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SCHEDULE OF BENEFITS
MEDICAL EXPENSE BENEFITS
IHC-SP GLOBAL-GLOBAL CARE PREFERRED - STUDENT PLAN
INJURY AND SICKNESS BENEFITS
Maximum Benefit
No Overall Maximum Dollar Limit
(Per Insured Person, Per Policy Year)
Deductible Preferred Provider
$50 (Per Insured Person, Per Policy Year)
Deductible Out-of-Network
$300 (Per Insured Person, Per Policy Year)
Coinsurance Preferred Provider
90% except as noted below
Coinsurance Out-of-Network
70% except as noted below
Out-of-Pocket Maximum Preferred Provider $5,000 (Per Insured Person, Per Policy Year)
Out-of-Pocket Maximum Preferred Provider $10,000 (For all Insureds in a Family, Per Policy Year)
Out-of-Pocket Maximum Out-of-Network
$7,000 (Per Insured Person, Per Policy Year)
Out-of-Pocket Maximum Out-of-Network
$14,000 (For all Insureds in a Family, Per Policy Year)
Eligible students have a choice of insurance plans. Please review the benefits and make your selections carefully. You cannot
upgrade coverage after the initial purchase for the policy year.
The Preferred Provider for this plan is UnitedHealthcare Options PPO.
If care is received from a Preferred Provider any Covered Medical Expenses will be paid at the Preferred Provider level of benefits. If
a Preferred Provider is not available in the Network Area, benefits will be paid at the level of benefits shown as Preferred Provider
benefits. If the Covered Medical Expense is incurred due to a Medical Emergency, benefits will be paid at the Preferred Provider
level of benefits. In all other situations, reduced or lower benefits will be provided when an Out-of-Network provider is used.
Out-of-Pocket Maximum: After the Out-of-Pocket Maximum has been satisfied, Covered Medical Expenses will be paid at 100%
for the remainder of the Policy Year subject to any benefit maximums or limits that may apply. Separate Out-of-Pocket Maximums
apply to Preferred Provider and Out-of-Network benefits. The policy Deductible, Copays and per service Deductibles will be applied
to the Out-of-Pocket Maximum. Services that are not Covered Medical Expenses and the amount benefits are reduced for failing to
comply with policy provisions or requirements do not count toward meeting the Out-of-Pocket Maximum. Even when the Out-of-
Pocket Maximum has been satisfied, the Insured Person will still be responsible for Out-of-Network per service Deductibles.
Student Health Center Benefits: The Preferred Provider Deductible will be waived when treatment is rendered at the SHC.
The benefits payable are as defined in and subject to all provisions of this policy and any endorsements thereto. Benefits are subject to
the policy Maximum Benefit unless otherwise specifically stated. Benefits will be paid up to the maximum benefit for each service as
scheduled below. All benefit maximums are combined Preferred Provider and Out-of-Network unless otherwise specifically stated.
Inpatient
Preferred Provider
Out-of-Network Provider
Room & Board:
Preferred Allowance
Usual and Customary Charges
Intensive Care:
Preferred Allowance
Usual and Customary Charges
Hospital Miscellaneous:
Preferred Allowance
Usual and Customary Charges
Routine Newborn Care:
Paid as any other Sickness
Paid as any other Sickness
(4 days Hospital Confinement expense maximum)
Physiotherapy:
Preferred Allowance
Usual and Customary Charges
Surgery:
Preferred Allowance
Usual and Customary Charges
Assistant Surgeon:
Preferred Allowance
Usual and Customary Charges
Preferred Allowance
Usual and Customary Charges
Registered Nurse's Services:
Preferred Allowance
Usual and Customary Charges
Physician's Visits:
Preferred Allowance
Usual and Customary Charges
Pre-admission Testing:
Preferred Allowance
Usual and Customary Charges
COL-12C SOB PPO
Outpatient
Preferred Provider
Out-of-Network Provider
Surgery:
Preferred Allowance
Usual and Customary Charges
Day Surgery Miscellaneous:
Preferred Allowance
Usual and Customary Charges
(Day Surgery Miscellaneous charges are based on the Outpatient Surgical Facility Charge Index)
Assistant Surgeon:
Preferred Allowance
Usual and Customary Charges
Preferred Allowance
Usual and Customary Charges
Physician's Visits:
Preferred Allowance
Usual and Customary Charges
$20 Copay per visit
Preferred Allowance
Usual and Customary Charges
Medical Emergency:
Preferred Allowance
Usual and Customary Charges
$150 Copay per visit
$150 Deductible per visit
(The Copay/per visit Deductible will be waived if admitted to the Hospital)
X-rays:
Preferred Allowance
Usual and Customary Charges
Radiation Therapy:
Preferred Allowance
Usual and Customary Charges
Laboratory:
Preferred Allowance
Usual and Customary Charges
Tests & Procedures:
Preferred Allowance
Usual and Customary Charges
Injections:
Preferred Allowance
Usual and Customary Charges
Preferred Allowance
Usual and Customary Charges
*Prescription Drugs:
UnitedHealthcare Pharmacy (UHCP)
$15 Copay per prescription for Tier 1 20% Coinsurance per prescription for Tier 2 30% Coinsurance per prescription for Tier 3 up to a 31 day supply per prescription
Ambulance:
Preferred Allowance
Usual and Customary Charges
Durable Medical Equipment:
Preferred Allowance
Usual and Customary Charges
($10,000 maximum (Per Policy Year))
Consultant:
Preferred Allowance
Usual and Customary Charges
$20 Copay per visit
90% of Usual and Customary Charges
90% of Usual and Customary Charges
($250 maximum per tooth) ($1,000 maximum (Per Policy Year)) (Benefits paid on Injury to Sound, Natural Teeth only.)
