Page 2 - Comparison of BLANK verses StudentSecure Plan of Tokio Marine HCC
P. 2
network of providers.
Co-Insurance:
In-network and Out-of-Network: Co-Insurance:
- ESSENTIAL: 80% for PPO. 70% for Non-PPO Claims incurred inside the U.S.
- BRONZE: 80% for PPO. 70% for Non-PPO In-network and Out-of-Network:
- SILVER: 80% for PPO. 70% for Non-PPO - ELITE: Within PPO: 100% of eligible expenses after
- ELITE: PPO: 90% Non-PPO: 70%. deductible to the overall maximum. Outside the PPO:
Usual, reasonable, and customary. You may be
responsible for charges exceed approved payable
amount.
- SELECT: Within PPO: 80% of next $5,000 of eligible
expenses after deductible, then 100% to the overall
maximum. Outside the PPO: Usual, reasonable, and
customary. You may be responsible for charges exceed
approved payable amount.
- BUDGET: Within PPO: 80% of next $25,000 of eligible
expenses after deductible, then 100% to the overall
maximum. Outside the PPO: Usual, reasonable, and
customary. You may be responsible for charges exceed
approved payable amount.
- SMART: Within PPO: 80% of eligible expenses after
deductible to the overall maximum. Outside the PPO:
Usual, reasonable, and customary. You may be
responsible for charges exceed approved payable
amount.
Claims incurred Outside the U.S.
- After the deductible, 100% of eligible expenses to the
certificate period maximum
3 Inpatient Mental Health Care: Must Paid as any other sickness. Services provided by a ELITE and SELECT: Maximum of 30 days
be paid at 80% in-network or 60% participating: PPO: 80%, Non-PPO: generally at 60%. BUDGET: Up to $10,000 maximum
out-of-network of the usual and SMART: Up to $5,000 maximum.
customary fees with a minimum 30-
day cap per benefit period. Treatment must not be provided at a student health center.
4 Outpatient Mental Health Care: Must Paid as any other sickness. Services provided by a ELITE and SELECT: Maximum of 30 visits.
be paid at 80% in-network or 60% participating: PPO: 80%, Non-PPO: generally at 60%. BUDGET: $50 maximum per day, $500 maximum
out-of-network of the usual and SMART: $50 maximum per day, $500 maximum
customary fees for a minimum of 30
(preferably 40) sessions per year. Treatment must not be provided at a student health center.
5 Maternity Benefits: Must be treated ESSENTIAL: $5,000 max for normal delivery. $7,500 ELITE: Up to $25,000
as any other temporary medical for C-section. Conception must occur during policy SELECT: Up to $10,000
condition and paid at no less than period, including complications of pregnancy. BUDGET: Up to $5,000
80% of usual and customary fees in- SMART: No coverage.
network or 60% out-of-network. BRONZE, SILVER, and ELITE:
Benefits as inpatient stay based on 48 hours normal Nursery care of newborn (not subject to coinsurance).
Co-Insurance:
In-network and Out-of-Network: Co-Insurance:
- ESSENTIAL: 80% for PPO. 70% for Non-PPO Claims incurred inside the U.S.
- BRONZE: 80% for PPO. 70% for Non-PPO In-network and Out-of-Network:
- SILVER: 80% for PPO. 70% for Non-PPO - ELITE: Within PPO: 100% of eligible expenses after
- ELITE: PPO: 90% Non-PPO: 70%. deductible to the overall maximum. Outside the PPO:
Usual, reasonable, and customary. You may be
responsible for charges exceed approved payable
amount.
- SELECT: Within PPO: 80% of next $5,000 of eligible
expenses after deductible, then 100% to the overall
maximum. Outside the PPO: Usual, reasonable, and
customary. You may be responsible for charges exceed
approved payable amount.
- BUDGET: Within PPO: 80% of next $25,000 of eligible
expenses after deductible, then 100% to the overall
maximum. Outside the PPO: Usual, reasonable, and
customary. You may be responsible for charges exceed
approved payable amount.
- SMART: Within PPO: 80% of eligible expenses after
deductible to the overall maximum. Outside the PPO:
Usual, reasonable, and customary. You may be
responsible for charges exceed approved payable
amount.
Claims incurred Outside the U.S.
- After the deductible, 100% of eligible expenses to the
certificate period maximum
3 Inpatient Mental Health Care: Must Paid as any other sickness. Services provided by a ELITE and SELECT: Maximum of 30 days
be paid at 80% in-network or 60% participating: PPO: 80%, Non-PPO: generally at 60%. BUDGET: Up to $10,000 maximum
out-of-network of the usual and SMART: Up to $5,000 maximum.
customary fees with a minimum 30-
day cap per benefit period. Treatment must not be provided at a student health center.
4 Outpatient Mental Health Care: Must Paid as any other sickness. Services provided by a ELITE and SELECT: Maximum of 30 visits.
be paid at 80% in-network or 60% participating: PPO: 80%, Non-PPO: generally at 60%. BUDGET: $50 maximum per day, $500 maximum
out-of-network of the usual and SMART: $50 maximum per day, $500 maximum
customary fees for a minimum of 30
(preferably 40) sessions per year. Treatment must not be provided at a student health center.
5 Maternity Benefits: Must be treated ESSENTIAL: $5,000 max for normal delivery. $7,500 ELITE: Up to $25,000
as any other temporary medical for C-section. Conception must occur during policy SELECT: Up to $10,000
condition and paid at no less than period, including complications of pregnancy. BUDGET: Up to $5,000
80% of usual and customary fees in- SMART: No coverage.
network or 60% out-of-network. BRONZE, SILVER, and ELITE:
Benefits as inpatient stay based on 48 hours normal Nursery care of newborn (not subject to coinsurance).
