Patriot Exchange
Benefits
| Benefits | Coverage |
|---|---|
| Overall Maximum Limit | $5,000,000 |
| Maximum Limit per illness/injury | $50,000, $100,000, $250,000, or $500,000 |
| Deductible per illness/injury | $0, $100, $250, or $500 |
| Student Health Center Copay Not subject to the deductible | $5 per visit |
| Coinsurance After the deductible |
USA In-Network: Plan pays 90%; $1000 out-of-pocket maximum USA Out-of-Network: Plan pays 80%; up to maximum limit International: Plan pays 100%; up to maximum limit |
|
Inpatient/Outpatient Benefits
Subject to Deductible unless otherwise noted. Eligible Medical Expenses are limited to Usual, Reasonable, and Customary Limits per Period of Coverage unless Stated as Maximum Limit |
|
| Eligible Medical Expenses | Up to the maximum limit |
| Physician/Specialist Visit | Up to the maximum limit 1 visit per day, unless visit is for different medical/surgical specialty |
| Urgent Care Not subject to deductible. | $50 copay. Copay is not applicable when the $0 deductible is selected. |
| Walk-in Clinic Not subject to deductible. | $20 copay. Copay is not applicable when the $0 deductible is selected. |
| Hospital Emergency Room |
Up to the maximum limit Illness: Subject to a $500 deductible for each ER visit for treatment that does not result in direct inpatient hospital admission. Injury: Not subject to emergency room deductible. |
| Hospitalization / Room & Board | Average semi-private room rate up to the maximum limit. Includes nursing service, miscellaneous and Ancillary services. |
| Intensive Care Unit | Up to the maximum limit |
| Bedside Visit Not subject to the deductible | $1,500 maximum. Must be hospitalized in an intensive care unit. |
| Outpatient Surgical / Hospital Facility | Up to the maximum limit |
| Laboratory | Up to the maximum limit |
| Radiology / X-ray | Up to the maximum limit |
| Pre-admission Testing | Up to the maximum limit |
| Surgery | Up to the maximum limit |
| Reconstructive Surgery | Up to the maximum limit Surgery is incidental to and follows surgery that was covered under the plan |
| Assistant Surgeon | 20% of the primary surgeon’s eligible fee |
| Anesthesia | Up to the maximum limit |
| Durable Medical Equipment | Up to the maximum limit Standard basic hospital bed and/or a standard basic wheelchair |
| Chiropractic Care | Up to the maximum limit Medical order or treatment plan required |
| Physical Therapy |
Up to the maximum limit
1 visit per day Medical order or treatment plan required |
| Extended Care Facility | Up to the maximum limit Upon direct transfer from an acute care facility |
| Home Nursing Care |
Up to the maximum limit
Provided by a Home Health Care Agency Upon direct transfer from an acute care facility |
| COVID-19 Coverage | COVID-19/SARD-CoV-2 shall be considered the same as any other illness or injury, subject to all other terms and conditions |
| Prescription Drugs and Medication Inpatient and Outpatient | Up to the maximum limit, may not exceed $250,000 Dispensing limit per prescription: 90 days |
| Mental or Nervous / Substance Abuse |
Outpatient: $50 limit per day, $500 maximum limit Inpatient: $10,000 maximum limit Not covered if incurred at the Student Health Center |
|
Emergency Services
NOT subject to Deductible unless otherwise noted Eligible Medical Expenses are limited to Usual, Reasonable, and Customary Limits per Period of Coverage unless Stated as Maximum Limit |
|
| Emergency Local Ambulance Subject to deductible |
Injury: Up to the maximum limit Illness: must result in an inpatient hospital admission |
| Emergency Medical Evacuation | $50,000 maximum limit Must be approved and coordinated in advance by the company |
| Emergency Reunion |
$15,000 maximum limit 15 day maximum, $25 per day meal maximum Must be approved in advance by the company |
| Repatriation for Medical Treatment | $100,000 maximum limit Must be approved in advance by the company |
| Political Evacuation and Repatriation | $10,000 maximum limit Must be approved in advance by the company |
| Return of Mortal Remains or Cremation/Burial |
$25,000 maximum limit for Return of Mortal Remains $5,000 maximum limit for Cremation/Burial Must be approved in advance by the company |
|
Other Services
NOT subject to Deductible unless otherwise noted Eligible Medical Expenses are limited to Usual, Reasonable, and Customary Limits per Period of Coverage unless Stated as Maximum Limit |
|
| Accidental Death and Dismemberment | $25,000 principal sum Death must occur within 90 days of the accident |
| Dental Treatment |
Treatment due to Unexpected Pain to natural teeth: $350 limit Non-emergency Treatment due to Accident: $500 maximum |
| Traumatic Dental Injury Subject to deductible | Up to the maximum limit Additional treatment for the same injury rendered by a dental provider will be paid at 100%. |
| Incidental Trip | 14 day maximum Country of Residence is outside the United States |
| Terrorism | $50,000 maximum limit |
| Pre-existing Conditions | $500 per period of coverage, $1,500 maximum limit Available after 12 months of continuous coverage |
| Sudden and Unexpected Reoccurrence of a Pre-Existing Condition Available on Patriot Exchange International (no U.S. coverage) only |
Maximum limit: $5,000 Emergency Medical Evacuation maximum limit: $25,000 |
|
Optional Add-On Rider
NOT subject to Deductible unless otherwise noted Eligible Medical Expenses are limited to Usual, Reasonable, and Customary Limits per Period of Coverage unless Stated as Maximum Limit |
|
| Interscholastic Athletics, Intramural Sports and Club Sports Subject to deductible |
Excluding Collision Sports: Up to the Maximum Limit Including Collision Sports: Maximum Limit: $50,000 |
| Baggage |
Lost or Stolen Baggage: $250 limit Lost or Stolen Valuables: $250 limit Lost or Stolen Personal Papers: $250 limit |
| Legal Assistance | $500 limit for initial consultation When the Insured Person receives a legal summons, threat of lawsuit, or other notice of a third-party claim regarding a personal Injury or property damage liability |
| Personal Liability Secondary to any other insurance |
Injury to a third party: $2,000 per period of coverage limit after $100 deductible Damage to third party’s property: $500 per period of coverage limit after a $100 deductible No coverage for injury to a related third party or damage to related third person’s property. |
|
Optional Adventure Sports Rider
Subject to Deductible unless otherwise noted Eligible Medical Expenses are limited to Usual, Reasonable, and Customary Limits per Period of Coverage unless Stated as Maximum Limit |
|
| Adventure Sports per Injury or Illness |
Through age 49: $50,000 maximum limit Ages 50 through age 59: $30,000 maximum limit Ages 60 through age 64: $15,000 maximum limit |
Please Note: The benefit table listed above is a consolidated version of the full plan benefits. Please view the plan certificate ( America | International) for more details about benefits and limitations of the plan. Limits apply to all benefits.
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