issues only (out of network for mental health issues). The SHC is out-of-network for all other insurance plans and is considered out-of-network under all other plans which utilize the Cigna network.
(See Referrals/Authorizations section below)

• Basic Plan (PDF 320KB)
  
• Comprehensive Plan (PDF 316KB)

REFERRALS ARE REQUIRED FOR SERVICES IN MANHATTAN (OUTSIDE SHC). Except for situations listed below, all students enrolled in the NYU sponsored student health insurance plans in need of medical care in Manhattan are required to first seek treatment and be evaluated at the SHC. If the evaluation by the SHC provider determines that the services are not available at the SHC, an off-site referral will be issued. Students are responsible for all Copayments or Coinsurance fees with respect to such referrals. Covered services received in Manhattan without an appropriate referral will not be paid by Wellfleet Group, LLC.

• Referrals from the SHC are required for follow-up treatment after an emergency.

• Primary and preventive obstetric and gynecologic services including annual examinations, care resulting from such annual examinations, treatment of Acute gynecologic conditions, or for any care related to a pregnancy from a qualified Participating Provider of such services;
• Emergency Services;*
• Pre-Hospital Emergency Medical Services and emergency ambulance transportation;
• Urgent Care;
• Maternal depression screening;
• When the Student Health Center is closed;
• When You are outside of Manhattan;
• Mental Health;
• Laboratory tests;
• Medical Care that is obtained by a Student who is not eligible to use the Student Health Center;
• Substance Use Services;
• Treatment of TMJ.

• Placing the health of the person afflicted with such condition or, with respect to a pregnant woman, the health of the woman or her unborn child in serious jeopardy, or in the case of a behavioral condition, placing the health of such person or others in serious jeopardy;
• Serious impairment to such person's bodily functions;
• Serious dysfunction of any bodily organ or part of such person; or
• Serious disfigurement of such person.

Referrals for Services Outside Manhattan

Students may use any provider outside the borough of Manhattan without an off-site referral from the SHC. All visit Copayments or Coinsurance fees incurred will be the responsibility of the student.

We encourage students to first seek services from an SHC provider who will be able to supervise and coordinate care with minimal out-of-pocket expense for medically necessary treatment. Students seeking care from providers outside the SHC should consider choosing a provider who participates in the Cigna network to ensure maximum benefits and reduce out-of-pocket expenses. To find a Cigna provider, go to www.wellfleetstudent.com/nyu or call (877) 373-1170 and a Wellfleet representative will assist you in locating a participating provider.

Referral Limitations

• Referrals are only valid for treatment of a specific condition for the period of time stated on the referral.
• Referrals may also limit the number of visits allowed within that time frame.
• Your condition must be re-evaluated by a SHC healthcare provider once the limits of the referral have been reached.

Preauthorization is required before You receive certain Covered Services. The Student Health Center or Preferred Provider is responsible for requesting Preauthorization for the in-network and out-of-network services listed in the Schedule of Benefits section of this brochure (PDF).

If You seek coverage for services that require Preauthorization or notification, the Student Health Center or Preferred Provider must call Wellfleet or Wellfleet's vendor at the number indicated on Your ID card.

The Student Health Center or Preferred Provider must contact Wellfleet to request Preauthorization as follows:

• At least two (2) weeks prior to a planned admission or surgery when Your Provider recommends inpatient Hospitalization. If that is not possible, then as soon as reasonably possible during regular business hours prior to the admission.
• At least two (2) weeks prior to ambulatory surgery or any ambulatory care procedure when Your Provider recommends the surgery or procedure be performed in an ambulatory surgical unit of a Hospital or in an Ambulatory Surgical Center. If that is not possible, then as soon as reasonably possible during regular business hours prior to the surgery or procedure.

You must contact Wellfleet to provide notification as follows:

• If You are hospitalized in cases of an Emergency Condition, You must call Wellfleet within 5 days after Your admission or as soon thereafter as reasonably possible.

After receiving a request for approval, Wellfleet will review the reasons for Your planned treatment and determine if benefits are available. Criteria will be based on multiple sources which may include medical policy, clinical guidelines, and pharmacy and therapeutic guidelines.

Costs for Students, for Dependent Coverage, and Family Coverage

NYU sponsored student health insurance plans are annual policies for students enrolled in an NYU sponsored plan. Students may choose from the following payment options:

A. ANNUAL PAYMENT IN FULL at the time of fall registration, with no insurance charge at spring registration.

• Student’s coverage will continue through August 20th, even if they are not registered for spring classes. (However, they will not have access to services at the SHC after January 8th for January graduates and after graduation for May graduates.)
• Students cannot get a partial refund of the spring/summer portion of the annual insurance charge after the September 30th enrollment deadline.

B. TWO INSTALLMENT PAYMENT PLAN (default plan): The first payment is due at the time of fall registration and the second at spring registration. The spring insurance charge is higher than the fall charge because it includes payment for coverage over the summer months.

• Students will be automatically enrolled in the same plan and billed the spring/summer health insurance charge if, and only if, they are registered for classes or maintaining matriculation for the spring semester.
• Students who are not registered for classes or maintaining matriculation for the spring semester will have their insurance coverage end on January 8th.

Whether payment option A or B is chosen, students may not change plans until the beginning of the next academic year.

Insurance ID Cards are available to each student in a variety of ways:

• An online insurance card can be obtained by going to the Wellfleet web site (www.wellfleetstudent.com/nyu). Click the link for “Online ID Card.”
• An email will be sent to those students enrolled in the insurance plan with instructions on how to obtain their electronic ID cards.
• Wellfleet will mail out ID cards to students who have a registered U.S. address in the Wellfleet system. If you opted out of receiving an ID you will not receive one.
  

We encourage you to carry your NYU ID and insurance card at all times.

Effective September 1, 2021, the University shall be providing its student health insurance plan (Basic Health Plan – Individual Coverage or Comprehensive Health Plan – Individual Coverage) at 5% of the applicable premium rate to eligible graduate student employees. In addition, eligible graduate student employees will be covered by the Stu-Dent Plan for NYU at no cost and will be automatically enrolled in the Stu-Dent Plan upon confirmation of union eligibility.

This provision does not apply to graduate employees who are covered under the Comprehensive Plan paid for by NYU.

For eligible Washington Square graduate student employees, a Basic Health Plan or Comprehensive Health Plan insurance charge may initially appear on the graduate student employee’s tuition bill, but will be adjusted when the student’s union eligibility is confirmed. At that time the insurance charge on the Bursar account will be adjusted to 5% of the Basic Health Insurance Plan or Comprehensive Health Insurance charge for that term.