Maternity:
Paid as any other Sickness
Paid as any other Sickness
Elective Abortion:
Preferred Allowance
Usual and Customary Charges
($1,500 maximum (Per Policy Year))
Complications of Pregnancy:
Paid as any other Sickness
Paid as any other Sickness
Benefits provided by FrontierMEDEX
Benefits provided by FrontierMEDEX
Medical Evacuation:
Benefits provided by FrontierMEDEX
Benefits provided by FrontierMEDEX
($1,250 - $5,000 maximum)
CAT Scan/MRI:
Preferred Allowance
Usual and Customary Charges
$100 Copay per visit
$100 Deductible per visit
Preventive Care Services:
100% of Preferred Allowance
Diabetes Services:
Paid as any other Sickness
Paid as any other Sickness
Mental Illness Treatment:
Paid as any other Sickness
Paid as any other Sickness
Reconstructive Breast Surgery
Paid as any other Sickness
Paid as any other Sickness
Following Mastectomy:
Substance Use Disorder
Paid as any other Sickness
Paid as any other Sickness
Treatment:
Urgent Care Center:
Preferred Allowance
Usual and Customary Charges
$50 Copay per visit
$50 Deductible per visit
COL-12C SOB PPO
MAJOR MEDICAL
Maximum Benefit
No Benefits
CATASTROPHIC MEDICAL
Maximum Benefit
No Benefits
*SHC Referral Required: Yes ( ) No (X) Continuation Permitted: Yes ( ) No (X)
*Pre-Admission Notification: Yes (X) No ( )
( ) 52 week Benefit Period or (X) Extension of Benefits
Other Insurance: (X) *Excess Insurance
( ) Excess Motor Vehicle
( ) Primary Insurance
*If benefit is designated, see endorsement attached.
COL-12C SOB PPO
PREFERRED PROVIDER INFORMATION
"Preferred Providers" are the Physicians, Hospitals and other health care providers who have contracted to provide specific
medical care at negotiated prices. Preferred Providers in the local school area are:
UnitedHealthcare Options PPO.
The availability of specific providers is subject to change without notice. Insureds should always confirm that a Preferred
Provider is participating at the time services are required by calling the Company at 1-888-251-6253 and/or by asking the
provider when making an appointment for services.
"Preferred Allowance" means the amount a Preferred Provider will accept as payment in full for Covered Medical Expenses.
"Out of Network" providers have not agreed to any prearranged fee schedules. Insureds may incur significant out-of-pocket
expenses with these providers. Charges in excess of the insurance payment are the Insured's responsibility.
"Network Area" means the 50 mile radius around the local school campus the Named Insured is attending.
Regardless of the provider, each Insured is responsible for the payment of their Deductible. The Deductible must be satisfied
before benefits are paid. The Company will pay according to the benefit limits in the Schedule of Benefits.
Inpatient Expenses
PREFERRED PROVIDERS – Eligible Inpatient expenses at a Preferred Provider will be paid at the Coinsurance percentages
specified in the Schedule of Benefits, up to any limits specified in the Schedule of Benefits. Preferred Hospitals include
UnitedHealthcare Options PPO United Behavioral Health (UBH) facilities. Call (888) 251-6253 for information about
Preferred Hospitals.
