| Benefit | Elite | Select | Budget | Smart |
|---|---|---|---|---|
| Savings for paying full premium in advance | ✔ | ✔ | ✔ | ✔ |
| Meets J-1 visa requirements | ✔ | ✔ | ✔ | ✔ |
| Overall Maximum Benefit | $5,000,000 | $600,000 | $500,000 | $200,000 |
| Maximum Benefit Per Injury or Illness | $500,000 | $300,000 | $250,000 | $100,000 |
| Deductible (except Emergency Room) | $25 per injury or illness | $35 per injury or illness | $45 per injury or illness | $50 per injury or illness |
| Emergency Room Deductible
(claims incurred in the U.S. only) |
$100 for treatment received in an emergency room | $200 for treatment received in an emergency room | $350 for treatment received in an emergency room | $350 for treatment received in an emergency room |
| Coinsurance – claims incurred inside U.S. | Within the PPO: We will pay 100% of eligible expenses, after the deductible, up to the overall maximum limit.
Outside the PPO: Usual, reasonable, and customary. You may be responsible for any charges exceeding the payable amount. |
Within the PPO: We will pay 80% of the next $5,000 of eligible expenses after deductible, then 100% to the overall maximum limit.
Outside the PPO: Usual, reasonable, and customary. You may be responsible for any charges exceeding the payable amount. |
Within the PPO: We will pay 80% of the next $25,000 of eligible expenses after deductible, then 100% to the overall maximum limit.
Outside the PPO: Usual, reasonable, and customary. You may be responsible for any charges exceeding the payable amount. |
Within the PPO: We will pay 80% of eligible expenses after the deductible up to the overall maximum limit.
Outside the PPO: Usual, reasonable, and customary. You may be responsible for any charges exceeding the payable amount. |
| Coinsurance – claims incurred outside of U.S. | After the deductible, 100% of eligible expenses to the certificate period maximum. | After the deductible, 100% of eligible expenses to the certificate period maximum. | After the deductible, 100% of eligible expenses to the certificate period maximum. | After the deductible, 100% of eligible expenses to the certificate period maximum. |
| *Pre-existing Condition Coverage | 6-month waiting period | 6-month waiting period | 12-month waiting period | No coverage |
| Acute Onset of Pre-existing Condition (excludes chronic and congenital conditions) | $25,000 lifetime maximum for eligible expenses | $25,000 lifetime maximum for eligible expenses | $25,000 lifetime maximum for eligible expenses | $25,000 lifetime maximum for eligible expenses |
| Intensive Care Unit | Up to overall maximum limit | Up to overall maximum limit | Up to overall maximum limit | Up to overall maximum limit |
| Hospital Room & Board | Average semi-private room rate, including nursing services | Average semi-private room rate, including nursing services | Average semi-private room rate, including nursing services | Average semi-private room rate, including nursing services |
| Outpatient Treatment | Up to overall maximum limit | Up to overall maximum limit | Up to overall maximum limit | Up to overall maximum limit |
| Local Ambulance (not subject to coinsurance) | Up to $750 per injury / illness if hospitalized as inpatient | Up to $750 per injury / illness if hospitalized as inpatient | Up to $500 per injury / illness if hospitalized as inpatient | Up to $300 per injury / illness if hospitalized as inpatient |
| Outpatient Prescription Drugs | Generic Drugs: 100% coinsurance.
Brand Name Drugs: 50% coinsurance. Specialty Drugs: No coverage. (not subject to deductible) |
50% of actual charge (not subject to deductible or coinsurance) | 50% of actual charge (not subject to deductible or coinsurance) | 50% of actual charge (not subject to deductible or coinsurance) |
| Vaccinations | Up to $150.
