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

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SHA Individual Standard 03.15.21

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