INPATIENT HEALTH INSURANCE

Transcription

1 E PL M SA INPATIENT HEALTH INSURANCE 2012

2 Global Benefits Group offers worldwide expertise, products and services unbound by geographic constraints. Any Country. Any Nationality. Experience and Expertise in the International Marketplace GBG Insurance Limited and Global Benefits Group have been specializing in the international insurance market for more than 30 years, serving as leading underwriters, developers and distributors of products and services designed especially for the needs of overseas workers and international travelers. GBG underwrites health, life, disability and other specialty insurances for groups and individuals who are expatriates, third-country nationals or high net-worth local nationals. As globalization of the world s economy has continued to accelerate, GBG has developed a specialized underwriting structure that is required to meet the needs of this select market niche. This structure is devoted to one business only: underwriting risks for organizations and individuals whose life and work transcend geographic boundaries. The GBG portfolio of products provides optimum security because it is supported by a world-class panel comprising some of the largest and most financially stable underwriters in the world: GBG Insurance Limited (rated B+ by A.M. Best Company) Chubb Insurance (rated A++) General Reinsurance Corporation (rated A++) Lloyd s of London (rated A) Hannover Re (rated A) Additionally, GBG partners with a multitude of local insurance companies around the world when an admitted carrier is required to meet specific country regulations. We are proud to offer this exciting and innovative structure to our clients. It provides the international marketplace with an unprecedented and unique combination: International expertise Dedicated underwriting facility Financial security Responsive customer service For the latest A.M. Best ratings: 2

3 INPATIENT HEALTH INSURANCE GBG has created a special health insurance plan customized for people who choose to be responsible for everyday outpatient healthcare but want robust protection for inpatient treatment. The plan is affordably priced to those individuals and families who balance economics with sound health insurance coverage. The GBG Inpatient Health Insurance plan offers coverage anywhere in the world, including the United States and Canada. The plan offers a range of deductibles and coverages for an individual and his or her dependents. The plan has coverage for inpatient care and emergencies with no policy limit; in addition, the plan covers outpatient testing to diagnose surgical or additional medical treatment that could be required. This customized combination of inpatient treatment and outpatient diagnostic testing provides a prudent option to health insurance coverage. As with all GBG health insurance plans, Inpatient Health Insurance includes the world-class services of GBG Assist for client services, case management and evacuations, if necessary, anywhere in the world any time of day. GBG Assist features a worldwide network of more than 550 medical facilities that will bill GBG directly, eliminating the need for a member to pay up-front for services. When a claim does need to be filed, GBG Assist offers state-of-the-art claims submission and reimbursement options through its gbg.com website. This process makes claims reimbursement simple, fast and easy. Key Benefits of Inpatient Health Insurance Inpatient coverage with no annual policy limit Outpatient diagnostic testing (up $10,000) Pharmacy benefit that follows treatment for a covered hospitalization Worldwide direct-bill network Emergency medical evacuation Online claims filing Online and Live customer service 3 3

4 GBG provides Technology at work for you world-class services. The essence of outstanding health insurance comes in the form of customer service, and a cornerstone of GBG is the worldwide expertise of GBG Assist. GBG Assist offers 24/7 assistance to answer any customer need around the world including emergency evacuation, if necessary no matter the day or time. GBG Assist is a member s onestop shop for any questions concerning benefits, deductibles & co-insurance, network providers, pre-authorization and coordination of benefits. In the case of hospitalization, Case Managers and the GBG Assist Medical Director work as a team to manage all aspects of a case from the initial referral until the patient returns home. GBG Assist provides empathetic patient advocacy while monitoring costs; whenever in doubt, make your first call to GBG Assist. GBG Assist also includes the services of Nurse Assist, which provides 24/7 consultation from registered nurses who can dispense expert advice to members over the phone through toll-free numbers. International Claims Services (ICS) supports group and individual clients around the world by providing claims processing and reimbursement to both providers and individuals. All ICS services are accessible to members online at gbg.com. Of special importance, ICS has developed proprietary claims software to handle the complexities of international reimbursements whenever a member files a pay-and-claim form. ICS is staffed with experienced claims processing professionals who are fully conversant with the needs of international clients. In the United States and Canada, GBG utilizes the Coventry Health Care Network as its Preferred Provider Network. Coventry is positioned as a leading PPO Network that includes more than 4,800 hospitals and 555,000 professional providers in the United States. The network has coverage in all 50 states plus the District of Columbia and Puerto Rico. Networks are important to health insurance members because the overwhelming majority of these facilities will invoice the insurance company directly for services rendered, avoiding the need for a member to pay and claim. Coventry s ever-expanding network speaks to its client satisfaction and pride in its track record of success and aggressive growth supported by exceptional service. Outside of North America, GBG has built a proprietary Preferred Provider Organization called World Medical Network (WMN). Facilities that participate in World Medical Network will not only provide the finest care available in the local environment, but they have been chosen for their expertise in dealing with expatriates. They maintain an English speaking staff, have many Western trained staff members, and provide high quality and professional medical care. In addition, all WMN network providers will bill GBG directly. GBG policies offer many levels of pharmacy benefits that are available worldwide, and our health plans can be customized to fit the specific pharmacy needs of every client. For pharmacy coverage in the United States, GBG utilizes CVS Caremark, giving members access to one of the leading pharmaceutical service companies. CVS Caremark fills or manages more than 1 billion prescriptions per year, more than any other pharmacy services provider in the United States. Outside of the United States, pharmacy expenses are reimbursed on a pay-and-claim basis. 4 GBG members and their eligible dependents who have worldwide coverage have access to the Vision Service Plan (VSP) Access discount plan and broad provider network. No special I.D. card is required, and no additional premium is charged. VSP provides discounts for eye exams, eye-glasses and contact lenses, when members use network providers in the United States.

