Student Health Advantage SM - International Student Insurance
Global Peace of Mind
?
INDIANA TRUSTEE CHANGE ENDORSEMENT
This Endorsement attaches to and forms part of your policy, contract or certificate.
The Trustee of your policy, contract or certificate has been changed from Mutual Wealth Management Group to RBB Financial LLC
effective March 1, 2024.
The definition of Assured will now be as follows:
Assured: The Global Medical Services Group Insurance Trust, c/o RBB Financial LLC, 6368 Oxbow Way, Indianapolis, IN,
46220.
All other terms and conditions of your policy, contract or certificate remain unchanged.
International Medical Group? (IMG?) continues to be the program administrator of your policy, contract or certificate. If you have any
questions, please contact:
International Medical Group
9200 Keystone Crossing, Suite 800
Indianapolis, IN USA 46240
Toll-Free: +1.800.628.4664
IMG? (International Medical Group?)
Phone: +1.317.655.4500
Fax: +1.317.833.1990
Toll-free: +1.800.628.4664
insurance@
WWW.
Student Health AdvantageSM
Certificate of Insurance
IMPORTANT NOTICE REGARDING PATIENT PROTECTION AND AFFORDABLE CARE ACT (PPACA):
This insurance is not subject to, and does not provide benefits required by, PPACA. On January 1, 2014,
PPACA requires United States citizens, United States nationals and resident-aliens to obtain PPACA
compliant insurance coverage unless they are exempt from PPACA. Penalties may be imposed on persons
who are required to maintain PPACA compliant coverage but do not do so.
Eligibility to purchase or renew this product, or its terms and conditions, may be modified or amended based
upon changes to applicable law, including PPACA. Please note that it is solely your responsibility to determine
if PPACA is applicable to you and the Company and IMG shall have no liability whatsoever, including for any
penalties that you may incur, for your failure to obtain required PPACA compliant coverage.
Table of Contents
Benefit Summary ........................................................................................................................1
A. Benefit Summary ..................................................................................................................6
B. Agreement ............................................................................................................................6
C. Conditions and General Provisions ......................................................................................6
D. Eligibility ............................................................................................................................. 12
E. Pre-certification Requirements ........................................................................................... 12
F. United States Preferred Provider Organization (PPO) ....................................................... 14
G. Eligible Medical Expenses .................................................................................................. 14
H. Accidental Death and Dismemberment .............................................................................. 16
I.
Emergency Medical Evacuation ......................................................................................... 16
J. Emergency Reunion ........................................................................................................... 17
K. Incidental Trip ..................................................................................................................... 18
L. Intercollegiate, Interscholastic, Intramural, or Club Sports ................................................. 18
M. Personal Liability ................................................................................................................ 18
N. Political Evacuation And Repatriation ................................................................................. 18
O. Public Health Emergency ................................................................................................... 19
P. Return of Mortal Remains................................................................................................... 19
Q. Exclusions .......................................................................................................................... 19
R. Definitions........................................................................................................................... 23
BENEFIT SUMMARY
Coverage Limit / Maximum Amount for Eligible Medical Expenses
Certificate Period of Coverage
Maximum Limit: 365 days
Maximum Limit
Insured Person: $500,000
Spouse and Child: $100,000
Per Illness or Injury limit
Insured Person: $300,000
Spouse and Child: $100,000
The per Illness or Injury limits accumulate towards the Maximum Limit.
Worldwide excluding Insured Person¡¯s Country of Residence
Area of Coverage
Benefit Plan Features
Benefit Levels
United States
United States
International
In-Network
Out-of-Network
International
Deductible for Eligible Medical Expenses
Deductible
? Per Illness or Injury
$100
$100
$100
Plan pays 100%
Plan pays 80%
Plan pays 100%
Insured pays 0%
Insured pays 20%
Insured pays 0%
$0
$1,000
$0
Coinsurance for Eligible Medical Expenses
Coinsurance
? In addition to Deductible
Out of Pocket Maximum
Student Health Center
Copayment per visit
? Not subject to Deductible
$5
Coinsurance
Plan pays 100%
Insured pays 0%
Pre-certification
? Interfacility Ambulance Transfer: No coverage if Pre-certification requirements are not met.
? Medical Evacuation: No coverage if not approved by the Company. Refer to the EMERGENCY MEDICAL EVACUATION
provision for complete requirements and coverage.
? All other Treatments & supplies: 50% reduction of Eligible Medical Expenses if Pre-certification requirements are not met.
? Deductible is taken after reduction.
? Coinsurance is applied to remainder of the reduced amount.
? Refer to PRE-CERTIFICATION REQUIREMENTS provision for a complete list of services that require Pre-certification.
Pre-existing Conditions
Charges are excluded until the Insured Person has maintained 12 months of continuous coverage under this insurance.
Inpatient or Outpatient Services
Subject to Deductible and Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable and Customary
Limits per Period of Coverage unless stated as Maximum Limit
Benefit
In-Network
Out-of-Network
International
Eligible Medical Expenses
100%
80%
100%
09.13.21 v1.1
1
SHA Individual Standard 03.15.21
Inpatient or Outpatient Services
Subject to Deductible and Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable and Customary
Limits per Period of Coverage unless stated as Maximum Limit
Benefit
In-Network
Out-of-Network
International
100%
80%
100%
100%
80%
100%
100%
80%
100%
Intensive Care
100%
80%
100%
Outpatient Surgical / Hospital Facility
100%
80%
100%
Laboratory
100%
80%
100%
Radiology / X-ray
100%
80%
100%
Chemotherapy / Radiation Therapy
100%
80%
100%
Pre-admission Testing
100%
80%
100%
Surgery
100%
80%
100%
Reconstructive Surgery
? Surgery is incidental to or follows Surgery that
was covered under the Plan
100%
80%
100%
Assistant Surgeon
? 20% of the primary surgeon¡¯s eligible fee
100%
80%
100%
Anesthesia
100%
80%
100%
Durable Medical Equipment
100%
80%
100%
Chiropractic Care
? Medical order or Treatment plan required
100%
80%
100%
100%
80%
100%
100%
80%
100%
100%
80%
100%
Physician Visits / Services
? Maximum visits per day: 1
? Surgery is not subject to the Maximum visit
limit
Hospital Emergency Room
? Injury: Not subject to Emergency Room
Deductible
? Illness: Subject to a $250 Deductible for each
Emergency Room visit for Treatment that does
not result in a direct Hospital admission.
Hospitalization / Room & Board
? Average semi-private room rate
? Includes nursing, miscellaneous and Ancillary
Services
Physical Therapy
? Maximum visits per day: 1
? Medical order or Treatment plan required
Extended Care Facility
? Upon direct transfer from acute care Hospital
Home Nursing Care
? Provided by a Home Health Care Agency
? Upon direct transfer from an acute care
Hospital
09.13.21 v1.1
2
SHA Individual Standard 03.15.21
................
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