Option to Change Individual Coverage

Eligible graduate student employees so covered may elect to change their individual coverage from the plan they are automatically enrolled in (see Automatic Enrollment Guide), to the other plan. This must be accomplished by the September 30th enrollment deadline. For example, in the case where an eligible graduate student employee is automatically enrolled in the Comprehensive Health Insurance Plan and wishes to change to the Basic Health Insurance Plan, the graduate student employee may do so during the online enrollment process (see Automatic Enrollment Guide section for more details).

Dependent Coverage Premium Support Plan

Effective September 1, 2015, the University established a Graduate Employee Student Health Insurance Dependent Premium Support Plan. For Academic Year 2022-2023, the Plan will be funded with $250,000, divided equally between the fall and spring semesters.

Those eligible graduate employees who actually purchase dependent coverage under the Basic Health Insurance Plan, or under the Comprehensive Plan, and provide proof thereof, may, during the subject semester, apply for up to 90% reimbursement of dependent coverage premiums. Actual reimbursement will depend on the number of applications and the funds allocated for that semester. Unused funds, if any, at the end of the academic year will carry over into the next academic year, and be divided equally between the fall and spring semesters. The application deadline for reimbursement for fall 2022 is January 8, 2023 and for spring 2023 is August 21, 2023.

Please note, eligible graduate student employees who are doctoral candidates and are enrolled in the Comprehensive Plan, paid for by NYU, for individual coverage, may only purchase Comprehensive Plan dependent care coverage, and in accordance with the agreement between NYU and Local 2110, the premium for such Comprehensive Plan dependent coverage will be at the same rate as the premium for dependent coverage under the Basic Student Health Insurance Plan.

• Graduate Employee Student Health Insurance Dependent Premium Support Plan Reimbursement Application (PDF 361 KB)

Students are eligible to enroll in an NYU sponsored student health plan if they are:

• registered for one or more credits in a degree-granting program at NYU
• maintaining matriculation (completing certain academic programs and not enrolled in classes)
• students with F-1 or J-1 visa status
• post-doctoral research trainees/fellows, paid by NYU on stipends (code 542) or paid directly by external sponsors
• dependents of an insured (spouse/domestic partner and children up until the end of the month in which the child turns age 26)
  

Most students are automatically enrolled in and charged a premium for either the Basic Plan or the Comprehensive Plan as part of the course registration process. Students should see the Automatic Enrollment Guide to determine if they will be automatically enrolled, and in which plan.

Students who are automatically enrolled and wish to change to a different plan may do so by completing the online enrollment process at www.nyu.edu/health/insurance before the appropriate deadline (see "Enrollment Deadlines" section below). Their tuition bills will be adjusted accordingly. Students who maintain alternate health insurance coverage that meets the University’s minimum health insurance criteria may apply to waive an NYU sponsored health insurance plan entirely (see Waiving the Student Health Insurance Plans section).

Please note: Adding or dropping courses during the registration period may affect a student’s automatic enrollment in a school-sponsored insurance plan. In such situations, confirm your enrollment status before the appropriate semester deadline (see "Enrollment Deadlines" section below) to ensure your coverage.

Any fully-funded graduate student whose funding package covers the cost of participation in the student health insurance plan, will be automatically enrolled in the Comprehensive Plan. A Basic Plan or Comprehensive Plan insurance charge may initially appear on the student’s tuition bill, but will be canceled when the program administrator notifies the Student Health Insurance Department of the student’s eligibility for the University to pay their insurance charge.

Post-Doctoral Research Trainees and Fellows paid by NYU on stipends [code 542], or paid directly by external sponsors, will be automatically enrolled in and charged premium for the Comprehensive Plan. They may waive the Comprehensive Plan insurance charge if they maintain health insurance coverage in an alternate plan, which meets the University’s requirements.

For students eligible for Graduate Employee NYU/UAW Local 2110, please see Graduate Employee NYU/UAW Local 2110 section.

Students should evaluate their options by reviewing the benefits, referral requirements and exclusions of the NYU sponsored student health insurance plans. Students should have their student ID number (shown on the admissions letter or on the back of the NYU ID card) handy before accessing the online system during the enrollment periods.

• Go to www.nyu.edu/health/insurance
• Click on the box that indicates, “Enroll in or Waive out.”
  
• Read the general information and follow the instructions for enrolling.
• At the end of the process, you must confirm your enrollment selection in order for your request to be processed.
• Print the Confirmation of Status letter. A confirmation will also be sent to the e-mail address provided.
  

Students registered for classes or maintaining matriculation but not automatically enrolled, have the option to choose a plan before the appropriate semester deadline (see "Enrollment Deadlines" section below) by completing the online enrollment process at www.nyu.edu/health/insurance (See Automatic Enrollment Guide).

If you are on a school sanctioned leave: review NYU's policy.

Eligibility

A dependent may only be added to the student health insurance plan if the Student is enrolled in the plan.

Eligible dependents are:

a) the covered student’s spouse or domestic partner; and/or
b) the covered student’s child under the age of 26 years.

How to Enroll

To enroll eligible dependents, insured students must complete the online enrollment application and make a payment at www.wellfleetstudent.com/nyu by clicking on the Dependent Enrollment link from the menu on the left side of the webpage by the appropriate deadline see Enrollment Deadlines section below). Dependent enrollment will be available from 8/1-9/30.Early Law Students will be able to enroll dependents as of 7/1.

• Dependent enrollment must be completed separately from the student’s online enrollment process.
• Dependents must be enrolled in the same plan and for the same time period as the covered student, unless there is a qualifying life event.
• Dependents will not have access to services at the SHC. Therefore, referrals are not required for any services outside the SHC.

Payment Options (Please see Costs section for rates)

Students enrolling dependents in an NYU sponsored student health insurance plan before the September 30th fall term deadline may choose an annual payment option or an installment payment option. For students choosing the installment payment option:

• The fall payment is due at the time of the fall enrollment.
• The spring payment is due by January 8th for the dependent coverage to continue until August 20th (the end of the policy period). Students will receive a 30-day notice before their fall coverage ends with a request for payment for the spring term coverage.

