Standard Plan

Gallagher Visiting Scholar Benefit Plan IMPORTANT NOTICE REGARDING THIS INSURANCE: This insurance is intended for Sponsoring Organizations with Students on expatriate status (Students who have a good faith belief that they will reside outside of their Country of Residence for at least six (6) months during a plan year) and their Spouses and Children. This insurance is provided by Sirius Specialty Insurance Corporation (publ) (the Company), and is considered to be Minimum Essential Coverage under the United States Patient Protection and Affordable Care Act (PPACA) for each month when the Student is outside of the United States for at least one (1) day of that month or when the Student is physically present in the United States. for an entire month if the coverage provides health benefits within the United States while the individual is on expatriate status. Eligibility to purchase or renew this product, or its terms and conditions, may be modified or amended based upon changes to applicable law, including PPACA. Please note that it is solely your responsibility to determine the insurance requirements that are applicable to you and the Company and its Administrator shall have no liability whatsoever, including for any penalties that you may incur, for your failure to obtain coverage required by any applicable law including without limitation PPACA. Plan Administered by: UC Berkeley Visiting Scholar Insurance Plan Sirius Specialty Group/Certificate Number: SHAAI00513547 Certificate Holder Name: UC Berkeley Visiting Scholar Insurance Plan Attention: Diane Sims Certificate Holder Address: Gallagher Benefit Services 18201 Von Karman Avenue, Suite 200 Irvine, CA 92612 USA Plan Type: Custom International Plan: Worldwide excluding Country of Residence The Period of Insurance From: September 1, 2021 To: September 1, 2022 Both days at 12:01 am Eastern Standard Time Law: USA Jurisdiction: The Courts of Indiana USA alone shall have jurisdiction in any dispute arising hereunder. Table of Contents Benefit Summary ........................................................................................................................ 1 A. Benefit Summary .................................................................................................................. 7 B. Agreement ............................................................................................................................ 7 C. Conditions and General Provisions ...................................................................................... 7 D. Eligibility ............................................................................................................................. 14 E. Pre-certification Requirements ........................................................................................... 14 F. United States Preferred Provider Organization (PPO) ....................................................... 15 G. Eligible Medical Expenses .................................................................................................. 16 H. Accidental Death and Dismemberment .............................................................................. 17 I. Emergency Medical Evacuation ......................................................................................... 17 J. Emergency Reunion ........................................................................................................... 19 K. Incidental Trip ..................................................................................................................... 19 L. Intercollegiate, Interscholastic, Intramural, or Club Sports ................................................. 19 M. Political Evacuation and Repatriation ................................................................................. 19 N. Public Health Emergency ................................................................................................... 20 O. Return of Mortal Remains................................................................................................... 20 P. Exclusions .......................................................................................................................... 20 Q. Definitions ........................................................................................................................... 