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How to read a schedule of benefits

Learning how to read a schedule of benefits is important when you want to buy a private insurance or apply for a waiver. Insurance policies are long and tricky. Here is a sample to help you understand how to read an insurance policy.

Benefits Plan A Explanation
Medical Lifetime Maximum* $250,000 Some plans have an overall maximum and a per condition maximum. The per condition maximum will be your actual benefit for any one illness or injury.
Benefits per illness or injury $50,000
Deductible* $150 It is the specific amount that must be paid by you before the insurance company begins to pay.
Copay $10 A specified dollar amount you pay for doctor visits and prescriptions drugs at the time the service is given
Coinsurance Plan pays 90% The percentage of the total medical bill the patient is responsible for paying. The insurance will cover the rest. In this example, patient is responsible for 10% of the bill.
Annual Maximum Out-of-pocket $1,650 Annual out-of-pocket max = deductibles1 + your share of coinsurance. It's the highest total amount your health insurance company requires you to pay towards the cost of your health care every year. Oftentimes when exceed, insurance company will cover 100% of the costs they consider to be necessary till you hit your plan maximum.
1Some plans don't include deductible in the annual max out-of-pocket. And most plans won't count the charges over Usual Customary & Reasonable Charges (UCR) towards your deductible or annual out-of-pocket maximum, so it is an additional out-of-pocket.
Provider Network • 90% if going to in-network or preferred care
• 70% if going to out-of-network or non-preferred care
Network is like club. If your provider is a member (in-network/ preferred care) , you'll have better coverage level and pay less. So make sure at least one of the 2 major hospitals* is an In-Network provider of the insurance plan.
Prescription* $1000
Maternity Covered as other illness If anyone in your family may become pregnant during your stay in the U.S., make sure the insurance you are purchasing will cover maternity costs.
Outpatient treatment limit • Mental health*: 1 visit per day, up to 30 days
• Physical therapy: 1 visit per day, up to 30 days
Hospital Room & Board limits $1000/day
Surgery limits $5000 max
Pre-existing condition limits 12 months Pre-existing condition: Any medical condition that was diagnosed before the beginning date of the insurance policy. Your pre-existing condition won't be covered until (12) months after the effective date of your insurance policy. Generally speaking, the pre-ex limit is 6 months or longer
Exclusions • Injuries sustained while intoxicated, engaging in motor vehicle or high risk sports
• Dental treatment
• Treatment of all forms of cancer / neoplasm
Limits and exclusions: The fewer the better. These limitations and exclusions are not just inadequate, they make it almost impossible to reach the overall plan maximum and you end up paying tons of $$$ when you really need these medical services.
Home country coverage $1,000 max, up to 30 days.
Medical evacuation* $10,000
Repatriation* $7,500

* are criteria of MSU minimum requirements