Student Health Advantage Platinum - Excluding USA

Plan Detail

Plan Administrator:  International Medical Group | AM Best Rating: A "Excellent" | Underwriter: Sirius International

  • PPO Network(Within USA or Canada): 80% of Eligible Expenses after the Deductible up to $5,000, then 100% up to policy max.
  • Eligibility:  A Full time Student & Non US Citizen  Age 14-64 travelling USA to study
  • Coverage length: Min 3months to 12months
  • Provider Network: PPO Providers are contracted separately through First Health Group Corp
  • Renew Online: Provided there is no break in coverage, the plan may be renewed for up to five years
  • Cancel: Before effective date full refund and after policy effective date unused portion of premium minus $50 cancellation fees.
  • ID card & Visa Letter comes in email instantly.

Benefits


Coverage Limit / Maximum Amount for Eligible Medical Expenses
Period of Coverage Maximum Limit: 365 days
Maximum Limit
Insured Person: $1,000,000 Spouse and Child: $100,000
Maximum Limit per Illness or Injury
Insured Person: $500,000 Spouse and Child: $100,000
Area of Coverage Worldwide excluding Insured Person’s Country of Residence
Benefit Plan Features
Benefit Levels
United States United States International
In-Network Out-of-Network International
Deductible for Eligible Medical Expenses
Deductible
  • Per Illness or Injury
$25 $50 $25
Coinsurance for Eligible Medical Expenses
Coinsurance
  • In addition to Deductible
Plan pays 100%
Insured pays 0%
Plan pays 80%
Insured pays 20%
Plan pays 100%
Insured pays 0%
Out of Pocket Maximum
$0 $1,000 $0
Student Health Center
Copayment per visit
  • Not subject to Deductible
$5
Coinsurance Plan pays 100%
Insured pays 0%
Pre-certification
  • Interfacility Ambulance Transfer: No coverage if Pre-certification requirements are not met.
  • Medical Evacuation: No coverage if not approved by the Company. Refer to the EMERGENCY MEDICAL EVACUATION provision for complete requirements and coverage.
  • Maternity: 50% reduction of Eligible Medical Expenses if Pre-certification requirements are not met.
  • All other Treatments & supplies: 50% reduction of Eligible Medical Expenses if Pre-certification requirements are not met.
  • Deductible is taken after reduction.
  • Coinsurance is applied to remainder of the reduced amount.
  • Refer to PRE-CERTIFICATION REQUIREMENTS provision for a complete list of services that require Pre-certification.
Pre-existing Conditions
Charges are excluded until the Insured Person has maintained 6 months of continuous coverage under this insurance.
Inpatient or Outpatient Services
Subject to Deductible and Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable and Customary
Limits per Period of Coverage unless stated as Maximum Limit
Benefit In-Network Out-of-Network International
Physician Visits / Services
  • Maximum Visits per Day: 1
  • Surgery is not subject to the maximum visit limit
100% 80% 100%
Hospital Emergency Room
  • Injury: Not subject to Emergency Room Deductible
  • Illness: Subject to a $250 Deductible for each Emergency Room visit for Treatment that does not result in a direct Hospital admission.
100% 80% 100%
Hospitalization / Room & Board
  • Average semi-private room rate
  • Includes nursing, miscellaneous and Ancillary Services
100% 80% 100%
Intensive Care 100% 80% 100%
Outpatient Surgical / Hospital Facility 100% 80% 100%
Laboratory 100% 80% 100%
Radiology / X-ray 100% 80% 100%
Chemotherapy / Radiation Therapy 100% 80% 100%
Pre-admission Testing 100% 80% 100%
Surgery 100% 80% 100%
Reconstructive Surgery
  • Surgery is incidental to or follows Surgery that was covered under the Plan
100% 80% 100%
Assistant Surgeon
  • 20% of the primary surgeon’s eligible fee
100% 80% 100%
Anesthesia 100% 80% 100%
Durable Medical Equipment 100% 80% 100%
Chiropractic Care
  • Medical order or Treatment plan required
100% 80% 100%
Physical Therapy
  • Maximum Visits per Day: 1
  • Medical order or Treatment plan required
100% 80% 100%
Maternity and Newborn Care
  • Maximum Limit: $5,000
  • Newborn routine care during the first 31 days of life
80% 60% 100%
Extended Care Facility
  • Upon direct transfer from acute care Hospital
100% 80% 100%
Inpatient or Outpatient Services
Subject to Deductible and Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable and Customary
Limits per Period of Coverage unless stated as Maximum Limit
Benefit In-Network Out-of-Network International
Home Nursing Care
  • Provided by a Home Health Care Agency
  • Upon direct transfer from an acute care Hospital
100% 80% 100%
Prescriptions
Subject to Deductible and Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable and Customary
Limits per Period of Coverage unless stated as Maximum Limit
Inpatient 100% 80% 100%
Outpatient Not Applicable 50% 50%
Mental or Nervous / Substance Abuse
Subject to Deductible and Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable and Customary
Limits per Period of Coverage unless stated as Maximum Limit
Inpatient Mental or Nervous / Substance Abuse
  • Maximum Limit: $10,000
  • Not covered if incurred at the Student Health Center
100% 80% 100%
Outpatient Mental or Nervous / Substance Abuse
  • Maximum Limit per Day: $50
  • Maximum Limit: $500
  • Not covered if incurred at the Student Health Center
100% 80% 100%
Emergency Services
NOT Subject to Deductible and Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable and Customary
Limits per Period of Coverage unless stated as Maximum Limit
Emergency Local Ambulance
  • Period of Coverage Limit per Injury: $750
  • Period of Coverage Limit per Illness $750
(resulting in an Inpatient Hospitalization)
100% 100% 100%
Emergency Medical Evacuation
  • Maximum Limit: $500,000
  • Must be approved in advance and coordinated by the Company
100% 100% 100%
Emergency Reunion
  • Maximum Limit: $50,000
  • Maximum Days: 15
  • Meal Maximum per Day: $25
  • Reasonable and necessary travel costs and accommodations
  • Must be approved in advance by the Company
100% 100% 100%
Emergency Services
NOT Subject to Deductible and Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable and Customary
Limits per Period of Coverage unless stated as Maximum Limit
Benefit In-Network Out-of-Network International
Interfacility Ambulance Transfer
  • Services rendered in the United States
  • Transfer must be a result of an Inpatient Hospitalization
100% 100% Not Applicable
Political Evacuation and Repatriation
  • Maximum Limit: $10,000
  • Must be approved in advance by the Company
100% 100% 100%
Return of Mortal Remains
  • Maximum Limit: $50,000
  • Local Burial / Cremation at place of death
    • Maximum Limit: $5,000
  • Return of Insured Person’s Mortal Remains to Country of Residence
  • Must be approved in advance by the Company
100% 100% 100%
Other Services
Subject to Deductible and Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable and Customary
Limits per Period of Coverage unless stated as Maximum Limit
Accidental Death & Dismemberment
  • Not subject to Deductible and Coinsurance
  • Death must occur within 90 days of the Accident
Accidental Death Principal Sum:
Insured Person
Spouse
Child

