Safe Passage International | Bright Virtue Services Limited
留学无忧 Premium – ScholarAmSure Premium
USA Accident & Sickness Insurance Plan for International Students
Bright Virtue Services Limited
| Accident and Sickness Insurance Plan for International Students | ||
| This is a brief, easy to read summary of the benefits of this international student accident and sickness insurance plan and provides only a general overview of your benefits. Please read the Evidence of Coverage for full details of the coverage, including costs, benefits, exclusions, and limitations. | ||
| Brief Benefit Summary | ScholarAmSure Premium Plan | |
| In Network | Out of Network | |
| Annual Maximum Benefit | Unlimited | Unlimited |
| Deductible – per School Year (Waived at Student Health Center) | $150 per Person | $500 per Person |
| Coinsurance (100% at Student Health Center) | 90% of Preferred Allowance | 60% of Usual, Reasonable & Customary (URC) |
| Maximum Out of Pocket Cost per School Year – Includes deductibles, copayments, and your coinsurance amounts. | $2,000 per Person | $5,000 per Person |
| Preferred Provider Network (Preferred Allowance means the rates that have been negotiated with Network Providers) | Aetna Passport to Healthcare PPO Network | |
| Accident and Sickness Medical Benefits (Including Hospice Care and the specific benefits as outlined Below) | 90% of Preferred Allowance, Except as Noted Below | 60% of URC, Except as Noted Below |
| Inpatient Benefits | In Network | Out of Network |
| Hospital Room and Board (including nursing services and inpatient rehabilitation) – Semi-private room. | 90% of Preferred Allowance | 60% of URC |
| Intensive Care / Cardiac Care | 90% of Preferred Allowance | 60% of URC |
| Hospital Miscellaneous – Includes services and supplies such as cost of operating room, lab tests, X-rays, anesthesia, drugs, and more. | 90% of Preferred Allowance | 60% of URC |
| Surgeon – If two or more procedures are performed through the same incision or in immediate succession at the same operative session, the maximum amount paid will not exceed 50% of the second procedure and 50% of all subsequent procedures. | 90% of Preferred Allowance | 60% of URC |
| Assistant Surgeon | 90% of Preferred Allowance | 60% of URC |
| Pre-admission Testing – If admitted within 7 days | 90% of Preferred Allowance | 60% of URC |
| Anesthetist Services | 90% of Preferred Allowance | 60% of URC |
| Diagnostic X-ray and Lab | 90% of Preferred Allowance | 60% of URC |
| Physician Visits | 90% of Preferred Allowance | 60% of URC |
| Consultant Physician Visit | 90% of Preferred Allowance | 60% of URC |
| Physiotherapy – Treatment prescribed by a Physician including ultrasonic, whirlpool, heat treatments, chiropractic, acupuncture, massage or any form of physical therapy. | 90% of Preferred Allowance | 60% of URC |
| Outpatient Benefits | In Network | Out of Network |
| Physicians Visits | 90% Preferred Allowance after $35 Copay/Visit (Waived at Student Health Center) | 60% of URC |
| Wellness Medical Services – No deductibles, copays, or coinsurance will be applied when the services are received from a Preferred Provider. Includes immunizations and routine physical exams. | 100% of Preferred Allowance | 100% of URC |
| Surgeon – If two or more procedures are performed through the same incision or in immediate succession at the same operative session, the maximum amount paid will not exceed 50% of the second procedure and 50% of all subsequent procedures. | 90% of Preferred Allowance | 60% of URC |
| Day Surgery Miscellaneous – Includes services and supplies such as cost of operating room, lab tests, X-rays, anesthesia, drugs, and more on an outpatient basis. | 90% of Preferred Allowance | 60% of URC |
| Assistant Surgeon | 90% of Preferred Allowance | 60% of URC |
| Anesthetist Services | 90% of Preferred Allowance | 60% of URC |
| Physiotherapy – Treatment prescribed by a Physician including ultrasonic, whirlpool, heat treatments, chiropractic, acupuncture, massage or any form of physical therapy. Review of Medical Necessity will be performed after 12 visits. | 90% Preferred Allowance after $35 Copay/Visit | 60% of URC |
| Emergency Room – The Copay will be waived if admitted to the Hospital. | 90% of Preferred Allowance after $150 Copay/Visit | 90% URC after $150 Copay/Visit |