Effective Dates of Coverage

Annual 2022-2023: August 21, 2022 - August 20, 2023
Fall 2022: August 21, 2022 - January 8, 2023
Spring/Summer 2023: January 9, 2023 - August 20, 2023
Summer 2023: May 14, 2023 - August 20, 2023

• If your first semester of the academic year is: Fall 2022
  
• The online enrollment system becomes available: June 23
  
• The SEMESTER DEADLINE for enrolling in the NYU Plans is: September 30

• If your first semester of the academic year is: Spring 2023
  
• The online enrollment system becomes available: November 17
  
• The SEMESTER DEADLINE for enrolling in the NYU Plans is: February 10

• If your first semester of the academic year is: Summer 2023
  
• The online enrollment system becomes available: April 5
  
• The SEMESTER DEADLINE for enrolling in the NYU Plans is: June 5

• If the online enrollment process is not completed by the deadline, the plan in which the student is automatically enrolled will be in effect for all or any remaining part of the academic year. There will be no option to upgrade or downgrade the level of coverage until fall of the next academic year.
• Students who were only billed the fall semester health insurance charge at the time of fall registration:
  • will be automatically enrolled in the same plan and billed the spring/summer health insurance charge if, and only if, they are registered for classes or maintaining matriculation for the spring semester.
  • will have their insurance coverage end on January 8th if they are not registered for classes or maintaining matriculation for the spring semester.
• Students who paid the annual health insurance charge at the time of fall registration:
  • will continue coverage through August 20th, even if they are not registered or matriculated for spring classes. (However, they will not have access to services at the SHC after January 8th for January graduates and after May 31st for May graduates.)
  • cannot get a partial refund of the spring/summer portion of the annual insurance charge after the September 30th enrollment deadline.

Important Note for Students Enrolled in an NYU sponsored plan for the fall semester

• If you are registered for classes for spring 2023 you will be enrolled in the same plan and billed the appropriate spring/summer 2023 insurance premium, regardless of your credit load.
• If you choose the two-payment option and are not registered for classes or paying a maintaining matriculation fee for spring 2023, you will not be billed for an NYU sponsored plan. Your coverage will end on January 8th.

Enrollment will only be processed by the Student Health Insurance Department. No school or other unit can enroll a student in the insurance plan.

January Graduates
(and other students not matriculating for spring 2023)

Choosing the annual option will guarantee that your coverage will remain in effect during the entire policy year, even though you will not be enrolled for classes during spring 2023.

Please note: You will not have access to services at the SHC after January 8th, and therefore no referral will be required for services outside SHC.

Automatic Enrollment Guide

You, and Your Spouse or Child can also enroll for coverage within 31 days of the loss of coverage in a health plan if coverage was terminated because You, Your Spouse or Child are no longer eligible for coverage under the other health plan due to:

1. Termination of employment;
2. Termination of the other health plan;
3. Death of the Spouse;
4. Legal separation, divorce or annulment;
5. Reduction of hours of employment;
6. Employer contributions toward a health plan were terminated for You or Your Dependent’s Coverage; or
7. A Child no longer qualifies for coverage as a Child under another health plan.

You, and Your Spouse or Child can also enroll 31 days from exhaustion of Your COBRA or if You gain a Dependent or become a Dependent through marriage, birth, adoption or placement for adoption.

Wellfleet Group, LLC must receive notice and Premium payment within 31 days of the loss of coverage. Your coverage will begin on the first day of the following month after Wellfleet Group, LLC receives Your application.

In order for NYU to grant a waiver, your health insurance coverage must meet the following criteria:

1. The insurance company must be headquartered and operating in the U.S., with a U.S. claims address and customer service telephone number. (Freshman First Year away students, see below*.)
2. The insurance coverage must remain in effect from:
   • SEMESTER: INSURANCE EFFECTIVE DATES
   • Fall: August 21st through August 20th of the following year
   • Spring: January 9th through August 20th of that year
   • Summer: May 14th through August 20th of that year
3. The plan must provide inpatient hospitalization benefits for medical/surgical, mental health, substance abuse, and alcohol related illness or injury in the New York City area.
4. The plan must provide outpatient benefits (including office visits for medical/surgical, mental health, substance abuse, and alcohol related illness or injury, and laboratory and radiology procedures) in the New York City area. Coverage limited to emergency care does not satisfy the requirement.
5. The maximum benefit payable under the insurance plan must be unlimited.

Based on the information provided, NYU reserves the right to deny your waiver request.

If your waiver is approved, the Bursar will be notified and the insurance charge will be removed from your account, usually within 3 business days.

* For students in the Freshman First Year Away program, their insurance company or government-issued health plan must be headquartered in their home country.

In order for NYU to grant a waiver, your health insurance coverage must meet the following criteria:

1. The insurance company must be headquartered and operating in the U.S., with a U.S. claims address and customer service telephone number. (Freshman First Year Away students, see below*.)
2. The insurance coverage must remain in effect from:
   • SEMESTER: INSURANCE EFFECTIVE DATES
   • Fall: August 21st through August 20th of the following year
   • Spring: January 9th through August 20th of that year
   • Summer: May 14th through August 20th of that year
3. The plan must provide inpatient hospitalization benefits for medical/surgical, mental health, substance abuse, and alcohol related illness or injury in the New York City area.
4. The plan must provide outpatient benefits (including office visits for medical/surgical, mental health, substance abuse, and alcohol related illness or injury, and laboratory and radiology procedures) in the New York City area. Coverage limited to emergency care does not satisfy the requirement.
5. The maximum benefit payable under the insurance plan must be unlimited.

F-1 and J-1 Visa Holders, in addition to the above criteria, your alternate insurance must meet the following criteria:

1. No waiting period for pre-existing conditions
2. Policy deductible not to exceed $1,500 per policy year
3. Medical Evacuation coverage of at least $50,000 USD
4. Repatriation of remains coverage of at least $25,000 USD

Based on the information provided, NYU reserves the right to deny your waiver request.

If your waiver is approved, the Bursar will be notified and the insurance charge will be removed from your account, usually within 3 business days after your waiver is approved.

To avoid being obligated to pay for two health insurance plans, please do not purchase another health insurance plan before your waiver request is approved. Your waiver will not be processed until the Student Health Insurance Department confirms that your insurance plan meets the University’s requirements.

* For students in the Freshman First Year Away program, their insurance company or government-issued health plan must be headquartered in their home country.

Supplemental Information
Health insurance is a requirement of the University and is a necessity in the United States because of the very high cost of healthcare. When you are registered for classes, you will be automatically charged for the NYU sponsored Comprehensive Insurance Plan. You will remain enrolled in that plan unless you complete the waiver process before the semester deadline.