OUT-OF-NETWORK PROVIDERS - If Inpatient care is not provided at a Preferred Provider, eligible Inpatient expenses
will be paid according to the benefit limits in the Schedule of Benefits.
Outpatient Hospital Expenses
Preferred Providers may discount bills for outpatient Hospital expenses. Benefits are paid according to the Schedule of
Benefits. Insureds are responsible for any amounts that exceed the benefits shown in the Schedule, up to the Preferred
Allowance.
Professional & Other Expenses
Benefits for Covered Medical Expenses provided by UnitedHealthcare Options PPO will be paid at the Coinsurance
percentages specified in the Schedule of Benefits or up to any limits specified in the Schedule of Benefits. All other providers
will be paid according to the benefit limits in the Schedule of Benefits.
EXCLUSIONS AND LIMITATIONS
No benefits will be paid for: a) loss or expense caused by, contributed to, or resulting from; or b) treatment, services or supplies for, at, or related to any of the following: 1. Acupuncture;
3. Congenital conditions, except as specifically provided for Newborn or adopted Infants;
4. Cosmetic procedures, except cosmetic surgery required to correct an Injury for which benefits are otherwise payable
under this policy or for newborn or adopted children;
5. Custodial Care; care provided in: rest homes, health resorts, homes for the aged, halfway houses, college infirmaries or
places mainly for domiciliary or Custodial Care; extended care in treatment or substance abuse facilities for domiciliary or Custodial Care;
6. Dental treatment, except for accidental Injury to Sound, Natural Teeth;
7. Elective Surgery or Elective Treatment; 8. Eye examinations, eye refractions, eyeglasses, contact lenses, prescriptions or fitting of eyeglasses or contact lenses,
vision correction surgery, or other treatment for visual defects and problems; except when due to a covered Injury or disease process;
9. Health spa or similar facilities; strengthening programs;
10. Immunizations, except as specifically provided in the policy; preventive medicines or vaccines, except where required
for treatment of a covered Injury or as specifically provided in the policy;
11. Injury or Sickness for which benefits are paid or payable under any Workers' Compensation or Occupational Disease
Law or Act, or similar legislation;
12. Injury or Sickness inside the Insured's home country;
13. Injury or sickness outside the United States and its possessions, except when traveling for academic study abroad
programs, business or pleasure, or to or from the Insured's home country;
14. Injury or Sickness when claims payment and/or coverage is prohibited by applicable law;
15. Injury sustained while (a) participating in any interscholastic, intercollegiate or professional sport, contest or
competition; (b) traveling to or from such sport, contest or competition as a participant; or (c) while participating in any practice or conditioning program for such sport, contest or competition;
16. Investigational services;
17. Participation in a riot or civil disorder; commission of or attempt to commit a felony;
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18. Prescription Drugs, services or supplies as follows:
Therapeutic devices or appliances, including: hypodermic needles, syringes, support garments and other non-medical substances, regardless of intended use, except as specifically provided in the policy;
Immunization agents, except as specifically provided in the policy, biological sera, blood or blood products administered on an outpatient basis;
Drugs labeled, "Caution - limited by federal law to investigational use" or experimental drugs;
Products used for cosmetic purposes;
Drugs used to treat or cure baldness; anabolic steroids used for body building;
Anorectics - drugs used for the purpose of weight control;
Fertility agents or sexual enhancement drugs, such as Parlodel, Pergonal, Clomid, Profasi, Metrodin, Serophene, or Viagra;
Growth hormones; or
Refills in excess of the number specified or dispensed after one (1) year of date of the prescription.