5 BENEFITS SCHEDULE TECHNOLOGY CONSULTING PROVIDES A TOTAL END TO END SOLU- TION. 5 5

6 Currency USD Insured Person (per policy year) Insured Individual Regional Option Option 1 Option 2 Option 3 Option 4 Option 5 Option 6 Deductible IN Residence Country 500 1,000 2,000 5,000 10,000 20,000 ANNUAL MAXIMUM ANNUAL DEDUCTIBLES Deductible OUTSIDE Residence Country 1,000 2,000 3,000 5,000 10,000 20,000 WORLDWIDE Option* Option 1 Option 2 Option 3 Option 4 Option 5 Option 6 No Annual or Lifetime Maximum Deductible IN Residence Country 500 1,000 2,000 5,000 10,000 20,000 Family 2 x Individual Deductible 2 x Individual Deductible Deductible OUTSIDE Residence Country 1,000 2,000 3,000 5,000 10,000 20,000 Benefits are per person per policy year and based upon medical necessity and Usual, Reasonable and Customary (URC) charges, after Annual Deductible. Additionally, many services require Pre-Authorization. Please refer to the Policy for more details. *Special notes: Residents of Brazil and Mexico only have the option of worldwide coverage. In Brazil, Option 1 is not available In the U.S., when a provider in our PPO network is available, benefits are paid 100% in-network, based on medical necessity and Usual, Reasonable & Customary (URC) charges. Outside of network, benefits are paid at 80%. Private or Semi-private room Intensive Care (medically necessary) Medical treatment, medicines, laboratory & diagnostic tests Inpatient Consultation by Physician or Specialist Inpatient Surgery & Surgeon Cancer treatment (chemotherapy/radiotherapy) Extended Care / Inpatient Rehabilitation **Must be confined to facility immediately following a Hospital stay Private Duty Nursing (Inpatient Only) Emergency Room **Covered if immediately admitted as an Inpatient HOSPITALIZATION & INPATIENT OUTPATIENT Emergency Room, Emergency Medical Services, Consultation by Specialist, Consultation by Specialist, X-Rays and Laboratory Outpatient Physicians Visit** Consultation by Specialist** **As follow-up care to a covered hospitalization Echocardiography, Ultrasound, CAT Scan, PET Scan, MRI **Pre-surgical testing purposes only ** 3 months waiting period Pre-authorization required Outpatient or Ambulatory Surgery Outpatient Surgeon Cancer treatment (chemotherapy/radiotherapy) SCHEDULE OF BENEFITS In-Network: ; Non-network: Maximum $2,000/day In-Network: ; Non-network: Maximum $4,000/day ** ** Private Duty Nursing, Skilled Nursing, Visiting Nurse, Home Health Nursing** **As follow-up care to a covered hospitalization Not Covered $5,000 Annual Maximum, up to 10 months from date of discharge $10,000 Annual Maximum** 6