Students have an option to:

• Waive the NYU sponsored plan if you maintain other health insurance coverage that meets the University’s minimum health insurance criteria described in the Waiving the Student Health Insurance Plan section, or
• Downgrade your coverage to the Basic Plan. Students may only opt to downgrade coverage when first registering for the academic year.

Domestic Student Waiver Process

Students should have their student ID number (shown on the admissions letter or on the back of the NYU ID card) handy before accessing the online system during the enrollment/waiver periods shown below.

1. Go to www.nyu.edu/health/insurance
2. Click on the box that indicates, “Enroll in or Waive out.” Read the general information and follow the instructions for waiving.
   
3. At the end of the process, you must confirm your waiver information in order for your request to be processed.
4. Print the Confirmation of Status letter. A confirmation will also be sent to the e-mail address provided.

International Student Waiver Process

(See Waiving Criteria for International Students section for waiver requirements.) Students with an F-1/J-1 visa who maintain other health insurance coverage and wish to waive the NYU sponsored student health insurance plan need to complete and sign the entire Student Acknowledgement and Insurance Carrier Certification Form before submitting it to the NYU Student Health Insurance Department. This must be completed for each new academic year before September 30th.

1. Read the International Student Waiver Application Instructions
   
2. Download the Student Acknowledgment and Insurance Carrier Certification Form (PDF 499KB)
   
3. Follow the instructions for completing the Student Acknowledgement and Insurance Carrier Certification Form.
4. Your insurance company representative must complete, sign and date the form.

The following types of insurance plans will not be acceptable for waiving the NYU sponsored student health insurance plans:

• Travel policies with limited benefits and exclusions of coverage important for a college population.
• Insurance plans that always require students to pay for treatment out-of-pocket and then be reimbursed.

Based on the information provided, NYU reserves the right to deny your waiver request.

If your waiver is approved, the Bursar will be notified and the insurance charge will be removed from your account, usually within 3 business days.

To avoid being obligated to pay for two health insurance plans, please do not purchase another health insurance plan before your waiver request is approved. Your waiver will not be processed until the Student Health Insurance Department confirms that your insurance plan meets the University’s requirements.

• If your first semester of the academic year is: Fall 2022
  
• The online enrollment system becomes available: June 23
  
• The SEMESTER DEADLINE for enrolling in the NYU Plans is: September 30

• If your first semester of the academic year is: Spring 2023
  
• The online enrollment system becomes available: November 17
  
• The SEMESTER DEADLINE for enrolling in the NYU Plans is: February 10

• If your first semester of the academic year is: Summer 2023
  
• The online enrollment system becomes available: April 5
  
• The SEMESTER DEADLINE for enrolling in the NYU Plans is: June 5

• If you successfully waived in the fall, your waiver automatically remains in effect for the spring and summer semesters. However, you must repeat the waiver process again at the start of each academic year beginning in the fall.
• Once the waiver process is completed, the waiver will apply as of the effective date of insurance for the term. (Example: if you submit a waiver on September 15th you will not be covered by the student health insurance plan for any services that were rendered on or after August 21st of that year).
• Waivers will only be processed by the Student Health Insurance Department. No school or other unit can waive students from the insurance plan.
• If you used the online system in the fall semester to select your insurance and now have a new health insurance plan, you may apply to waive the spring coverage by submitting a Petition to Change Insurance Form to the Student Health Insurance Department before the February 10 spring semester deadline. You should contact the Student Health Insurance Department at (212) 443-1020 or health.insurance@nyu.edu for more information.
• If you waive the NYU sponsored student health insurance plan and then find yourself without insurance due to divorce, loss of employment, termination of coverage due to age, or a similar reason, you may be eligible to enroll in an NYU sponsored student health insurance plan by submitting a Petition to Change Form to the Student Health Insurance Department. You will be required to pay the premium for the entire semester, regardless of when you enroll.

Based on the information provided, NYU reserves the right to deny your waiver request.

If your waiver is approved, the Bursar will be notified and the insurance charge will be removed from your account, usually within 3 business days.

(The following is not affiliated with the Student Health Insurance Plan underwritten by Wellfleet New York Insurance Company)
New York University requires that students studying away as part of their educational program be covered under the NYU sponsored Study Away health insurance plan administered by Worldwide Insurance Services. The school- sponsored GeoBlue program utilizes the Blue Cross Blue Shield provider network in the United States and provides easy access to care. The program has four major components:

• Semester Long Programs (including Freshman First Year Away students)*
• Short-Term Programs*
• NYU Abu Dhabi
• NYU Shanghai

* Students enrolled in these GeoBlue plans are still required to maintain other health insurance coverage in their home countries. Visit www.nyu.edu/health/GeoBlue for more information.

(The following is not affiliated with the Student Health Insurance Plan underwritten by Wellfleet New York Insurance Company.)

The Stu-Dent Plan is a prepaid dental plan that offers high quality, low-cost dental care to NYU students, with convenient appointment times to accommodate busy schedules. Services are provided by graduating DDS and hygiene students overseen by licensed dental faculty members in a convenient location adjacent to the SHC on the 3rd floor of 726 Broadway.

As a Stu-Dent plan member, you are eligible to receive semiannual check-ups and two cleanings, X-rays, and as many fillings and sealants as you may need for one low enrollment fee of $275. You will also receive a 20% discount on most dental services not included in the plan.

How to Enroll: From June 23-September 30, you can enroll in the Stu-Dent plan online as part of the student health insurance online enrollment/waiver process. Please be sure to check the box for Stu-Dent enrollment (automatic enrollment in the health insurance plan does not automatically enroll you in Stu-Dent). You may also enroll directly at the Stu-Dent Website, http://dental.nyu.edu/patientcare/stu-dent-plan.html.

For more information about the Stu-Dent plan fees or to enroll after September 30, call (212) 443-1313.

Please note: The Dental Faculty Practice and the Stu-Dent program are not part of the SHC or the NYU sponsored plans and bill separately from the SHC. Changes in the Stu-Dent Dental Plan can only be made during the designated enrollment period from June 23-September 30.

Stu-Dent Plan Dental Service Costs (annual)

$275    Initial Enrollment
$275    Spouse/Partner
$225    Renewal
$105      Dependent (under age 16)

NYU requires that all students registered in degree-granting programs maintain health insurance. While most undergraduate and graduate students are in good health and face few serious illnesses while in school, medical and psychological issues can arise at any time, sometimes without warning. With the high cost of healthcare in the United States, the absence of adequate insurance coverage can result in temporary or permanent interruption of a student’s education.