19. Reproductive/Infertility services including but not limited to: family planning; fertility tests; infertility (male or female),
including any services or supplies rendered for the purpose or with the intent of inducing conception; premarital examinations; impotence, organic or otherwise; female sterilization procedures, except as specifically provided in the policy; vasectomy; sexual reassignment surgery; reversal of sterilization procedures;
20. Research or examinations relating to research studies, or any treatment for which the patient or the patient's
representative must sign an informed consent document identifying the treatment in which the patient is to participate as a research study or clinical research study;
21. Routine Newborn Infant Care, well-baby nursery and related Physician charges; in excess of 48 hours for vaginal
delivery or 96 hours for cesarean delivery;
22. Preventive care services; routine physical examinations and routine testing; preventive testing or treatment; screening
exams or testing in the absence of Injury or Sickness; except as specifically provided in the policy;
23. Services provided normally without charge by the Health Service of the institution attended by the Insured; or services
covered or provided by a student health fee;
24. Deviated nasal septum, including submucous resection and/or other surgical correction thereof; nasal and sinus surgery,
except for treatment of a covered Injury or treatment of chronic purulent sinusitis;
25. Skydiving, parachuting, hang gliding, glider flying, parasailing, sail planing, bungee jumping, or flight in any kind of
aircraft, except while riding as a passenger on a regularly scheduled flight of a commercial airline;
26. Supplies, except as specifically provided in the policy;
27. Surgical breast reduction, breast augmentation, breast implants or breast prosthetic devices, or gynecomastia; except as
specifically provided in the policy;
28. Treatment in a Government hospital, unless there is a legal obligation for the Insured Person to pay for such treatment; 29. War or any act of war, declared or undeclared; or while in the armed forces of any country (a pro-rata premium will be
refunded upon request for such period not covered); and
30. Weight management, weight reduction, nutrition programs, treatment for obesity, surgery for removal of excess skin or
202818-91
POLICY ENDORSEMENT
In consideration of the premium charged, it is hereby understood and agreed that the policy to which this endorsement
is attached is amended as follows:
EXCESS PROVISION
No benefit of this policy is payable for any expense incurred for Injury or Sickness which is paid or payable by: 1) other valid and collectible insurance; or, 2) under an automobile insurance policy. This Excess Provision will not be applied to the first $100 of medical expenses incurred. Covered Medical Expenses excludes amounts not covered by the primary carrier due to penalties imposed on the Insured for failing to comply with policy provisions or requirements.
This endorsement takes effect and expires concurrently with the policy to which it is attached, and is subject to all of the
terms and conditions of the policy not inconsistent therewith.
COL-12C END (5A)
202818-91
POLICY ENDORSEMENT
In consideration of the premium charged, it is hereby understood and agreed that the policy to which this endorsement
is attached is amended as follows:
ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS
Loss of Life, Limb or Sight If such Injury shall independently of all other causes and within 180 days from the date of Injury solely result in any one of the
following specific losses, the Insured Person or beneficiary may request the Company to pay the applicable amount below.
Payment under this endorsement when added to payment under the "Basic Medical Expense Benefit" (and under Major
Medical, if coverage is afforded under Major Medical) shall not exceed the policy Maximum Benefit.
For Loss Of:
Two or More Members
Thumb or Index Finger
Member means hand, arm, foot, leg, or eye. Loss shall mean with regard to hands or arms and feet or legs, dismemberment by severance at or above the wrist or ankle joint; with regard to eyes, entire and irrecoverable loss of sight. Only one specific loss (the greater) resulting from any one Injury will be paid.
This endorsement takes effect and expires concurrently with the policy to which it is attached, and is subject to all of the
terms and conditions of the policy not inconsistent therewith.
COL-12C END (6A)
202818-91
POLICY ENDORSEMENT
In consideration of the premium charged, it is hereby understood and agreed that the policy to which this endorsement
is attached is amended as follows:
PRE-ADMISSION NOTIFICATION
UnitedHealthcare should be notified of all Hospital Confinements prior to admission.
1.
PRE-NOTIFICATION OF MEDICAL NON-EMERGENCY HOSPITALIZATIONS: The patient, Physician or
Hospital should telephone 1-877-295-0720 at least five working days prior to the planned admission.
2.
NOTIFICATION OF MEDICAL EMERGENCY ADMISSIONS: The patient, patient's representative, Physician
or Hospital should telephone 1-877-295-0720 within two working days of the admission to provide notification of any admission due to Medical Emergency.
UnitedHealthcare is open for Pre-Admission Notification calls from 8:00 a.m. to 6:00 p.m. C.S.T., Monday through Friday.
Calls may be left on the Customer Service Department's voice mail after hours by calling 1-877-295-0720.
IMPORTANT: Failure to follow the notification procedures will not affect benefits otherwise payable under the policy;
however, pre-notification is not a guarantee that benefits will be paid.
This endorsement takes effect and expires concurrently with the policy to which it is attached, and is subject to all of the
terms and conditions of the policy not inconsistent therewith.
COL-12C END (7)
202818-91
BENEFITS FOR DRUG TREATMENT OF CANCER OR LIFE THREATENING CONDITIONS
Source: http://www.visitinsurance.com/Global%20Care%20-%20Preferred%20-%20SOB%20and%20Excl.pdf
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