| Diagnostic X-ray and Lab | 90% of Preferred Allowance | 60% of URC |
| Urgent Care Center | 90% of Preferred Allowance after $35 Copay | 60% of URC |
| Radiation/Chemotherapy | 90% of Preferred Allowance | 60% of URC |
| Emergency Dental Treatment – Benefits paid for Injury to sound, natural teeth only. | 90% of Preferred Allowance | 60% of URC |
| Prescription Drugs – 30 day supply per prescription. | $15 Copay for Generic | $30 Copay for | Preferred Brand | $60 Copay for non-Preferred Brand | 60% of URC |
| Other Benefits | In Network | Out of Network |
| Ambulance Services | 90% of Preferred Allowance | 60% of URC |
| Durable Medical Equipment – Such as wheelchairs, crutches, hospital beds, and oxygen. | 90% of Preferred Allowance | 60% of URC |
| Mental & Nervous Conditions – Inpatient & Outpatient (Outpatient: one visit per day maximum) | Covered as Any Other Sickness | |
| Alcohol & Drug Abuse – Inpatient & Outpatient | Covered as Any Other Sickness | |
| Maternity and Pre-Natal Care – Includes expenses before, during, and after delivery. | Covered as Any Other Sickness | |
| Pregnancy – Including complications of pregnancy. A newborn child is covered from birth for 31 days. | 90% of Preferred Allowance | 60% of URC |
| Elective Termination of Pregnancy | Covered as Any Other Sickness | |
| Diabetes Treatment | Covered as Any Other Sickness | |
| Home Health Care – 100 visits maximum per Policy Year. | 90% of Preferred Allowance | 60% of URC |
| Skilled Nursing Facility | 90% of Preferred Allowance | 60% of URC |
| Athletic Sports Activity ($6,000 Maximum per Injury) | 90% of Preferred Allowance | 60% of URC |
| Accidental Death and Dismemberment | $25,000 | |
| Incidental International Travel – Copays and deductibles do not apply outside USA. There is no coverage in your home country. | 100% of URC | |
| Pediatric Dental Services Benefit | 50% of Preferred Allowance after $500 Copay | 50% of URC after $500 Deductible |
| Pediatric Vision Services Benefit | 50% of Preferred Allowance | 50% of URC |
| Additional Included Coverage | ||
| Medical Evacuation, Repatriation, and Security Evacuation Benefits – Benefits provided by On Call International | Unlimited | |
| Personal Liability – Benefits provided by XN Financial Services (Canada) Inc. | $50,000 | |
Eligibility
You are eligible for the insurance if you are a non-United States citizen residing temporarily outside your home country or country of permanent residence, have a current passport and F, J or M visa, are involved in educational activities in the USA, and are actively enrolled in classes. Your non-U.S. spouse and dependent children are also eligible.
Coverage Period
Coverage will begin at 12:01 AM on the latest of:
- The Effective Date of the Policy
- The date the Plan Administrator receives a completed enrollment form
- The date requested in the enrollment form
- The moment the Plan Participant exits their Home Country airspace
- The date requested by the Participating Organization
Coverage will end at the earliest of:
- The last date for which the premium has been paid
- The date shown on the insurance ID Card issued by the Plan Administrator
- The date the Plan Participant returns to his Home Country and is no longer eligible
- The date the Plan Participant becomes a permanent resident of the United States
- The date of entry into active duty in any military service
Preferred Provider Network (PPO)
You receive the highest level of benefits when you obtain services from a Preferred Provider. These are your “In Network” benefits. The Preferred Provider Network for this plan is Aetna Passport to Healthcare PPO Network. Preferred Providers can be found using this link: http://www.Aetna.com/docfind/custom/passport. You may choose to be treated by medical providers within or outside the Network. Your share of treatment cost will be lower with Network providers because the PPO has negotiated special rates with them. If you use an outside provider, we will pay a specific amount for your claim called “Usual, Reasonable and Customary”. If the provider’s charge is higher than the amount we pay, you will be responsible for the difference. This is in addition to your deductible and your coinsurance share.
Student Health Center Benefits
The Deductible will be waived, and benefits will be paid at 100% for treatment at the Student Health Center.