Yes. Students who are automatically enrolled in a plan and wish to change to a different plan (upgrade or downgrade) may do so by completing the online enrollment process at www.nyu.edu/health/insurance before the appropriate deadline. The tuition bill will be adjusted accordingly usually within 3 days of the on-line system change.

No. If you maintain other health insurance coverage that meets the University’s requirements (see Waiving the Student Health Insurance Plans section), you may apply to waive the NYU sponsored plan.

Yes. If the student had waived out of the NYU sponsored student health insurance plan and due to a loss of coverage now needs insurance coverage, a Petition to Change Insurance Form must be submitted to the Student Health Insurance Department along with proof of the termination of the coverage. Contact the Student Health Center Insurance Department at (212) 443-1020 or health.insurance@nyu.edu. The insurance charge will be assessed for the entire semester (there is no prorating of the charges).

The following outlines the deadline dates for either enrolling/changing the assigned plan or waiving out of the assigned plan

• If your first semester of the academic year is: Fall 2022
  
• The online enrollment system becomes available: June 23
  
• The SEMESTER DEADLINE for enrolling in the NYU Plans is: September 30

• If your first semester of the academic year is: Spring 2023
  
• The online enrollment system becomes available: November 17
  
• The SEMESTER DEADLINE for enrolling in the NYU Plans is: February 10

• If your first semester of the academic year is: Summer 2023
  
• The online enrollment system becomes available: April 5
  
• The SEMESTER DEADLINE for enrolling in the NYU Plans is: June 5

Yes. If the student was automatically enrolled in a plan for the fall semester and did not confirm the selection through the online enrollment process, they may waive the spring coverage online before the February 10 spring term deadline.

However, if they used the online system in the fall semester to select their insurance and now have a new health insurance plan, they may apply to waive the spring coverage by submitting a Petition to Change Insurance Form to the Student Health Insurance Department before the February 10 spring semester deadline. They should contact the Student Health Insurance Department at (212) 443-1020 or health.insurance@nyu.edu for more information.

Costs for the NYU sponsored plans are listed in the Costs section.

A. Aviation.
We do not Cover services arising out of aviation, other than as a fare-paying passenger on a scheduled or charter flight operated by a scheduled airline.

B. Convalescent and Custodial Care.
We do not Cover services related to rest cures, custodial care or transportation. "Custodial care" means help in transferring, eating, dressing, bathing, toileting and other such related activities. Custodial care does not include Covered Services determined to be Medically Necessary.

C. Conversion Therapy.
We do not Cover conversion therapy. Conversion therapy is any practice by a mental health professional that seeks to change the sexual orientation or gender identity of a Member under 18 years of age, including efforts to change behaviors, gender expressions, or to eliminate or reduce sexual or romantic attractions or feelings toward individuals of the same sex. Conversion therapy does not include counseling or therapy for any individual who is seeking to undergo a gender transition or who is in the process of undergoing a gender transition, that provides acceptance, support and understanding of an individual or the facilitation of an individual’s coping, social support, and identity exploration and development, including sexual orientation-neutral interventions to prevent or address unlawful conduct or unsafe sexual practices, provided that the counseling or therapy does not seek to change sexual orientation or gender identity.

D. Cosmetic Services.
We do not Cover cosmetic services, Prescription Drugs, or surgery unless otherwise specified, except that cosmetic surgery shall not include reconstructive surgery when such service is incidental to or follows surgery resulting from trauma, infection or diseases of the involved part, and reconstructive surgery because of congenital disease or anomaly of a covered Child which has resulted in a functional defect. We also Cover services in connection with reconstructive surgery following a mastectomy, as provided elsewhere in the Certificate. Cosmetic surgery does not include surgery determined to be Medically Necessary. If a claim for a procedure listed in 11 NYCRR 56 (e.g., certain plastic surgery and dermatology procedures) is submitted retrospectively and without medical information, any denial will not be subject to the Utilization Review process in the Utilization Review and External Appeal sections of the Certificate unless medical information is submitted.

E. Dental Services.
We do not Cover dental services except for: care or treatment due to accidental injury to sound natural teeth within 12 months of the accident; dental care or treatment necessary due to congenital disease or anomaly; or dental care or treatment specifically stated in the Outpatient and Professional Services and Pediatric Dental Care sections of the Certificate.

F. Experimental or Investigational Treatment.
We do not Cover any health care service, procedure, treatment, device or Prescription Drug that is experimental or investigational. However, We will Cover experimental or investigational treatments, including treatment for Your rare disease or patient costs for Your participation in a clinical trial as described in the Outpatient and Professional Services section of the Certificate, when Our denial of services is overturned by an External Appeal Agent certified by the State. However, for clinical trials, We will not Cover the costs of any investigational drugs or devices, non-health services required for You to receive the treatment, the costs of managing the research, or costs that would not be Covered under the Certificate for non-investigational treatments. See the Utilization Review and External Appeal sections of the Certificate for a further explanation of Your Appeal rights.

G. Felony Participation.
We do not Cover any illness, treatment or medical condition due to Your participation in a felony, riot or insurrection. This exclusion does not apply to coverage for services involving injuries suffered by a victim of an act of domestic violence or for services as a result of Your medical condition (including both physical and mental health conditions).

H. Foot Care.
We do not Cover routine foot care, in connection with corns, calluses, flat feet, fallen arches, weak feet, chronic foot strain or symptomatic complaints of the feet. However, We will Cover foot care when You have a specific medical condition or disease resulting in circulatory deficits or areas of decreased sensation in Your legs or feet.

I. Government Facility.
We do not Cover care or treatment provided in a Hospital that is owned or operated by any federal, state or other governmental entity, except as otherwise required by law.

J. Medically Necessary.
In general, We will not Cover any health care service, procedure, treatment, test, device or Prescription Drug that We determine is not Medically Necessary. If an External Appeal Agent certified by the State overturns Our denial, however, We will Cover the service, procedure, treatment, test, device or Prescription Drug for which coverage has been denied, to the extent that such service, procedure, treatment, test, device or Prescription Drug is otherwise Covered under the terms of the Certificate.

K. Medicare or Other Governmental Program.
We do not Cover services if benefits are provided for such services under the federal Medicare program or other governmental program (except Medicaid).

L. Military Service.
We do not Cover an illness, treatment or medical condition due to service in the Armed Forces or auxiliary units.

