Visit USA HealthCare - Standard

Plan Detail

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

Benefits


SCHEDULE OF BENEFITS AND LIMITS

Plan Details

 
Overall Maximum Limit Up through age 69: $75,000 or $200,000
Age 70 to 79: $75,000
Age 80+: $20,000
Maximum per Injury / Illness Up through age 69: $75,000 or $200,000
Age 70 to 79: $75,000
Age 80+: $20,000
Deductibles $0, $250, $500, or $1,000 per certificate period
Coinsurance – Claims incurred outside U.S. We will pay 100% of eligible expenses after the deductible up to the overall maximum limit.
Coinsurance – Claims incurred in U.S.  
In-Network Payment Within the PPO: We will pay 100% of eligible expenses, after the deductible, to the overall maximum limit.
Out-of-Network Payment Outside the PPO: Usual, reasonable, and customary. You may be responsible for any charges exceeding the payable amount.

Eligible expenses are subject to deductible, coinsurance, overall maximum limit, and are per certificate period unless specifically indicated otherwise.

Benefit Limit
Hospital Room and Board Average semi-private room rate, including nursing services
Intensive Care Unit Up to the overall maximum limit
Local Ambulance Usual, reasonable and customary charges, when covered illness or injury results in hospitalization as inpatient.
Emergency Room Co-payment Claims incurred outside the U.S.
No co-payment

Claims incurred in U.S.
You shall be responsible for a $250 co-payment for each use of emergency room for an illness unless you are admitted to the hospital. There will be no co-payment for emergency room treatment of an injury.
Urgent Care Center Co-payment Claims incurred outside the U.S.
No co-payment

Claims incurred in U.S.
For each visit, you shall be responsible for a $50 co-payment, after which coinsurance will apply.
– Co-payment is waived for members with a $0 deductible.
– not subject to deductible
Outpatient Physical Therapy and Chiropractic Care Usual, reasonable and customary charges. Must be ordered in advance by a physician.
Emergency Dental Treatment due to Accident Up to $1,000
Emergency Dental (Acute Onset of Pain) Up to $100 - not subject to deductible or coinsurance
Acute Onset of Pre-existing Condition (excludes chronic and congenital conditions) Ages 65 and above: $2,500
All others: $20,000
Terrorism Up to $50,000 lifetime maximum, eligible medical expenses only
All Other Eligible Medical Expenses Up to the overall maximum limit
Emergency Travel Benefits Limit
Emergency Medical Evacuation Up to $250,000 lifetime maximum - not subject to deductible, coinsurance, or overall maximum limit
Repatriation of Remains Up to $50,000 - not subject to deductible or coinsurance
Local Burial or Cremation Up to $5,000 - not subject to deductible or coinsurance
Emergency Reunion Up to $15,000, subject to a maximum of 15 days - not subject to deductible or coinsurance
Return of Minor Children Up to $25,000 - not subject to deductible or coinsurance
Political Evacuation Up to $25,000 lifetime maximum - not subject to deductible or coinsurance
Trip Interruption Up to $2,500 - not subject to deductible or coinsurance
Accidental Death & Dismemberment
Ages 18 through 69



Under age 18



Ages 70 through 74



Ages 75 and older

Lifetime Maximum - $50,000
Death - $50,000
Loss of 2 Limbs - $50,000
Loss of 1 Limb - $25,000

Lifetime Maximum - $5,000
Death - $5,000
Loss of 2 Limbs - $5,000
Loss of 1 Limb - $2,500

Lifetime Maximum - $20,000
Death - $20,000
Loss of 2 Limbs - $20,000
Loss of 1 Limb - $10,000

Lifetime Maximum - $10,000
Death - $10,000
Loss of 2 Limbs - $10,000
Loss of 1 Limb - $5,000

$250,000 maximum benefit any one family or group.
- not subject to deductible, coinsurance, or overall maximum limit
Optional Enhanced Accidental Death & Dismemberment Rider (only available to members age 18 through age 69) Lifetime Maximum - $50,000
Death - $50,000
Loss of 2 Limbs - $50,000
Loss of 1 Limb - $25,000
- not subject to deductible, coinsurance, or overall maximum limit

Certificate Period means the period of time beginning on the date and time of the certificate effective date and ending on the date and time of the certificate termination date.

Coinsurance means your payment of eligible expenses as specified in the Schedule of Benefits and Limits.

Deductible means the dollar amount of eligible expenses, specified in the Schedule of Benefits and Limits that you must pay per certificate period before eligible expenses are paid.

Usual, Reasonable and Customary means the lesser of the following:

  1. One and a half times (150%) of the charges payable under the United States Medicare program, for claims incurred outside the PPO network within the U.S., or
  2. Most common charge for similar services, medicines or supplies within the area in which the charge is incurred, so long as those charges are reasonable. What is defined as usual, reasonable and customary charges will be determined by us. In determining whether a charge is usual, reasonable and customary, we may consider one or more of the following factors: the level of skill, extent of training, and experience required to perform the procedure or service; the length of time required to perform the procedure or services as compared to the length of time required to perform other similar services; the severity or nature of the illness or injury being treated; the amount charged for the same or comparable services, medicines or supplies in the locality; the amount charged for the same or comparable services, medicines or supplies in other parts of the country; the cost to the provider of providing the service, medicine or supply; such other factors we, in the reasonable exercise of discretion, determine are appropriate.