Schedule/Summary of Coverage for CIEE Insurance Coverage
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Provider Network	Aetna Preferred Provider Network with access to over 672,000 health care service providers nationwide
Claims Administrator	Chickering Claims Administrator
Copays	Preferred or Non Preferred Care    Outpatient - $50 per visit    Inpatient - $100 per visit
Coinsurance	Preferred Care – 100% of Negotiated Charge Non Preferred Care – 80% of Reasonable Charge
Maximum Limit	Please refer to your Confirmation of Insurance Coverage document
Treatment Period	120 days per Injury or Illness
Hospital Room & Board	Up to the average semi-private room rate, including nursing service after $100 copay
Intensive Care Unit	Up to the average semi-private room rate, including nursing service after $100 copay
Physical Therapy	Outpatient benefits are limited to 1 visit per day
Physician’s Visits	Benefits are limited to 1 visit per day after $50 copay not applicable to Surgery
Eligible Medical Expenses	Preferred Providers: 100% of Negotiated Charge Non Preferred Providers: 80% of Reasonable Charge; 100% of Negotiated Charge if Insured Person lives more than 50 miles from a Preferred Provider
Prescription Drugs	$20 copay per prescription per 30 day supply
Temporomandibular Joint Disorder and/or Craniomandibular Disorder	Up to $5,000 lifetime maximum benefit
Dental Treatment	Relief of sudden and unexpected pain to sound natural teeth: Up to $350 maximum Injury: Up to $500 per accident, including fracture of the jaw
Pre-certification	50% Reduction of Eligible Medical Expenses if Pre-certification requirements are not met or if the expenses are not Pre-certified
Urgent Travel Expense	Up to $500 for transportation to home country in the event of death of father, mother, brother or sister
Emergency Medical Evacuation Expenses	Up to $15,000 Maximum Limit.
Emergency Reunion	Up to $15,000 Maximum Limit
Return of Mortal Remains	Up to $15,000 Maximum Limit
Accidental Death and Dismemberment	Accidental Death: $8,500 Dismemberment: Up to $85,500 Maximum Limit
Baggage Loss or theft of Baggage Loss or theft of Valuables Loss or theft of Personal Papers	Up to $1,500 per Period of Insurance Up to $350 per Period of Insurance Up to $500 per Period of Insurance
Legal Assistance Attorney Fees Advance of Bail	Up to $20,500 Sublimit: Up to $500 for initial consultation expenses in the event of a legal summons or threat of lawsuit, or other notice of a third-party claim in regard to personal injury or property damage liability Up to $8,500
Personal Liability Injury to a third Person Damage to Third Person’s Property Damage to related Third Person’s property	Up to $100,000 Up to $100,000 Up to $2,500, subject to a $100 deductible