M. No-Fault Automobile Insurance.
We do not Cover any benefits to the extent provided for any loss or portion thereof for which mandatory automobile no-fault benefits are recovered or recoverable. This exclusion applies even if You do not make a proper or timely claim for the benefits available to You under a mandatory no-fault policy.

N. Services Not Listed.
We do not Cover services that are not listed in the Certificate as being Covered.

O. Services Provided by a Family Member.
We do not Cover services performed by a member of the covered person's immediate family. “Immediate family" shall mean a child, spouse, mother, father, sister or brother of You or Your Spouse.

P. Services Separately Billed by Hospital Employees.
We do not Cover services rendered and separately billed by employees of Hospitals, laboratories or other institutions.

Q. Services With No Charge.
We do not Cover services for which no charge is normally made.

R. Vision Services.
We do not Cover the examination or fitting of eyeglasses or contact lenses, except as specifically stated in the Routine Vision Care section of the Certificate.

S. War.
We do not Cover an illness, treatment or medical condition due to war, declared or undeclared.

T. Workers' Compensation.
We do not Cover services if benefits for such services are provided under any state or federal Workers' Compensation, employers' liability or occupational disease law.

1. Report to a Physician, Hospital or the School’s Student Health Center.
2. Claims for services must be submitted to Wellfleet Group, LLC for payment within 120 days after You receive the
   services for which payment is being requested. If it is not reasonably possible to submit a claim within the 120-day
   period, You must submit it as soon as reasonably possible.
   
3. Mail to the address below all medical and hospital bills along with the patient's name and insured student's name,
   address, Social Security number or student ID number and name of the University under which the student is insured. A Company claim form is not required for filing a claim.
   Bills should be received by the Company within 120 days of service.

CIGNA
PO Box 188061
Chattanooga, TN 37422 – 8061
Electronic Payor ID: 62308

Claims Administrator:
WELLFLEET GROUP, LLC
PO Box 15369
Springfield, MA 01115
Toll Free (877) 373-1170
www.wellfleetstudent.com
Group Number: ST0645SH

Acute: The onset of disease or injury, or a change in the Member's condition that would require prompt medical attention.

Allowed Amount: The maximum amount on which Our payment is based for Covered Services. See the Cost- Sharing Expenses and Allowed Amount section of the Certificate for a description of how the Allowed Amount is calculated. If Your Non-Participating Provider charges more than the Allowed Amount, You will have to pay the difference between the Allowed Amount and the Provider's charge, in addition to any Cost- Sharing requirements.

Ambulatory Surgical Center: A Facility currently licensed by the appropriate state regulatory agency for the provision of surgical and related medical services on an outpatient basis.

Appeal: A request for Us to review a Utilization Review decision or a Grievance again.

Balance Billing: When a Non-Participating Provider bills You for the difference between the Non-Participating
Provider's charge and the Allowed Amount. A Participating Provider may not Balance Bill You for Covered Services.

Certificate: The Certificate issued by Wellfleet New York Insurance Company, including the Schedule of Benefits and any attached riders.

Child, Children: The Student's Children, including any natural, adopted or step-children, unmarried disabled Children, newborn Children, or any other Children as described in the Who is Covered section of the Certificate.

Coinsurance: Your share of the costs of a Covered Service, calculated as a percent of the Allowed Amount for the service that You are required to pay to a Provider. The amount can vary by the type of Covered Service.

Copayment: A fixed amount You pay directly to a Provider for a Covered Service when You receive the service. The amount can vary by the type of Covered Service.

Cost-Sharing: Amounts You must pay for Covered Services, expressed as Copayments, Deductibles and/or Coinsurance.

Cover, Covered or Covered Services: The Medically Necessary services paid for, arranged, or authorized for You by Us under the terms and conditions of the Certificate.

Deductible: The amount You owe before We begin to pay for Covered Services. The Deductible applies before any Copayments or Coinsurance are applied. The Deductible may not apply to all Covered Services. You may also have a Deductible that applies to a specific Covered Service (e.g., a Prescription Drug Deductible) that You owe before We begin to pay for a particular Covered Service

Dependents: The Student's Spouse and Children.

Durable Medical Equipment ("DME"): Equipment which is:

• Designed and intended for repeated use;
• Primarily and customarily used to serve a medical purpose;
• Generally not useful to a person in the absence of disease or injury; and
• Appropriate for use in the home.

Emergency Condition: A medical or behavioral condition that manifests itself by Acute symptoms of sufficient severity, including severe pain, such that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in:

• Placing the health of the person afflicted with such condition or, with respect to a pregnant woman, the health of the woman or her unborn child in serious jeopardy, or in the case of a behavioral condition, placing the health of such person or others in serious jeopardy;
• Serious impairment to such person's bodily functions;
• Serious dysfunction of any bodily organ or part of such person; or
• Serious disfigurement of such person.

Emergency Department Care: Emergency Services You get in a Hospital emergency department.

Emergency Services: A medical screening examination which is within the capability of the emergency department of a Hospital, including ancillary services routinely available to the emergency department to evaluate such Emergency Condition; and within the capabilities of the staff and facilities available at the Hospital, such further medical examination and treatment as are required to stabilize the patient. "To stabilize" is to provide such medical treatment of an Emergency Condition as may be necessary to assure that, within reasonable medical probability, no material deterioration of the condition is likely to result from or occur during the transfer of the patient from a Facility, or to deliver a newborn child (including the placenta).

Exclusions: Health care services that We do not pay for or Cover.

External Appeal Agent: An entity that has been certified by the New York State Department of Financial Services to perform external appeals in accordance with New York law.

Facility: A Hospital; Ambulatory Surgical Center; birthing center; dialysis center; rehabilitation Facility; Skilled Nursing Facility; hospice; Home Health Agency or home care services agency certified or licensed under Article 36 of the New York Public Health Law; a comprehensive care center for eating disorders pursuant to Article 27-J of the New York Public Health Law; and a Facility defined in New York Mental Hygiene Law Sections 1.03(10) and (33), certified by the New York State Office of Alcoholism and Substance Abuse Services, or certified under Article 28 of the New York Public Health Law (or, in other states, a similarly licensed or certified Facility). If You receive treatment for substance use disorder outside of New York State, a Facility also includes one which is accredited by The Joint Commission to provide a substance use disorder treatment program.

Grievance: A complaint that You communicate to Us that does not involve a Utilization Review determination.

Habilitation Services: Health care services that help a person keep, learn or improve skills and functioning for daily living. Habilitative Services include the management of limitations and disabilities, including services or programs that help maintain or prevent deterioration in physical, cognitive, or behavioral function. These services consist of physical therapy, occupational therapy and speech therapy.

