attached to and made part of

Blue Cross and Blue Shield of Massachusetts, Inc.

Blue Care Elect Preferred Provider Plan Subscriber Certificate
and
Prescription Drug Plan Subscriber Certificate

Student Health Policy

You are enrolled in the student health plan sponsored by the institution of higher education (the group)
that has entered into an agreement (a group “contract”) with Blue Cross and Blue Shield of
Massachusetts, Inc. to provide health care benefits to eligible students and their eligible dependents. Your
plan sponsor is the institution of higher education.

You hereby expressly acknowledge your understanding that the group contract constitutes a contract
solely between your group on your behalf and Blue Cross and Blue Shield of Massachusetts, Inc., which
is a corporation independent of and operating under a license from the Blue Cross and Blue Shield
Association, an association of independent Blue Cross and Blue Shield Plans (the “Association”),
permitting Blue Cross and Blue Shield to use the Blue Cross and Blue Shield Service Marks in the
Commonwealth of Massachusetts, and that Blue Cross and Blue Shield is not contracting as the agent of
the Association. You further acknowledge and agree that your group on your behalf has not entered into
the group contract based upon representations by any person other than Blue Cross and Blue Shield and
that no person, entity, or organization other than Blue Cross and Blue Shield will be held accountable or
liable to you or your group on your behalf for any of Blue Cross and Blue Shield’s obligations to you
created under the group contract. This paragraph will not create any additional obligations whatsoever on
the part of Blue Cross and Blue Shield other than those obligations created under other provisions of the
group contract.

Eligibility and Enrollment for Student Health Plan

Coverage
Eligible Student
You are eligible for coverage under the group’s student health plan as long as you are a student enrolled in
a certificate, diploma, or degree-granting program through the group and you are either:
 A full-time student who meets the minimum academic requirements for full-time students set by the
group; or
 A part-time student who participates in at least 75% of the academic requirements for full-time
students.

Automatic Enrollment
An eligible student will be automatically enrolled in the group’s student health plan by the group. The
group may allow an eligible student to waive enrollment in the group’s student health plan if he or she has
coverage in another health plan that is comparable to the coverage that is required by law for a student
health plan. For enrollment information or details about waiving coverage in the group’s student health
plan, you must contact the group. You must also contact the group if you would like to request the group’s
written policy regarding partial year student enrollment.

Premium Payments
For coverage in the group’s student health plan, the group will include the enrolled student’s total
premium amount in the student’s tuition bill. Then each month, the group will pay the monthly premium
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amount to Blue Cross and Blue Shield for your coverage in the group’s student health plan. For more
information about your premium or if you would like to request the group’s written policy regarding
premium refunds, you must contact the group.

Eligible Spouse
An eligible student who is enrolled in the group’s student health plan may enroll an eligible spouse for
coverage under his or her student health plan membership. An “eligible spouse” includes the enrolled
student’s legal spouse. (A legal civil union spouse, where applicable, is eligible to enroll under the
student’s student health plan membership to the extent that a legal civil union spouse is determined
eligible by the group. For more details, contact your plan sponsor.)

Former Spouse
In the event of a divorce or a legal separation, the person who was the spouse of the enrolled student prior
to the divorce or legal separation will remain eligible for coverage under the enrolled student’s student
health plan membership, whether or not the judgment was entered prior to the effective date of the
enrolled student’s student health plan membership. This coverage is provided with no additional premium
other than the normal cost of covering a current spouse. The former spouse will remain eligible for this
coverage only until the enrolled student is no longer required by the judgment to provide health insurance
for the former spouse or the enrolled student or former spouse remarries, whichever comes first. In these
situations, Blue Cross and Blue Shield must be notified within 30 days of a change to the enrolled
student’s former spouse’s address. Otherwise, Blue Cross and Blue Shield will not be liable for any acts or
omissions due to having the enrolled student’s former spouse’s incorrect address on file. If the enrolled
student remarries, the former spouse may continue coverage under a separate student health plan
membership with the group, provided the divorce judgment requires that the enrolled student provide
health insurance for the former spouse. This is true even if the enrolled student’s new spouse is not
enrolled under the enrolled student’s student health plan membership.