Covered vaccinations and testing are: Measles, Mumps, Rubella (MMR); Tetanus/Diphtheria/Pertussis (TDAP); Chicken Pox (Varicella); Hepatitis B; and Meningitis (Meningococcal MCV4 and B) (not subject to deductible or coinsurance) |
No coverage | No coverage | No coverage |
| Maternity Care for Covered Pregnancy | Up to $25,000 | Up to $10,000 | Up to $5,000 | No coverage |
| Nursery Care of Newborn | Up to $750 | Up to $750 | Up to $250 | No coverage |
| Sports & Activities – Leisure, Recreational, Entertainment, or Fitness | Up to the overall maximum limit | Up to the overall maximum limit | Up to the overall maximum limit | Up to the overall maximum limit |
| Optional Intercollegiate, Interscholastic, Intramural, or Club Sports Rider | Up to $5,000 maximum per injury or illness; medical expenses only | Up to $5,000 maximum per injury or illness; medical expenses only | Up to $3,000 maximum per injury or illness; medical expenses only | No coverage |
| Mental Health Disorders
(treatment must not be provided at a student health center) |
Outpatient: Maximum of 30 visits.
Inpatient: Maximum of 30 days. |
Outpatient: Maximum of 30 visits.
Inpatient: Maximum of 30 days. |
Outpatient: Maximum of 30 visits.
Inpatient: Maximum of 30 days. |
Outpatient: $50 maximum per day, $500 maximum.
Inpatient: Up to $5,000. |
| Outpatient Physical Therapy & Chiropractic Care
(Not subject to coinsurance. Must be ordered in advance by a physician and not obtained at a student health center.) |
Up to $75 per visit per day | Up to $50 per visit per day | Up to $50 per visit per day | Up to $25 per visit per day |
| Dental treatment due to accident
(not subject to coinsurance) |
Up to $250 maximum per tooth; $500 maximum per certificate period. | Up to $250 maximum per tooth; $500 maximum per certificate period. | Up to $250 maximum per tooth; $500 maximum per certificate period. | Up to $250 maximum per tooth; $500 maximum per certificate period. |
| Emergency dental – acute onset of pain
(not subject to coinsurance) |
Up to $100. | Up to $100. | Up to $100. | Up to $100. |
| Terrorism | Up to $50,000 lifetime maximum, eligible medical expenses only | Up to $50,000 lifetime maximum, eligible medical expenses only | Up to $50,000 lifetime maximum, eligible medical expenses only | No coverage |
| Emergency Medical Evacuation (not subject to deductible, coinsurance, or overall maximum limit) |
Up to $500,000 lifetime maximum | Up to $300,000 lifetime maximum | Up to $250,000 lifetime maximum | Up to $50,000 lifetime maximum |
| Repatriation of Remains
(not subject to deductible, coinsurance, or overall maximum limit) |
Up to $50,000 lifetime maximum | Up to $50,000 lifetime maximum | Up to $25,000 lifetime maximum | Up to $25,000 lifetime maximum |
| Accidental Death and Dismemberment (AD&D)
(not subject to deductible, coinsurance, or overall maximum limit) |
Lifetime Maximum – $25,000
Death – $25,000 Loss of 2 Limbs – $25,000 Loss of 1 Limb – $12,500 Optional AD&D Rider: Additional $25,000 lifetime maximum |
Lifetime Maximum – $25,000
Death – $25,000 Loss of 2 Limbs – $25,000 Loss of 1 Limb – $12,500 Optional AD&D Rider: Additional $25,000 lifetime maximum |
No coverage | No coverage |
| Emergency Reunion
(not subject to deductible, coinsurance, or overall maximum limit) |
Up to $5,000, subject to a maximum of 15 days | Up to $5,000, subject to a maximum of 15 days | Up to $1,000, subject to a maximum of 15 days | Up to $1,000, subject to a maximum of 15 days |
| Personal Liability
(not subject to deductible, coinsurance, or overall maximum limit) |
Up to $250,000 lifetime maximum.
Up to $250,000 third person injury or property. Up to $2,500 related third person property. |
No coverage | No coverage | No coverage |
| Optional Crisis Response Rider – Ransom, Personal Belongings, and Crisis Response Fees and Expenses
(not subject to deductible, coinsurance, or overall maximum limit) |
Up to $100,000 | Up to $100,000 | No coverage | No coverage |
HCC StudentSecure Benefits and Limits
05/08/2016
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