$25,000
$10,000
$5,000
Accidental Dismemberment:
Loss
Sight of one eye
One hand or one foot
One hand and the loss of sight of one eye
One foot and the loss of sight of one eye
One hand and one foot
Both hands or both feet
Sight of both eyes

Percent of Principal Sum
50%
50%
100%
100%
100%
100%
100%
Dental Treatment
  • Period of Coverage Limit: $350 (Treatment due to Unexpected pain to sound, natural teeth)
  • Period of Coverage Limit per Injury: $500 (Non-emergency Treatment by a Dental Provider due to an Accident)
Not Applicable 80% 100%
Other Services
Subject to Deductible and Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable and Customary
Limits per Period of Coverage unless stated as Maximum Limit
Benefit In-Network Out-of-Network International
Traumatic Dental Injury
  • Treatment at a Hospital Facility due to an Accident
  • Additional Treatment for the same Injury rendered by a Dental Provider will be paid at 100%
100% 80% 100%
Incidental Trip
  • Maximum Days: 14
  • Insured Person’s Country of Residence is not the United States
  • Refer to the INCIDENTAL TRIP provision for further details
100% 80% 100%
Intercollegiate, Interscholastic, Intramural, or Club Sports
  • Period of Coverage Limit per Illness or Injury: $5,000
100% 80% 100%
Personal Liability
  • Secondary to any other insurance
  • No coverage for Injury to a related Third Party or damage to related Third Person’s property
  • Refer to the PERSONAL LIABILITY provision for further details and requirements
Combined Maximum Limit: $10,000
Injury to Third Person:
  • Per Injury Deductible: $100

Damage to Third Person’s property:
  • Per damage Deductible: $100
Terrorism
  • Not subject to Deductible and Coinsurance
  • Maximum Limit: $50,000
100% 100% 100%