Description of Medical Benefits
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Payment will be made as allocated herein, for Covered Medical Expenses incurred for any illness or injury while insured under the Policy. Please refer to your Confirmation of Insurance Coverage document for the maximum lifetime benefit for your Policy.

The payment of any Copays and the balance above any Coinsurance amount, and any medical expenses not covered are the responsibility of the Insured Person. To maximize your savings and reduce out-of-pocket expenses, we recommend that you select a Preferred Provider. It is to your advantage to utilize a Preferred Provider because significant savings can be achieved from the substantially lower rates these providers have agreed to accept as payment for their services. Non-Preferred Care is subject to the Reasonable Charge allowance maximums. Any charges in excess of the Reasonable Charge allowance are not covered under the Plan.

The following benefits are subject to the imposition of Policy limits and exclusions.

Inpatient Hospitalization Benefits
Hospital Room and Board Expenses –	Covered Medical Expenses are payable as follows: Preferred Care: 100% of the Negotiated Charge for an overnight stay after a $100 copay per admission. Non-Preferred Care: 80% of the Reasonable Charge for the semi-private room rate for an overnight stay after a $100 copay per admission.
Intensive Care Expenses –	Covered Medical Expenses are payable as follows: Preferred Care: 100% of the Negotiated Charge for an overnight stay after a $100 copay per admission. Non-Preferred Care: 80% of the Reasonable Charge for the semi-private room rate for an overnight stay.
Miscellaneous Hospital Expenses –	Covered Medical Expenses are payable as follows: Preferred Care: 100% of the Negotiated Charge. Non-Preferred Care: 80% of the Reasonable Charge. Covered Medical Expenses include but are not limited to: laboratory tests, X-rays, anesthesia, use of special equipment, medicines, and use of operating room.
Physician Hospital Visit Expenses –	Covered Medical Expenses for charges for the non-surgical services of the attending Physician are payable as follows: Preferred Care: 100% of the Negotiated Charge. Non-Preferred Care: 80% of the Reasonable Charge. Benefits are limited to 1 visit per day not applicable to Surgery.
Surgical Expenses –	Covered Medical Expenses for charges for surgical services performed by a physician are payable as follows: Preferred Care: 100% of the Negotiated Charge after a $50 copay. Non-Preferred Care: 80% of the Reasonable Charge after a $50 copay.
Anesthetist and Assistant Surgeon Expenses –	Covered Medical Expenses for charges of an anesthetist and an assistant surgeon during a surgical procedure for surgical services performed during a surgical operation are payable as follows: Preferred Care: 100% of the Negotiated Charge. Non-Preferred Care: 80% of the Reasonable Charge.
Outpatient Benefit Expenses Covered Medical Expenses include, but are not limited to: Physician’s office visits, specialist expenses, hospital or outpatient department or emergency room visits, durable medical equipment, physical therapy, clinical lab, radiological facility, or other similar facility licensed by the state.
Physician’s Office Visit/Hospital Outpatient Department –	Covered Medical Expenses are payable as follows: Preferred Care: 100% of the Negotiated Charge after a $50 copay per visit. Non-Preferred Care: 80% of the Reasonable Charge after a $50 copay per visit. Benefits are limited to 1 visit per day.
Lab and X-ray Expenses – (Non-Hospitalization)	Covered Medical Expenses are payable as follows: Preferred Care: 100% of the Negotiated Charge. Non-Preferred Care: 80% of the Reasonable Charge.
Treatment Expenses for An Emergency Medical Condition –	Covered Medical Expenses are payable as follows: Preferred Care: 100% of the Negotiated Charge after $100 copay if admitted. Non-Preferred Care: 80% of the Reasonable Charge after $100 copay if admitted.
Additional Benefits
High Cost Procedure –	Covered Medical Expenses for high cost procedures in excess of $200, such as, but not limited to, outpatient diagnostic C.A.T. Scans, Magnetic Resonance Imaging are payable as follows: Preferred Care: 100% of the Negotiated Charge. Non-Preferred Care: 80% of the Reasonable Charge.
Durable Medical Equipment Expenses-	Covered Medical Expenses are payable as follows: Preferred Care: 100% of the Negotiated Charge. Non-Preferred Care: 80% of the Reasonable Charge.
Ambulance Expenses –	Covered Medical Expenses are payable at 100% of the Reasonable Charge for the services of a professional ambulance to or from a hospital when required due to the emergency nature of a covered Accident or Sickness.
Home Health Care Expenses –	Covered Medical Expenses are payable at 100% of the Reasonable Charge incurred within 12 months from the date of the first home health care visit. The maximum number of covered visits is limited to 40. Four Hours of home health aide service shall be considered as one home care visit.
Physical Therapy Expenses –	Covered Medical Expenses are payable as follows: Preferred Care: 100% of the Negotiated Charge. Non-Preferred Care: 80% of the Reasonable Charge. Outpatient benefits are limited to 1 visit per day.
Prescription Drug Benefit Expenses –	Covered Medical Expenses for outpatient Prescription Drugs associated with a covered Illness or Injury which occurs during a Policy Year are payable as follows: 100% of the Reasonable Charge after $20 copay per prescription. Benefits are not payable for more than a 30 day supply.
Dental Injury Expenses –	Covered Medical Expenses are payable as follows: Preferred Care: 100% of the Negotiated Charge for the treatment of an Injury to sound, natural teeth after a $50 copay per visit. Non-Preferred Care: 80% of the Reasonable Charge for the treatment of an Injury to sound, natural teeth after a $50 copay per visit. Benefit is capped at $500 per accident, including fracture of jaw.
Dental Sickness Expense –	Covered Medical Expenses are payable as follows up to $350 per sickness: Preferred Care: 100% of the Negotiated Charge for the treatment to sound, natural teeth after a $50 copay per visit. Non-Preferred Care: 80% of the Reasonable Charge for the treatment to sound, natural teeth after a $50 copay per visit.
Emergency Medical Evacuation	Up to $15,000 Maximum Limit. Must be approved in advance and coordinated with CIEE
Emergency Reunion	Up to $15,000 per Period of Insurance. Must be approved and coordinated by CIEE
Return of Mortal Remains	Up to $15,000 Must be approved and coordinated by CIEE