Skip to main content
Navigate Up
Sign In
SMC|Enrollment Development|International Education Center|Benefit Schedule

Benefit Schedule

Medical Insurance 2013-2014

Schedule of Benefits


​ The Company will pay for the Eligible Expenses listed below, up to the following limits.

Maximum Benefit:
$500,000 per policy year for all conditions, including Medical Evacuation and Repatriation of Remains expenses.
Deductible:
$100 per policy year. The $100 Deductible is reduced to $25 if the Covered Student first utilizes and/or is referred by SHS, or if SHS is closed. There is no Deductible for services rendered at SHS.
Office Visit Copay:
$25 per visit for office visits or urgent care (when SHS is closed or if referred by SHS), or $50 for emergency room (waived only if admitted to Hospital)
Out-of Pocket Maximum:
$5,000 per policy year

The Covered Person is responsible for paying the Deductible amount listed before the Company will begin paying benefits, except as indicated below.

When a Covered Person has incurred $5,000 of out-of pocket Eligible Expenses for all conditions during a policy year (not including Copays), the Company payment for Eligible Expenses incurred will increase to 100% of Reasonable and Customary (R&C) for the remainder of the policy year, up to the Maximum Benefit.

Eligible Expenses include the following, subject to the limitations indicated above or below:

 

PREVENTATIVE/WELLNESS SERVICES
PPO
NON-PPO
Preventative Services
includes screening for certain conditions such as: cancer, high cholesterol, depression, diabetes, obesity, and sexually transmitted diseases, and women's preventative care; as recommended by the U.S. Department of Health and Human Services
100% of Allowable Charges
DEDUCTIBLE & COPYA WAIVED
Paid as any other Sickness
Immunizations
includes but not limited to: flu shot, tetanus, diphtheria, pertussis, Tdap, hepatitis A, hepatitis B, HPV, measles-mumps-rubella, pneumonia, varicella, meningococcal; as recommended by the U.S. Centers for Disease Control and Prevention
100% of Allowable Charges
DEDUCTIBLE & COPYA WAIVED
Paid as any other Sickness
Contraceptives
FDA-approved contraceptive methods and medications, as prescribed by a Doctor
100% of Allowable Charges
DEDUCTIBLE & COPYA WAIVED
Please visit www.hhs.gov/healthcare/prevention for more details on what is included under the federal preventative services requirement.
 
OUTPATIENT
PPO
NON-PPO
Doctor Visits
100% of Allowable Charges after Copay of $25 per visit
70% of R&C after Copay of $25 per visit
Urgent Care
always use urgent care facilities instead of a Hospital emergency room, when possible
100% of Allowable Charges after Copay of $25 per visit
70% of R&C after Copay of $25 per visit
Emergency Medical Condition Expense
use of emergency room and supplies
100% of R&C after $50 Copay per visit (waived if admitted)
Surgeon’s Fee
if multiple procedures are performed through the same incision or in immediate succession, the Company will pay the maximum coinsurance amount for the primary procedure, 50% for the second procedure, and 25% for all subsequent procedures
100% of Allowable Charges
70% of R&C
Assistant Surgeon
100% of Allowable Charges
70% of R&C
Anesthetist
professional services in connection with outpatient surgery
100% of Allowable Charges
70% of R&C
Day Surgery Miscellaneous
100% of Allowable Charges
70% of R&C
Physiotherapy
100% of Allowable Charges after Copay of $25 per visit
70% of R&C after Copay of $25 per visit
Chiropractic Services
up to a maximum of $500 per Sickness or Injury
100% of Allowable Charges after Copay of $25 per visit
70% of R&C after Copay of $25 per visit
Acupuncturist Care or Treatment
up to a maximum of $500 per Sickness or Injury
100% of Allowable Charges after Copay of $25 per visit
70% of R&C after Copay of $25 per visit
Treatment of Mental Or Nervous Disorders
up to a maximum of 20 visits per policy year
100% of Allowable Charges after Copay of $25 per visit
70% of R&C after Copay of $25 per visit
Treatment of Alcoholism of Substance Abuse
up to a maximum of 20 visits per policy year
100% of Allowable Charges after Copay of $25 per visit
70% of R&C after Copay of $25 per visit
Diagnostic X-Ray and Laboratory Services

100% of Allowable Charges
70% of R&C
Radiation Therapy and Chemotherapy
100% of Allowable Charges
70% of R&C
Tests and Procedures
diagnostic services and medical procedures performed by a Doctor (other than Doctor’s visits, physiotherapy, X-rays, and lab procedures)
100% of Allowable Charges
70% of R&C
 
INPATIENT
PPO
NON-PPO
Hospital Confinement/Room and Board and Hospital Miscellaneous
daily room and board limited to average semi-private room rate; miscellaneous hospital expenses, such as expenses incurred for anesthesia and operating room; laboratory tests and X-rays, (including professional fees); oxygen tent; drugs, medicines (excluding take-home drugs), dressings; and other Medically Necessary and prescribed Hospital expenses
100% of Allowable Charges
70% of R&C
Maternity and Newborn Care
while Hospital Confined, and routine nursery care provided immediately after birth, up to 48 hours after birth (96 hours for cesarean delivery)
paid as any other Sickness
Licensed Nurse Expense
private-duty nursing care
100% of Allowable Charges
70% of R&C
Surgeon’s Fee
if multiple procedures are performed through the same incision or in immediate succession, the Company will pay the maximum coinsurance amount for the primary procedure, 50% for the second procedure, and 25% for all subsequent procedures
100% of Allowable Charges
70% of R&C
Assistant Surgeon
100% of Allowable Charges
70% of R&C
Anesthetist
professional services in connection with inpatient surgery
100% of Allowable Charges
70% of R&C
Pre-Admission Testing
if testing occurs within 3 days prior to admission
100% of Allowable Charges
70% of R&C
Doctor Visits
100% of Allowable Charges after Copay of $25 per visit
70% of R&C after Copay of $25 per visit
Treatment of Mental of Nervous Disorders
up to a maximum of 45 days per policy year
paid as any other Sickness
Treatment of Alcoholism or Substance Abuse
up to a maximum of 45 days per policy year
paid as any other Sickness
 
OTHER
PPO
NON-PPO
Ambulance Services
100% of R&C
Durable Medical Equipment/Orthopedic Appliances/Prosthetic Devices
100% of Allowable Charges
70% of R&C
Consultant Doctor Fees
when requested and approved by the attending Doctor
100% of Allowable Charges after Copay of $25 per visit
70% of R&C after Copay of $25 per visit
Dental Treatment
for Injury to natural teeth only; up to a maximum of $100 per tooth and $500 per Injury
100% of R&C
Pregnancy
including complications of pregnancy
paid as any other Sickness
Elective Abortion Expense
up to a maximum of $500 per occurrence
100% of Allowable Charges
70% of R&C
Medical Evacuation
100% of R&C
Repatriation of Remains
100% of R&C
 
OUTPATIENT PRESCRIPTION DRUGS
Deductible is waived for prescription medications. Prescriptions must be paid for in full at the time of pickup; you must then submit a claim for reimbursement for the portion the Company is responsible for paying.
Prescription Drugs
50% of Actual Charges
Contraceptives paid at 100% of Actual Charges
 
 

 

 

Health Care Links: