Visit USA HealthCare - Budget

Plan Detail

Plan Administrator: USI Affinity Travel Insurance Services | AM Best Rating: A+ "Superior" | Underwriter: Lloyd's of London

Eligibility: Non US citizen age 0-99 traveling to USA Only
Coverage Length: Maximum up to 364 days.
Renew Online: Non Renewable.
Acute Onset of Pre-X Coverage: Ages 65 and above: $2,500 All others: $20,000
Provider Network: Member will be receiving treatment by accessing the Internet website for HCC Medical Insurance Services, LLC at: www.hccmis.com.
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Benefits Pre-existing Coverage Description Exclusions Cancel Claims Provider Network

Benefits

SCHEDULE OF BENEFITS AND LIMITS

All benefits, except Emergency Medical Evacuation, Repatriation of Remains, Local Burial or Cremation, and Emergency Reunion, are subject to deductible and are per injury or illness, up to the overall policy maximum, unless stated otherwise.

DEDUCTIBLE
	Plan A	Plan B
Ages 14 days - 69 years	$0, $50, $100, or $250
Age 70 and above	$100 or $250
OVERALL POLICY MAXIMUM
	Plan A	Plan B
Ages 14 days - 69 years	$50,000	$150,000
Ages 70-79	$50,000
Ages 80 and above	$20,000
INPATIENT TREATMENT
	Plan A	Plan B
Hospital Room &Board, including miscellaneous unless specified	$1,500 per day, 30 days max	$2,750 per day, 30 days max
Intensive Care Unit, including miscellaneous unless specified	$2,500 per day, 8 days max	$4,000 per day, 8 days max
Surgery	$4,000 per session	$8,000 per session
Consultant physician	$450	$650
Private duty nurse	$550	$700
Physician visits	$75 per visit, 30 visits max	$125 per visit, 30 visits max
INPATIENT TREATMENT
	Plan A	Plan B
Surgery	$3,300 per session	$7,150 per session
Outpatient Surgical Facility	$1,100	$1,500
Pre-admission Testing	$1,100	$1,450
Diagnostic X-ray and Labs	$500, plus $400 for one CAT Scan, MRI or PET	$750, plus $650 for one CAT Scan, MRI or PET
Emergency Room (all expenses incurred therein)	$375	$785
Observation Room Services (all expenses incurred therein)	$355	$750
Outpatient Prescription Drugs	$150	$300
Office Visits, including Urgent Care	$75 per visit, 10 visits max	$150 per visit, 10 visits max
MISCELLANEOUS INPATIENT & OUTPATIENT TREATMENT
	Plan A	Plan B
Anesthesiologist	$825	$1,775
Assistant Surgeon	$825	$1,775
Local Ambulance	$500	$500
Physical Therapy	$50 per visit, 1 visit per day, maximum 12 visits
Durable Medical Equipment	$1,100	$1,700
Acute Onset of Pre-existing Conditions	Ages 65 and above: $2,500 All others: $20,000	Ages 65 and above: $2,500 All others: $20,000
Acute Onset of Pre-existing Conditions	$25,000 Lifetime Maximum for Emergency Medical Evacuation
Terrorism	Up to $25,000, eligible medical expenses only
OTHER BENEFITS Not subject to deductible or overall policy maximum
	Plan A	Plan B
Emergency Medical Evacuation	$100,000 Lifetime Maximum, except as provided under Acute Onset of Pre-existing Condition.
Repatriation of Remains	$25,000
Local Burial & Cremation	$5,000
Emergency Reunion	$15,000, subject to a maximum of 15 days - not subject to deductible or coinsurance