Health Care Professional: An appropriately licensed, registered or certified Physician; dentist; optometrist; chiropractor; psychologist; social worker; podiatrist; physical therapist; occupational therapist; midwife; speech- language pathologist; audiologist; pharmacist; behavior analyst; or any other licensed, registered or certified Health Care Professional under Title 8 of the New York Education Law (or other comparable state law, if applicable) that the New York Insurance Law requires to be recognized who charges and bills patients for Covered Services. The Health Care Professional's services must be rendered within the lawful scope of practice for that type of Provider in order to be covered under the Certificate.

Home Health Agency: An organization currently certified or licensed by the State of New York or the state in which
it operates and renders home health care services.

Hospice Care: Care to provide comfort and support for persons in the last stages of a terminal illness and their families that are provided by a hospice organization certified pursuant to Article 40 of the New York Public Health Law or under a similar certification process required by the state in which the hospice organization is located.

Hospital: A short term, acute, general Hospital,
which:

• Is primarily engaged in providing, by or under the continuous supervision of Physicians, to patients, diagnostic services and therapeutic services for diagnosis, treatment and care of injured or sick persons;
• Has organized departments of medicine and major surgery;
• Has a requirement that every patient must be under the care of a Physician or dentist;
• Provides 24-hour nursing service by or under the supervision of a registered professional nurse (R.N.);
• If located in New York State, has in effect a Hospitalization review plan applicable to all patients which meets
  at least the standards set forth in 42 U.S.C Section 1395x(k);
• Is duly licensed by the agency responsible for licensing such Hospitals; and
• Is not, other than incidentally, a place of rest, a place primarily for the treatment of tuberculosis, a place for
  the aged, a place for drug addicts, alcoholics, or a place for convalescent, custodial, educational, or rehabilitory care.

Hospital does not mean health resorts, spas, or infirmaries at schools or camps.

Hospitalization: Care in a Hospital that requires admission as an inpatient and usually requires an overnight stay.

Hospital Outpatient Care: Care in a Hospital that usually doesn't require an overnight stay.

In-Network Coinsurance: Your share of the costs of a Covered Service, calculated as a percent of the Allowed Amount for the Covered Service that You are required to pay to a Participating Provider or Preferred Provider. The amount can vary by the type of Covered Service.

In-Network Copayment: A fixed amount You pay directly to a Participating Provider or Preferred Provider for a Covered Service when You receive the service. The amount can vary by the type of Covered Service.

In-Network Out-of-Pocket Limit: The most You pay during a Plan Year in Cost-Sharing before We begin to pay 100% of the Allowed Amount for Covered Services received from Participating Providers or Preferred Providers. This limit never includes Your Premium or services We do not Cover.

Medically Necessary: See the How Your Coverage Works section of the Certificate for the definition.

Medicare: Title XVIII of the Social Security Act, as amended.

Member: The Student or a covered Dependent for whom required Premiums have been paid. Whenever a Member is required to provide a notice pursuant to a Grievance or emergency department visit or admission, "Member" also means the Member's designee.

Non-Participating Provider: A Provider who doesn't have a contract with Us to provide services to You. You will pay more to see a Non-Participating Provider.

Out-of-Network Coinsurance: Your share of the costs of a Covered Service calculated as a percent of the Allowed Amount for the service that You are required to pay to a Non-Participating Provider. The amount can vary by the type of Covered Service.

Out-of-Network Copayment: A fixed amount You pay directly to a Non-Participating Provider for a Covered Service when You receive the service. The amount can vary by the type of Covered Service.

Out-of-Network Out-of-Pocket Limit: The most You pay during a Plan Year in Cost-Sharing before We begin to pay 100% of the Allowed Amount for Covered Services received from Non-Participating Providers. This limit never includes Your Premium, Balance Billing charges or services We do not Cover. You are also responsible for all differences, if any, between the Allowed Amount and the Non-Participating Provider's charge for out-of- network services regardless of whether the Out-of-Pocket Limit has been met.

Out-of-Pocket Limit: The most You pay during a Plan Year in Cost-Sharing before We begin to pay 100% of the Allowed Amount for Covered Services. This limit never includes Your Premium, Balance Billing charges or the cost of health care services We do not Cover.

Participating Provider: A Provider who has a contract with Us to provide services to You. A list of Participating Providers and their locations is available on Our website at www.wellfleetstudent.com/nyu or upon Your request to Us. The list will be revised from time to time by Us. You will pay higher Cost-Sharing to see a Participating Provider as compared to a Preferred Provider, but less than if You received Covered Services from a Non-Participating Provider.

Physician or Physician Services: Health care services a licensed medical Physician (M.D. -Medical Doctor or D.O. - Doctor of Osteopathic Medicine) provides or coordinates.

Plan Year: The 12-month period beginning on the effective date of the Policy or any anniversary date thereafter, during which the Certificate is in effect.

Policy: The Policy issued by Wellfleet New York Insurance Company to the Policyholder.

Policyholder: the institution of higher education that has entered in to an agreement with Us.

Preauthorization: A decision by Us prior to Your receipt of a Covered Service, procedure, treatment plan, device, or Prescription Drug that the Covered Service, procedure, treatment plan, device or Prescription Drug is Medically Necessary. We indicate which Covered Services require Preauthorization in the Schedule of Benefits section of the Certificate.

Preferred Provider: A Provider who has a contract with Us to provide certain services to You at the highest level of coverage available to You. You will pay the least amount of Cost-Sharing to see a Preferred Provider.

Premium: The amount that must be paid for Your health insurance coverage.

Prescription Drugs: A medication, product or device that has been approved by the Food and Drug Administration ("FDA") and that can, under federal or state law, be dispensed only pursuant to a prescription order or refill and is on Our formulary. A Prescription Drug includes a medication that, due to its characteristics, is appropriate for self- administration or administration by a non-skilled caregiver.

Primary Care Physician ("PCP"): A participating nurse practitioner or Physician who typically is an internal medicine, family practice or pediatric Physician and who directly provides or coordinates a range of health care services for You.

Provider: A Physician, Health Care Professional or Facility licensed, registered, certified or accredited as required by state law. A Provider also includes a vendor or dispenser of diabetic equipment and supplies, durable medical equipment, medical supplies, or any other equipment or supplies that are Covered under the Certificate that is licensed, registered, certified or accredited as required by state law.

