PA Group offers comprehensive international solutions so you can focus on what matters most. In the schedule of benefits you will find detailed information regarding plan coverage features, limits and benefits.
| All benefits are subject to Usual, Customary and Reasonable (UCR) fees. The benefits, coverage and exclusions listed herein are only a summary, and a subject to the specific terms and conditions of the plan concerning eligible benefit, limitations, eligibility and exclusions. Please refer to the Conditions of Coverage for details. Penalties to the benefits payable under this plan may apply if the requirements are not met. Please refer to the section labeled Pre-Certification Requirements and Procedures in the plan’s Policy Wording. You must contact the pre-certification provider number listed on your identification card. THE FOLLOWING SERVICES REQUIRE PRE-CERTIFICATION: HOSPITALIZATION | SURGERY | DIAGNOSTIC TESTING | ONCOLOGY TREATMENT | REPATRIATION OF MORTAL REMAINS | THERAPY | ORGAN TRANSPLANT | MEDICAL AIR EVACUATION / AIR AMBULANCE | REHABILITATION | HOME HEALTH CARE | EXTENDED CARE FAMILY Failure to perform the pre-certification requirements within a minimum of 5 business days prior to the planned treatment of non-emergency service or within 72 hours of an emergency service, will result in a penalty of 30% of the allowable charge for the entire episode of care. The penalty will not count toward the deductible or co-insurance maximum as defined on the Certificate of Coverage. For travel Assistance all notifications must be done within 24 hours of occurrence. |
| BENEFIT DESCRIPTION | DETAILS | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Maximum Annual Coverage | $500,000 | ||||||||||
| International Network | 100% UCR | ||||||||||
| U.S. In-Network | 100% UCR | ||||||||||
| U.S Out-of-Network | 50% UCR | ||||||||||
| Co-Insurance Limit (Out-of-Pocket) U.S. In-Network | $5,000 | ||||||||||
| Co-Insurance Limit (Out-of-Pocket) U.S. Out-of-Network | $10,000 | ||||||||||
| Policy Waiting Period | 12-month waiting period on pre-existing conditions | ||||||||||
| Area of Coverage | Worldwide, including the United States | ||||||||||
| Deductible Options Inside Country of Residence / Outside Country of Residence (Deductible for Family is a maximum of two (2) individually met deductibles per policy year.) |
|
| INPATIENT BENEFITS | COVERAGE |
|---|---|
| Hospital Room & Board Payable up to 365 days per policy year | 100% Private Room |
| Intensive Care Unit (ICU) Payable up to 365 days per policy year | 100% |
| Inpatient Ancillary Hospital Services Including, but not limited to X-Rays, drugs, bandages, operating room fees, surgical implants | 100% |
| Inpatient Psychiatric Treatment Subject to 12 month waiting period | 100% |
| Inpatient Physician / Specialist Visits Limited to one visit per day per specialty | 100% |
| Inpatient Surgery Including Primary Surgeon fees | 100% |
| Adult Companion of Hospitalized Child For a hospitalized child under the age of 19 | Up to $100 per day 10 days per policy year |
| Pre-Admission Testing Must be performed 3-5 days in advance | 100% |
| Inpatient Prescriptions | 100% |
| Extended Care Facility | 100% |
| OUTPATIENT BENEFITS | COVERAGE |
|---|---|
| Outpatient Surgery Including Primary Surgeon fees | 100% |
| Assistant Surgeon | 100% |
| Anesthesiologist | 100% |
| Congenital Disorders, Birth Defects & Hereditary Conditions | Up to $200,000 lifetime if diagnosed before 18 years of age; 100% if diagnosed after 18 years of age |
| Diagnostic Testing Echocardiography, Ultrasound, CAT Scan, PET Scan, MRI, Endoscopy, Gastroscopy, Colonoscopy, Cystoscopy, X-rays, laboratory, etc, | Up to $10,000 per policy year |
| Dialysis | 100% |
| Durable Medical Equipment | Up to $5,000 policy year |
| Emergency Dental Treatment | 100% |
| Major Accident | 100% Deductible waived |
| Emergency Ground Ambulance | Up to $1,000 per incident |
| Hospice Care Including home health care services | 100% 60 days lifetime |
| Outpatient Physician Visits / Specialist Visits | 100% |
| Home Visits by a Physician | Up to $75 per visit 5 visits per policy year |
| Prescription Medication | Up to $3,000 per policy year |
| Oncology / Cancer Treatment | 100% |
| Podiatric Services Subject to 24-month waiting period | Up to $20,000 per policy year Up to $75,000 lifetime |
| Prosthetic Limbs | 100% |
| Outpatient Rehabilitation / Therapeutic Services Physical, Speech & Occupational Therapy | 100% 30 visits per policy year for all therapies combined |
| Organ Transplant & Services Subject to 6-month waiting period | Up to $250,000 per organ/tissue per lifetime |
| Organ Acquisition Includes organ harvesting, acquisition, transportation and living transplant donor | Up to $30,000 per transplant |
| Wellness Benefit for Children under the age of 19 | Up to $250 per policy year; Deductible waived |
| Wellness Benefit for Adults | Up to $250, if used once a year; Deductible waived |
| MATERNITY BENEFITS | COVERAGE |
|---|---|
| Normal Delivery or C-Section Subject to 10-month waiting period | Up to $8,000 per pregnancy; Deductible waived |
| Complications of Pregnancy Subject to 10-month waiting period | Up to $150,000 per pregnancy; Deductible waived |
| Inclusion of Newborn (requires notification to insurer within 31 days of birth) | Covered up to policy max without underwriting if born under a Covered Maternity |
| ADDITIONAL BENEFITS | COVERAGE |
|---|---|
| Emergency Air Transportation | Up to $25,000 per event; Deductible waived |
| Repatriation of Mortal Remains | Up to $10,000 for Repatriation; or up to $10,000 for local burial in lieu of Repatriation; Deductible waived |
| Travel Assistance Coverage | Up to $10,000 per trip Deductible waived |