24 BENEFIT SUMMARY Coverage Limit / Maximum Amount for Eligible Medical Expenses Period of Coverage Maximum Limit: 365 days Maximum Limit Insured Person: $500,000 Spouse and Child: $100,000 Maximum Limit per Illness or Injury Insured Person: $100,000 Spouse and Child: $100,000 Benefit Plan Features Benefit Levels United States United States International In-Network Out-of-Network International Deductible for Eligible Medical Expenses Deductible $500 $500 $500 • Per Illness or Injury Coinsurance for Eligible Medical Expenses Coinsurance Plan pays 100% Plan pays 80% Plan pays 100% • In addition to Deductible Insured pays 0% Insured pays 20% Insured pays 0% Out of Pocket Maximum $0 $1,000 $0 Pre-certification • Interfacility Ambulance Transfer: No coverage if Pre-certification requirements are not met. • Medical Evacuation: No coverage if not approved by the Company. Refer to the EMERGENCY MEDICAL EVACUATION provision for complete requirements and coverage. • All other Treatments & supplies: 50% reduction of Eligible Medical Expenses if Pre-certification requirements are not met. • Deductible is taken after reduction. • Coinsurance is applied to remainder of the reduced amount. • Refer to PRE-CERTIFICATION REQUIREMENTS provision for a complete list of services that require Pre-certification. Pre-existing Conditions Charges are excluded until the Insured Person has maintained 12 months of continuous coverage under this insurance. Inpatient or Outpatient Services Subject to Deductible and Coinsurance unless otherwise noted Eligible Medical Expenses are limited to Usual, Reasonable and Customary Limits per Period of Coverage unless stated as Maximum Limit Benefit In-Network Out-of-Network International Eligible Medical Expenses 100% 80% 100% Physician Visits / Services 100% 80% 100% UC Berkeley Visiting Scholar Insurance Plan 08.03.21 v1.0 1 GVSB SHAAI 08.01.21 Inpatient or Outpatient Services Subject to Deductible and Coinsurance unless otherwise noted Eligible Medical Expenses are limited to Usual, Reasonable and Customary Limits per Period of Coverage unless stated as Maximum Limit Benefit In-Network Out-of-Network International Teladoc Consultation • Applicable in the United States • Not Subject to Deductible and Coinsurance • Mental or Nervous Disorders are not covered • Coverage for a Teladoc Consultation is not a determination that any specific condition discussed, raised or identified 100% Not Applicable Not Applicable during such consultation is covered under this insurance. The Company reserves the right to decline future claims relating to or arising from any condition discussed, raised or identified during a Teladoc Consultation where the Illness or Injury is directly or indirectly related to any Pre-existing Condition or is otherwise excluded under this Certificate of Insurance Hospital Emergency Room • Injury: Not subject to Emergency Room Deductible • Illness: Subject to a $250 Deductible for 100% 80% 100% each Emergency Room visit for Treatment that does not result in a direct Hospital admission. Hospitalization / Room & Board • Average semi-private room rate 100% 80% 100% • Includes nursing, miscellaneous and Ancillary Services Intensive Care 100% 80% 100% Outpatient Surgical / Hospital Facility 100% 80% 100% Laboratory 100% 80% 100% Radiology / X-ray 100% 80% 100% Chemotherapy / Radiation Therapy 100% 80% 100% Pre-admission Testing 100% 80% 100% Surgery 100% 80% 100% Reconstructive Surgery • Surgery is incidental to or follows 100% 80% 100% Surgery that was covered under the Plan Assistant Surgeon 100% 80% 100% 20% of the primary surgeon’s eligible fee Anesthesia 100% 80% 100% Durable Medical Equipment 100% 80% 100% UC Berkeley Visiting Scholar Insurance Plan 08.03.21 v1.0 2 GVSB SHAAI 08.01.21 Inpatient or Outpatient Services Subject to Deductible and Coinsurance unless otherwise noted Eligible Medical Expenses are limited to Usual, Reasonable and Customary Limits per Period of Coverage unless stated as Maximum Limit Benefit In-Network Out-of-Network International Hospitalization / Room & Board • Average semi-private room rate 100% 80% 100% • Includes nursing, miscellaneous and Ancillary Services Intensive Care 100% 80% 100% Outpatient Surgical / Hospital Facility 100% 80% 100% Laboratory 100% 80% 100% Radiology / X-ray 100% 80% 100% Chemotherapy / Radiation Therapy 100% 80% 100% Pre-admission Testing 100% 80% 100% Surgery 100% 80% 100% Reconstructive Surgery • Surgery is incidental to or follows 100% 80% 100% Surgery that was covered under the Plan Assistant Surgeon 100% 80% 100% • 20% of the primary surgeon’s eligible fee Anesthesia 100% 80% 100% Durable Medical Equipment 100% 80% 100% Chiropractic Care 100% 80% 100% • Medical order or Treatment plan required Physical Therapy • Maximum Outpatient Visits per Day: 1 100% 80% 100% • Medical order or Treatment plan required Maternity Not Covered Not Covered Not Covered Newborn Care Not Covered Not Covered Not Covered Extended Care Facility • Upon direct transfer from acute care 100% 80% 100% Hospital Home Nursing Care • Provided by a Home Health Care Agency 100% 80% 100% • Upon direct transfer from an acute care Hospital Preventative Care NOT Subject to Deductible and

Load more