Referral: An authorization given to one Participating Provider from the Student Health Center in order to arrange for additional care for a Member. A Referral can be transmitted electronically or by Your Provider completing a paper Referral form. Except as provided in the Access to Care and Transitional Care section of the Certificate or as otherwise authorized by Us, a Referral will not be made to a Non-Participating Provider.

Rehabilitation Services: Health care services that help a person keep, get back, or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt, or disabled. These services consist of physical therapy, occupational therapy, and speech therapy in an inpatient and/or outpatient setting.

Schedule of Benefits: The section of the Certificate that describes the Copayments, Deductibles, Coinsurance, Out- of-Pocket Limits, Preauthorization requirements, Referral requirements and other limits on Covered Services.

Service Area: The geographical area, designated by Us and approved by the State of New York, in which We provide coverage. Our Service Area consists of Albany; Allegany; Bronx; Broome; Cattaraugus; Cayuga; Chautauqua; Chemung; Chenango; Clinton; Columbia; Cortland; Delaware; Dutchess; Erie; Essex; Franklin; Fulton; Genesee; Greene; Hamilton; Herkimer; Jefferson; Kings; Lewis; Livingston; Madison; Monroe; Montgomery; Nassau; New York; Niagara; Oneida; Onondaga; Ontario; Orange; Orleans; Oswego; Otsego; Putnam; Queens; Rensselaer; Richmond; Rockland; St. Lawrence; Saratoga; Schenectady; Schoharie; Schuyler; Seneca; Steuben; Suffolk; Sullivan; Tioga; Tompkins; Ulster; Warren; Washington; Wayne; Westchester; Wyoming; Yates County.

Skilled Nursing Facility: An institution or a distinct part of an institution that is: currently licensed or approved under state or local law; primarily engaged in providing skilled nursing care and related services as a Skilled Nursing Facility, extended care Facility, or nursing care Facility approved by The Joint Commission or the Bureau of Hospitals of the American Osteopathic Association, or as a Skilled Nursing Facility under Medicare; or as otherwise determined by Us to meet the standards of any of these authorities.

Specialist: A Physician who focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions.

Spouse: The person to whom the Student is legally married, including a same sex Spouse. Spouse also includes a domestic partner.

Student: The person to whom the Certificate is issued.

Student Health Center: Any organization, facility or clinic operated, maintained or supported by the school which provides health care services to a Student and has received accreditation by either the Accreditation Association of Ambulatory Health Care (AAAHC) or The Joint Commission for the ambulatory health care provided within their student health services.

UCR (Usual, Customary and Reasonable): The cost of a medical service in a geographic area based on what Providers in the area usually charge for the same or similar medical service.

Urgent Care: Medical care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require Emergency Department Care. Urgent Care may be rendered in a Physician's office or Urgent Care Center.

Urgent Care Center: A licensed Facility (other than a Hospital) that provides Urgent Care.

Us, We, Our: Wellfleet New York Insurance Company and anyone to whom We legally delegate performance, on Our behalf, under the Certificate.

Utilization Review: The review to determine whether services are or were Medically Necessary or experimental or investigational (i.e., treatment for a rare disease or a clinical trial).

You,Your: The Member.

Student Health Insurance Department
726 Broadway, Suite 346
New York, NY 10003
(212) 443-1020
Fax: (212) 443-1011
www.nyu.edu/health/insurance
health.insurance@nyu.edu

Wellfleet Student
Attn: NYU Unit
PO Box 15369
Springfield, MA 01115
(877) 373-1170
Fax: (413) 214-6482
www.wellfleetstudent.com/nyu
nyu@wellfleetinsurance.com

GeoBlue Worldwide Insurance
(NYU Programs outside the US)
(866) 281-1668
(610) 254-8741 (collect outside the U.S.)
globalhealth@geo-blue.com

Student Health Patient Accounts Department
726 Broadway, Suite 346
(212) 443-1010
health.patientaccounts@nyu.edu

(646) 846-4698
www.nyu.edu/studentlink

Manhattan
383 Lafayette Street, First Floor
New York, NY 10003

Brooklyn
5 MetroTech Center, Suite 2015
Brooklyn, NY 11201

Your policy also includes Emergency Medical Evacuation and Repatriation of Remains benefits. To access these benefits and for Travel Guard assistance, You may contact Wellfleet at the number on Your ID card. To contact Travel Guard directly, You should call (877) 305-1966 if traveling and You need assistance in North America, or if You are in a foreign country, You can call collect at (715) 295-9311. When You call, provide Your name, advise that You are a New York University Student Health Plan Member and describe the situation. If possible, You should have Your ID card available.

Travel Guard, a travel assistance services provider, must make all arrangements and must authorize all expenses in advance for any Emergency Medical Evacuation benefits to be payable. We reserve the right to determine the benefits payable, including reductions, if it is not reasonably possible to contact Travel Guard in advance.

Emergency Medical Evacuation means: (1) Transportation to the nearest adequate medical facility following Your injury or Emergency Condition if You are outside Your home country and the Physician determines that adequate treatment is not available locally; or (2) ambulance service to the nearest airport and air ambulance upon departure; or (3) special air transportation costs for Your return to Your home country if the Physician recommends in writing that Your condition requires a stretcher, oxygen or other special medical arrangements; or (4) Your immediate Transportation from the place where You suffered the injury or Emergency Condition to the nearest hospital or other medical facility where appropriate medical treatment can be obtained; or (5) Transportation to Your current place of primary residence to obtain further medical treatment in a Hospital or other medical facility or to recover after suffering the injury or Emergency Condition and being treated at a local Hospital or other medical Facility; or (6) both (4) and (5) above. An Emergency Medical Evacuation also includes medical treatment, medical services and medical supplies necessarily received in connection with such Transportation.

Repatriation of Remains. If a Member suffers loss of life due to injury or Emergency Condition, We will pay, subject to the limitations set out herein, for Covered expenses reasonably incurred to transport Your body to a mortuary near Your place of primary residence, but not exceeding the Maximum Amount per Member.

Covered expenses under this provision includes: (1) embalming or cremation; (2) the most economical coffins or receptacles adequate for transportation of the remains; and (3) the most economical transportation of the remains by the most direct and economical conveyance and route possible.

In addition to the Exclusions and Limitations in section XVII of the Certificate, Repatriation of Remains benefits are not payable if loss of life is caused in whole or in part by, or results in whole or in part from, any condition for which You are entitled to benefits under any Workers' Compensation Act or similar law.