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Summary of Health Plan Benefits

Summary of Health Plan Benefits for school year 2011-2012

For more detailed information regarding insurance benefits, please review the Plan brochure or contact our office at 815-753-0122

Student Lifetime Maximum $500,000
Deductible $250 of covered Medical Expenses per Policy year per student
Emergency Room co-pay $100 per visit
Out of Pocket Maximum $2,000 per policy year excluding deductible
Hospital Benefits Preferred Provider: 80% of preferred allowance
Non-Preferred Provider: 60% of Usual & Customary Charges
Physician’s Benefits Preferred Provider: 80% of preferred allowance
Non-Preferred Provider: 80% of Usual & Customary Charges
Emergency Care -
Medical Emergencies only		 Preferred Provider: 80% of preferred allowance
Non-Preferred Provider: 80% of Usual & Customary Charges
Diagnostic & Lab Services Preferred Provider: 80% of preferred allowance
Non-Preferred Provider: 80% of Usual & Customary Charges
Physical Therapy - $3,000 maximum/policy year Preferred Provider: 80% of preferred allowance
Non-Preferred Provider: 80% of Usual & Customary Charges
Prescription Drugs Inpatient: 80% of actual charges
Outpatient: Not Covered
Mental Health Care & Drug Abuse Inpatient: 30 days maximum per policy year
Outpatient: 25 visits maximum per policy year
  Outpatient Preferred Provider: 80% of preferred allowance
Outpatient Non-Preferred Provider: 80% of Usual & Customary Charges
Alcoholism Care Benefits are subject to Hospital benefits levels shown above
  Inpatient Preferred or Non-preferred: Paid as any other sickness
Outpatient Preferred Provider: 80% of preferred allowance
Outpatient Non-Preferred Provider: 80% of Usual & Customary Charges
Skilled Nursing Facility Limited to a maximum of 120 days of confinement per Policy Year
  Preferred Provider: 80% of preferred allowance
Non-Preferred Provider: 80% of Usual & Customary Charges
Home Health Care Limited to a maximum of 40 visits per policy year
  Preferred Provider: 80% of preferred allowance
Non-Preferred Provider: 80% of Usual & Customary Charges
Dental
 (Injury only to sound natural teeth)		 Preferred Provider: 80% of preferred allowance
Non-Preferred Provider: 80% of Usual & Customary Charges
Other Covered Medical Expenses Preferred Provider: 80% of preferred allowance
Non-Preferred Provider: 80% of Usual & Customary Charges

Summary of Global Emergency Services Plan Benefits:

  • Medical consultation
  • Evaluation & referral
  • Emergency medical evacuation
  • Critical care monitoring
  • Medically supervised repatriation
  • Prescription assistance
  • Emergency message transmission
  • Compassionate visit
  • Care of minor children
  • Return of mortal remains
  • Emergency trauma counseling
  • Lost luggage or document assistance
  • Interpreter & legal referrals
  • Pre-trip information