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Insurance in the USA
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What is a Deductible?
For a covered medical expense, the deductible is the portion of
your medical bill that is your responsibility. The
deductible will first be subtracted from the total medical
bill and you will need to pay this portion directly to the
doctor or hospital.
If the deductible is “per accident or illness,” not per visit to
the doctor. This
means if you have to go to the doctor more than once for the
same illness, you will only need to pay the deductible one time
for that illness.
What is Co-insurance?
You
pay coinsurance
plus any deductibles you owe. For example, if the health
insurance
allowed amount for an office visit is
$100 and you've met your
deductible, your
coinsurance
payment of 20% would be $20. The health
insurance
or plan pays the rest of the allowed amount.
How do I Pay
for My Prescriptions?
Most plans require that you pay for your prescription first and
be reimbursed. Be sure to complete a claim form and
include your receipt and prescription.
What is a pre-existing condition?
Any (1) condition for which medical advice,
diagnosis, care, or treatment (includes receiving services and
supplies, consultations, diagnostic tests or prescription
medicines) was recommended or received during the 12 months
immediately preceding the Certificate Effective Date; (2)
condition that had manifested itself in such a manner that would
have caused a reasonably prudent person to seek medical advice,
diagnosis, care, or treatment (includes receiving services and
supplies, consultations, diagnostic tests or prescription
medicines) within the 12 months immediately preceding the
Certificate Effective Date; (3) injury, illness, sickness,
disease, or other physical, medical, mental, or nervous
conditions, disorder or ailment (whether known or unknown) that,
with reasonable medical certainty, existed at the time of
application or within the 12 months immediately preceding the
Certificate Effective Date.
Some Plan cover pre-existing condition immediately (PGH Global
Plus and Preferred), some require a
waiting period (Student Secure
and Student Health Advantage) and some have restrictions on
coverage for pre-existing conditions (Plan E Plus).
What is Precertification?
Emergency Pre-certification: In the event
of an Emergency Hospital admission, Pre-certification must be
made within 48 hours after the admission, or as soon as is
reasonably possible.
Pre-certification Does
Not Guarantee Benefits – The fact that expenses are
Pre-certified does not guarantee either payment of benefits or
the amount of benefits. Eligibility for and payment of benefits
are subject to all the terms, conditions, provisions and
exclusions herein.
Concurrent Review – For Inpatient stays of any
kind, the Plan Administrator will Pre-certify a limited number
of days of confinement. Additional days of Inpatient confinement
may later be Pre-certified if a Member receives prior approval.
What is a Reasonable & Customary charge?
Reasonable and Customary charge is the amount normally charged
by medical service providers for similar services and supplies
in your area of living.
What is Medical Evacuation?
Medical Evacuation means transferring the insured person to the
nearest hospital or medical facility in case of an emergency
injury or sickness or back to his/her home country. It can be
done by any necessary means of transportation.
What is Repatriation?
In case of death, the Repatriation benefit covers the
transportation of your remains back to your family and your home
country.
Are Injuries from Sports Covered?
Recreational sports are covered through the regular medical
coverage. If you are
a member of an intercollegiate, interscholastic,
intramural or club sports, there is $5000 per injury coverage
for injuries sustained while participating in a team sports on
the Student Secure
and Student Health
Advantage Plans. The
VISIT Sports PLUS Plan
covers
athletic injuries at $10,000 per injury. Additional
coverage may be available through the Athletic Department for
some sports.
Is there Dental Coverage?
There is limited coverage for dental pain and injury to natural
teeth on your policy.
Student Secure
includes Relief of
sudden and unexpected pain to sound, natural teeth, including
but not limited to fillings will be covered up to $100 maximum.
Injury due to an accident will be covered up to $500 per
Accident maximum.
Do I need a referral to go to a Specialist?
A doctor’s referral typically is not required.
If you have a special medical condition, we recommend
that you check with the Claims Office
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