Sirius International Insurance Corporation insures the Global Medical plan. Sirius is a well-established insurance firm with a worldwide reputation and an A.M. Best Company rating of ‘A’ (Excellent) and Standard & Poor’s rating of ‘A-‘.
What’s the difference between the Bronze, Silver, Gold, and Platinum level of the Global Medical?
The Global Medical plan comes in four levels, allowing you to select the degree of coverage that is suitable for you.
- Platinum The Platinum level of coverage includes medical, dental, vision, wellness, political evacuation, remote transportation, and maternity care. Due to its extensive benefit structure, the Platinum gives $8 million in lifetime coverage per insured and is referred to as the “Cadillac” insurance plan.
- Gold The Gold level of health insurance is the second most comprehensive, providing $5 million in lifetime coverage per covered individual. Doctor visits, hospitalization, prescription medicine, medical evacuation, repatriation, mental health, and wellbeing are all covered under the plan.
- Silver The Silver level is a capped benefit plan that provides a cost-effective choice for people on a tight budget who nevertheless want worldwide coverage. This plan is ideal for people who are going to nations where health care is inexpensive.
- Bronze The Bronze plan level is a capped benefit plan with the lowest cost of the four plan levels. This plan also includes worldwide coverage to fit even the tightest budgets, as well as coverage for accidents and illnesses that occur while you’re on the plan.
Which coverage is right for me?
The Global Medical Plan comes in four different levels: Bronze, Silver, Gold, and Platinum, each of which includes or excludes the United States, Canada, China, Hong Kong, Japan, Macau, Singapore, and Taiwan. If you don’t require coverage in these countries, the “Worldwide Excluding” option may help you save money on your rates.
Am I eligible for the Global Medical insurance plan?
Individuals and families from all over the world who are at least 14 days old and under the age of 74 and meet the following criteria are eligible for the Global Medical plan:
- US citizens: Must be resident outside of the United States as of the Effective Date (or renewal date) and expect to do so for at least six (6) of the next twelve (12) months.
- Non-US citizens: If you are a non-resident immigrant or have an exemptedVisa type, you are eligible for new business and renewal (A, F, G, J, M, R, Q)
- Non-US citizens: If they meet the significant presence requirement or are a resident alien with a non-exempted visa, they are ineligible for new business or renewal.
http://www.irs.gov/Individuals/International-Taxpayers/Substantial-Presence-Test
Is coverage under the Global Medical Plan renewable?
Yes. Medical products are renewed on a yearly basis over the world. At renewal, there are no medical questions. Renewal is contingent on your continuous eligibility and timely premium payment. All plans with an effective date of 2018 or later will automatically renew on an annual basis beginning in 2019 to assure continued coverage. Members will get an email 45 days ahead to their anniversary date with more information regarding the renewal and the associated premium hike.
Global Senior Plan
The basic Global Medical plan terminates at age 75, while the Global Senior Plan is offered with no medical questions for members who joined before age 65 and have maintained coverage for at least 10 years. Many of the same benefits and limitations apply to the Global Senior Plan as they do to the basic Global Medical Plan. The Senior Plan includes a $5,000 deductible and a $100,000 annual overall maximum limit, with a lifetime maximum of $1 million.
What should I expect during the underwriting process?
The Global Medical is a medically underwritten plan, which means that your and your family’s medical history and status will be used to establish your coverage eligibility. An underwriter will assess your application within 5 business days after you submit it. You will hear from the underwriters within that time frame, and they will either:
- Add a rider to your policy that restricts or eliminates specific medical conditions.
Once your application is complete or if additional information is required, you will be notified of its progress. You will be alerted if an arider or premium increase is added to your plan. A 30-day ‘free look’ period will be granted if you are issued a rider. If you don’t like our counter offer, simply cancel coverage during the first 30 days of your free trial and we’ll return your entire payment.
Preferred Provider Network (PPO) & Medical Concierge
Inside the United States, where you can obtain treatment, the Global Medical plan uses UnitedHealthcarePPO. If you see one of these doctors, you must first meet your deductible, after which your coinsurance will be waived. These businesses have also agreed to receive payment from the insurance company directly.
The Global Medical plan includes an International Provider Accessnetwork of over 17,000 physicians, clinics, and hospitals abroad, in addition to the huge PPO network in the United States. These businesses have agreed to accept direct payment in order to make it easier for you to avoid paying in advance.
The Global Medical plan also gives you access to the Medical Concierge program in the United States, which can help you discover physicians and provide you with more information on provider ratings, previous outcomes, and general pricing in the area where you want to seek treatment. Your deductible will be waived in half (up to $2,500) and your coinsurance will be waived if you use the Medical Concierge services.
How do I file a claim?
It’s simple to file a claim. You will receive a packet containing Claimant’s Statement and Authorization paperwork after your application has been approved. Fill out this Claimant’s Statement and Authorization form, attach original, itemized bills, and send them to be processed. Make sure your Claimant’s Statement is completely filled out and signed. Attach copies of your payment receipts if you have already paid specific expenses. Medical and dental expenditures that are covered by the plan will be repaid. Payments will be given directly to the hospital or physician who treated you in many circumstances. Remember that you are liable for the deductible, coinsurance, and other expenditures that are not covered by your insurance.
