Us-Based Medical Benefits - Plan Comparison Chart

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Plan Comparison Chart
US-based medical benefits — plan comparison chart
In-Network
Out-of-Network
HIP Health Plan
Benefits
AETNA
BLUE CROSS
AETNA
BLUE CROSS
1
of New York
(In-Network
Only)
$0.00
$0.00
$0.00
Individual: $250
Individual: $250
Annual Deductible
Family: $750
Family: $750
100%
100%
100%
80% after deductible
80% after deductible
Insurance Coverage
N/A
N/A
N/A
Individual: $1,250
Individual: $1,250
Annual Out-of-
Family: $3,750
Family: $3750
Pocket Maximum
(w/deductible)
(w/deductible)
Unlimited
Unlimited
Unlimited
Unlimited
Unlimited
Lifetime Maximum
Provider files
Provider files
Provider files
You file
You file
Claim Submission
HOSPITAL BENEFITS
100%
100%
100%
100%
US: 80% after deductible
Inpatient
Pre-registration
Int’l: 100%
required
100%
100%
100%
100%
US: 80% after deductible
Outpatient
Int’l: 100%
100%
100%
100%
100%
100%
Emergency Room
Accidental injury;
after $50 co-pay
after $50 co-pay
after $50 co-pay
after $ 50 co-pay
(initial visit)
Sudden and
(waived if
(waived if
(waived if admitted
(waived if admitted within
serious medical
admitted within
admitted within
within 24 hours)
24 hours)
condition
24 hours)
24 hours)
100%
80%
Not covered
80% after deductible
Not covered
Emergency Room
Urgent care
visit (for non-
covered in the
emergency care)
United States
1
Please note that HIP Health Plan for New York is a “closed” plan and will not accept new participants except for new dependents of
subscribers currently enrolled in the plan.

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