Emergency Room Services
In an emergency, such as a suspected heart attack, stroke, poisoning, or serious injury, you should go to the nearest hospital or call 911 (or the local emergency phone number). You pay a copayment and coinsurance per visit for in-network or out-of-network emergency room services. The copayment is waived if you are admitted to the hospital.
Exclusions and Limitations
This brochure summarizes the benefits of your health plan. Your Evidence of Coverage defines the full terms and conditions in greater detail. Should any questions arise concerning benefits, the Evidence of Coverage will govern. Some of the services and situations not covered are: most dental care, vision care, hearing aids, cosmetic surgery, organ transplants, services that are not medically necessary, certain dangerous sports, travel in certain vehicles, visits to a hospital emergency room that are not of an emergency nature, and treatment in your home country. For a complete list of exclusions and limitations, refer to your Evidence of Coverage at http://www.1administration.com/587107.
Claims
In the event of a sickness or injury, participants should visit the Student Health Center for treatment or referral, if open, or a physician or hospital. Locate a Network provider using the link under Preferred Provider Network above. You should show your provider your insurance ID Card.
All available documentation should be sent to Administrative Concepts, Inc. (ACI), P.O. Box 4000, Collegeville, PA 19426. You may call ACI at 888-293-9229 or send an email to aciclaims@visit-aci.com.
Questions??
For questions about the coverage, premium, or claims, call the Plan Administrator: Administrative Concepts, Inc. (ACI) at 888-293-9229, or email to aciclaims@visit-aci.com.
Underwritten by Crum & Forster SPC
This insurance plan is not subject to regulation under the Patient Protection and Affordable Care Act (ACA). This insurance plan includes benefits that are designed to meet or exceed requirements that would otherwise apply to student health insurance programs in the USA.
Notice: For further information on this Plan, visit http://www.1administration.com/587107.
Please keep this summary as a brief description of the important features of the plan. It is not a contract of insurance. This plan includes both insurance and non-insurance benefits. The terms and conditions of coverage are set forth in the Plan issued to Safe Passage International Student Programs, LLC). For a detailed plan description, exclusions, and limitations please view the plan on file with info@spibrokers.com/student/. The Policy contains a complete description of all of the terms, conditions, and exclusions of the insurance plan as underwritten by Crum & Forster, SPC. The Policy will prevail in the event of any discrepancy between this Brochure and the Policy.
Note: This insurance is not subject to and does not provide certain insurance benefits required by the United States’ Patient Protection and Affordable Care Act (“PPACA”). PPACA requires certain US citizens or US residents to obtain PPACA compliant health insurance, or “minimum essential coverage.” PPACA also requires certain employers to offer PPACA compliant insurance coverage to their employees. Tax penalties may be imposed on U.S. residents or citizens who do not maintain minimum essential coverage, and on certain employers who do not offer PPACA compliant insurance coverage to their employees. In some cases, certain individuals may be deemed to have minimum essential coverage under PPACA even if their insurance coverage does not provide all of the benefits required by PPACA. You should consult your attorney or tax professional to determine whether the policy meets any obligations you may have under PPACA.
Privacy Statement:
We know that your privacy is important to you and we strive to protect the confidentiality of your non-public personal information. We do not disclose any non-public personal information about our insureds or former insureds to anyone, except as permitted or required by law. We maintain appropriate physical, electronic and procedural safeguards to ensure the security of your non-public personal information. You may obtain a detailed copy of our privacy policy by calling ACI at 1-888-293-9229 or 1-610-293-9229, or by visiting us at http://www.1administration.com/587107.
Complaints:
In the event that you remain dissatisfied and wish to make a complaint you can do so to the Complaints team at Administrative Concepts, Inc. at P.O. Box 4000, Collegeville, PA 19426, Phone: 1-888-293-9229, or email to aciclaims@visit-aci.com.
Data Protection:
Please note that sensitive health and other information that you provide may be used by us, our representatives, the insurers and industry governing bodies and regulators to process your insurance, handle claims and prevent fraud. This may involve transferring information to other countries (some of which may have limited, or no data protection laws). We have taken steps to ensure your information is held securely. Where sensitive personal information relates to anyone other than you, you must obtain the explicit consent of the person to whom the information relates both to the disclosure of such information to us and its use as set out above. Information we hold will not be shared with third parties for marketing purposes. You have the right to access your personal records.
By purchasing this insurance provided by Crum & Forster SPC, you become a member of the ITA Global Trust, LTD.