Domestic Partner
As determined by the group, an enrolled student may have the option to enroll an eligible domestic
partner (instead of an eligible spouse) under his or her student health plan membership. (If the group’s
student health plan does not include a domestic partner rider, this section does not apply to you.) A
“domestic partner” is a person with whom the enrolled student has entered into an exclusive relationship.
This means that both the enrolled student and domestic partner: are 18 years of age or older and of legal
age of consent in the state where they reside; are competent to enter into a legal contract; share the same
residence and must intend to continue to do so; are jointly responsible for basic living costs; are in a
relationship of mutual support, caring, and commitment in which they intend to remain; are not married to
anyone else; and are not related to each other by adoption or blood to a degree of closeness that would
otherwise bar marriage in the state in which they live. A “domestic partner” may also include a person
with whom the enrolled student has registered as a domestic partner with any governmental domestic
registry (whether or not all of the conditions stated above have been met). If the enrolled student enrolls
an eligible domestic partner under his or her student health plan membership, the domestic partner’s
dependent children are eligible for coverage to the same extent that the enrolled student’s dependent
children are eligible for coverage under his or her student health plan membership. If the enrolled student
terminates the domestic partnership, the former domestic partner and any children of a former domestic
partner are no longer eligible for coverage.

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Eligible Dependents
An eligible student who is enrolled in the group’s student health plan may enroll eligible dependents
under his or her student health plan membership. “Eligible dependents” include the enrolled student’s (or
his or her spouse’s or, if applicable, domestic partner’s) children who are under age 26. To be an eligible
dependent, a child under age 26 is not required to live with the enrolled student or the enrolled student’s
spouse (or domestic partner), be a dependent on the enrolled student’s or the spouse’s (or domestic
partner’s) tax return, or be a full-time student. These eligible dependents may include:
 A newborn child. The effective date of coverage for a newborn child will be the child’s date of birth
provided that the enrolled student formally notifies the group within 30 days of the date of birth. (A
claim for the enrolled mother’s maternity admission may be considered to be this notice when the
enrolled student’s coverage is a family plan.) The group’s student health plan provides coverage for
newborn infants for injury and sickness. This includes the necessary care and treatment of medically
diagnosed congenital defects, birth abnormalities, and premature birth. The coverage for these
services is subject to all of the provisions of the group’s student health plan.
 An adopted child. The effective date of coverage for an adopted child will be the date of placement
with the enrolled student for the purpose of adoption. The effective date of coverage for an adoptive
child who has been living with the enrolled student and for whom the enrolled student has been
getting foster care payments will be the date the petition to adopt is filed. If the enrolled student is
enrolled under a family plan as of the date he or she assumes custody of a child for the purpose of
adoption, the child’s health care services for injury or sickness will be covered from the date of
custody. (This coverage is provided without a waiting period or pre-existing condition restriction.)
This includes the necessary care and treatment of medically diagnosed congenital defects, birth
abnormalities and premature birth. The coverage for these services is subject to all of the provisions
of the group’s student health plan.
 A newborn infant of an enrolled dependent child immediately from the moment of birth and
continuing after, until the enrolled dependent child is no longer eligible as a dependent.

If an eligible dependent child is married, the dependent child can enroll for coverage under the enrolled
student’s membership. And, as long as that enrolled child is an eligible dependent, his or her children are
also eligible for coverage under the enrolled student’s membership. The dependent child’s spouse is not
eligible to enroll as a dependent for coverage under the enrolled student’s membership.

An eligible dependent may also include:

 A person under age 26 who is not the enrolled student’s (or the student’s spouse’s or, if applicable,
domestic partner’s) child but who qualifies as a dependent of the enrolled student under the Internal
Revenue Code. When the dependent loses his or her dependent status under the Internal Revenue
Code, that dependent will continue to be eligible as a dependent for coverage in the group’s student
health plan under the enrolled student’s membership for two years after the end of the calendar year
in which he or she last qualified as a dependent under the Internal Revenue Code or until the
dependent turns age 26, whichever comes first.
 A child recognized under a Medical Child Support Order as having the right to enroll for health care
coverage.
 A disabled dependent child age 26 or older. A dependent child who is mentally or physically
incapable of earning his or her own living and who is enrolled under the enrolled student’s
membership will continue to be covered after he or she would otherwise lose dependent eligibility for
coverage under the enrolled student’s membership, so long as the child continues to be mentally or
physically incapable of earning his or her own living. In this case, the enrolled student must make
arrangements with Blue Cross and Blue Shield not more than 30 days after the date the child would
normally lose eligibility. Also, Blue Cross and Blue Shield must be given any medical or other
information that it may need to determine if the child can maintain coverage in the group’s student
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health plan under the enrolled student’s membership. From time to time, Blue Cross and Blue Shield
may conduct reviews that will require a statement from the attending physician. This is to confirm
that the child is still an eligible disabled dependent child.

Important The eligibility provisions for dependents that are described in this section may differ from
Reminder: the federal tax laws that define who may qualify as a dependent.

Membership Changes
Generally, the enrolled student may make membership changes (for example, change from a student-only
plan to a family plan) only if he or she has a change in family status. This includes a change such as:
marriage or divorce; birth, adoption or change in custody of a child; death of an enrolled spouse or
dependent; or the loss of an enrolled dependent’s eligibility under the enrolled student’s student health
plan membership. If you want to ask for a membership change or you need to change your name or
mailing address, you should call or write to your plan sponsor. The plan sponsor will send you any
special forms you may need. You must request the change within the time period required by the group to
make a change. All changes are allowed only when they comply with the eligibility and enrollment rules
set by the plan sponsor for the group’s student health plan and they must also comply with applicable
laws and regulations.

Termination of Coverage
When your eligibility for the group’s student health plan ends, your coverage in this health plan will be
terminated as of the date you lose eligibility. Your eligibility ends when:
 You are no longer an “eligible student” as determined by the group. In the event that a spouse
and/or dependents are enrolled under the student’s membership, their coverage will also be terminated
as of the date the student loses eligibility for coverage in the group’s student health plan. The
coverage for the student’s enrolled spouse and/or dependents will also be terminated in the event the
enrolled student dies.
 You are enrolled as a dependent and you lose your status as an eligible dependent under the
enrolled student’s membership.

Whether you are the enrolled student or you are the enrolled student’s spouse or other enrolled dependent,
your coverage in this health plan will end when:
 The group fails to pay your premium for your coverage in the group’s student health plan to Blue
Cross and Blue Shield within 30 days of the due date.
 The group’s contract with Blue Cross and Blue Shield is terminated (or is not renewed).
 You commit misrepresentation or fraud to Blue Cross and Blue Shield. For example, you misused the
ID card by letting another person not enrolled in the group’s student health plan attempt to get
coverage. Termination will go back to your effective date. Or, it will go back to the date of the
misrepresentation or fraud, as determined by Blue Cross and Blue Shield, subject to applicable federal
law. Or, in some cases Blue Cross and Blue Shield may limit your benefits.
 You commit acts of physical or verbal abuse that pose a threat to, or a threat to the health of, health
care providers or other members or employees of Blue Cross and Blue Shield or Blue Cross and Blue
Shield of Massachusetts HMO Blue, Inc., and these acts are not related to your physical condition or
mental condition. In this case, this termination will follow the procedures that have been approved by
the Massachusetts Commissioner of Insurance.

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 You fail to comply in a material way with any provision of this health plan. For example, if you fail to
provide information that Blue Cross and Blue Shield requests related to your coverage in this health
plan, Blue Cross and Blue Shield may terminate your coverage.
 Blue Cross and Blue Shield discontinues this health plan. Blue Cross and Blue Shield may discontinue
this health plan for any reason as of a date approved by the Massachusetts Commissioner of
Insurance.

Medicare Program
Generally, the benefits that are available under the group’s student health plan are secondary to or in
excess of the benefits provided by Medicare. This means that when you are eligible for Medicare and
Medicare is allowed by federal law to be the primary payor, the coverage provided by the group’s student
health plan will be reduced by the amount of benefits allowed under Medicare for the same covered
services. This reduction will be made whether or not you actually receive the benefits from Medicare.

All other provisions remain as described in your Subscriber Certificate.

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