7 SCHEDULE OF BENEFITS Currency USD In the U.S., when a provider in our PPO network is available, benefits are paid 100% in-network, based on medical necessity and Usual, Reasonable & Customary (URC) charges. Outside of network, benefits are paid at 80%. Ground Ambulance ** Covered if immediately admitted as an Inpatient Air Ambulance **Refer to Policy EMERGENCY AMBULANCE ** Included** Repatriation of Mortal Remains $20,000 OTHER COVERED SERVICES Human Organ, Bone Marrow, Stem Cell Transplants, and other similar procedures. (Expenses for Donor are covered.) Subject to pre-authorization Therapeutic Services: Physical Therapy, Chiropractic, Occupational Therapy, Vocational Speech Therapy Homeopathy and Acupuncture Hospice -- licensed agency which provides a physician-directed coordinated plan of home and inpatient care, 24/7, to a terminally ill person. Agency must meet validation tests, as described in policy. Durable Medical Equipment : Rental up to purchase price **As follow-up care to a covered hospitalization **Refer to Policy for details Alcohol and drug abuse, Outpatient & Inpatient rehabilitation Mental Health Inpatient Mental Health Outpatient Human Immunodeficiency Virus (HIV), Acquired Immunodeficiency Syndrome (AIDS), AIDS Related Complex (ARC), Sexually transmitted diseases and all related conditions. **Covered if not a pre-existing condition Child Examinations (child immunizations & routine medical exams) Preventive Care, Annual Exams & Immunizations **Covered after 3 months waiting period Emergency Dental Care (Limited to accidental injury of sound natural teeth sustained while covered under policy.) War and Terrorism PRESCRIPTION $750,000 per diagnosis Not Covered Not covered Not covered $40,000 Annual Maximum** Inpatient Hospitalization only, Benefit up to age 6 months Maximum 5 visits, up to $600 per person** Deductible does not apply Included Use of the Insurer s U.S. Pharmacy Network is preferred for prescription drugs obtained in the U.S. Failure to use a participating pharmacy will result in a reduction of benefit payment. Following covered hospitalization or out-patient surgery ** Deductible applies to this benefit., up to 6 months from date of discharge $3,000 Annual Maximum** thereafter, combined maximum for all medical conditions Related to Outpatient or Non-Hospitalization/surgery Not covered 7 7

8 RESIDENCY Country of Residence is defined as: 1) Where the Insured resides the majority of any calendar or policy year; or 2) Where the Insured has resided more than 180 days during any 12-month period while the policy is in effect. EXCLUSIONS The following is only a brief summary of exclusions. Please refer to the Policy for complete details. SCHEDULE OF BENEFITS All applicants will submit health evidence for coverage consideration. Coverage is not guaranteed and subject to underwriting approval. This policy contains a 60-day waiting period, during which only illnesses or injuries caused by an accident occurring within this period, or diseases of infectious origin that first manifest themselves within this period, will be covered. Pre-Existing Conditions: Coverage for pre-existing conditions is subject to a 12-month waiting period. If a pre-existing condition is not disclosed on the application, the Insurer may deny claims for such condition, or terminate or rescind the coverage. Cosmetic surgery and treatments. Medical conditions as a result of self-inflicted injuries, suicide, abuse of alcohol, drug addiction or abuse. Injuries resulting from engaging in professional sports, or activities related to the use of a weapon or firearm (e.g. hunting). Inpatient Private Duty Nursing is not covered. All vitamins, minerals, and dietary supplements prescribed or purchased over the counter, except during pregnancy or to treat diagnosed, clinically significant vitamin deficiency syndromes. Any experimental treatment. Any reproductive treatments, including abortion, contraception, infertility, sterilization, sexual dysfunction, and post/pre-natal classes. Obesity. Treatment to change the refraction of one or both eyes (laser eye correction). Sex change operations and related treatments. Charges in excess of usual and customary charges. KEY PROVISIONS The following is only a brief summary of key Plan provisions. Please refer to the Policy for complete details. The insurance company will reimburse medical expenses at the established Usual & Customary rates for the region, country and category of Pre-Authorization is required for some medical services. Where Pre-Authorization is required, the insured must obtain it in writing from the insurance company. Failure to pre-authorize will result in a 40% penalty for the entire episode of care. Some of the situations where it is required include a) medical evacuation, b) where treatment may exceed $5,000, c) in and out-patient surgery, d) maternity (For ongoing treatment purposes), e) emergency dental and f) hospitalization. This is not a complete list of situations where Pre-Authorization is required. Please refer to the Pre-Authorization section of the policy for a complete description. When in doubt, the insured is encouraged to consult with GBG Assist. If services are received in the United States, use of the PPO network is required to optimize benefit payment. Failure to use a preferred provider when available will result in a reduction of benefit payment with no coinsurance out-of-pocket maximum. The information contained herein is for illustrative purposes only. Please contact GBG for policy details and/or to request a customized proposal. Sample_Inpatient_[E]_23AUG2012