Is there a waiting period for maternity?
Maternity coverage is only available on the Platinum level of the Global Medical plan, and there is a 10-month waiting time. Prenatal, birth, postnatal, child wellness, congenital diseases, and other services are covered at the Platinum level. The plan covers maternity up to a lifetime maximum of $50,000 and has an additional $2,500 deductible per pregnancy. Please keep in mind that you cannot apply if you are pregnant.
What other optional coverage can I get with this plan?
You have the option of adding five optional coverage choices to your Global Medical plan:
- AD&D (Accidental Death and Dismemberment) coverage is included with Global Term Life Insurance.
- Dental and vision coverage (offered in Bronze, Silver, and Gold plan choices) After a 6-month waiting period, dental is covered up to a lifetime maximum of $750 with a $50 deductible (maximum of two per household). Routine Services: 90% (deductible waived); Minor Restorative Services: 70%; Major Restorative Services: 50%. Routine eye exams will be covered up to $100 each 24 months, and materials will be covered up to $150 per 24 months.
- Terrorism Rider (only available on the Platinum) If an insured person is harmed as a result of a terrorist attack and the insured person had no direct or indirect involvement in the incident, the plan will reimburse qualified medical claims up to a lifetime maximum of $50,000. This benefit does not cover an act of terrorism if the US government issues an advice to leave a specific country or area after the insured person’s arrival date, and the insured person fails or refuses to leave the country or location for whatever reason.
- Sports Rider (offered only on the Gold and Platinum) Provides a lifetime limit of $10,000 for amateur athletics.
How can I pay for this plan?
A credit card or a debit card can be used to purchase the Global Medical plan online. When you apply for the plan, you will have the option of paying annually, semi-annually, quarterly, or monthly. Keep in mind that the more frequently you pay, the higher your administrative charges will be. While you must provide your payment information on your online application, your card will not be charged until the underwriting review is complete.
What does Usual Reasonable and Customary (URC) mean?
Insurance companies use the term “usual, reasonable, and customary” to define a restriction on their responsibility to pay for qualified medical expenses. URC refers to the fee that a provider normally charges for a certain procedure in a specific geographic area. So, if a procedure costs $5,000 in the New York City area, and most providers charge around $5,000 for the same procedure, the insurance company will not pay your New York City provider $10,000 for the same procedure. Instead, they’ll stick to the “Usual Reasonable and Customary” payment level, which in this case is $5,000.
What does UCR stand for in insurance?
The amount paid for a medical treatment in a geographic area based on what providers in the area generally charge for the same or similar medical service. The allowable amount is sometimes determined by the UCR amount.
How is UCR calculated?
UCR fees are ostensibly a tool that gives a precise fee or payment reference. The reimbursement of a non-contracted or Non-Par provider is usually limited to the “Reasonable Value” of the service performed in most states. The goal is to give medical professionals and their services a realistic value. Trying to determine an MSRP (manufacturer’s suggested retail price) for medical services is comparable.
A perfect set of UCR fee data would be based on actual, posted costs for medical services by providers across the country; the more providers questioned, the more accurate the UCR data would be.
However, most medical organizations do not now publicize their costs or charge schedules on the internet.
Many providers rely on UCR data created by public or private groups from public and/or private claim data because this ideal UCR data collection does not exist.
The data utilized to compute UCR charges comes from a variety of public and private sources. Statistics from Medicare and Medicaid claims that are summarized to offer data on a carrier/contractor or state-level is an example of a public source. Information from claims made to non-Medicare payers can be included in private data. PHI (private/protected health information) is practically never included because the data is aggregated and summarized.
But, before you choose a certain UCR data collection, you should ask yourself, “Are UCR fees reliable in the first place?”
The extent of data collected and the methods utilized to acquire it can differ from one UCR vendor to the next. Fee benchmarking methods are largely vendor-defined, raising the question of whether credible UCR price data is real or a myth. UCR data sets are known to exist, but where do they come from and how reliable are they? Is it even possible to be precise? Should we just assume they’re estimates as well?
Administrative data from the Medicare program is the most widely utilized public data source on provider payments (CMS). The geographic coverage is a benefit, as it collects data for over 48 million participants across all 50 states, totaling over 1 billion claims per year. Patient demographics, provider type, amounts charged, and amounts paid are all part of Medicare’s database and basic data pieces. Having a national pool of data makes it easier to ensure that fees are consistent across the country.
The most common way for calculating UCR using Medicare is to use a percentage of the Medicare rate.
Two or more people using the same data might obtain two different rates for the same operation and geographic location by simply calculating a percentage of the Medicare rate. Additionally, because Medicare rates are set by the Medicare Fee Schedule, they do not always reflect the genuine market value. “200 percent of Medicare is 200 percent of ridiculous!” said one fee consultant in response to this predicament.
Other datasets are compiled from a small number of health insurance policies, solo practices, or a single provider organization. In addition to being influenced by the payment policies and market dynamics of a small sampling of insurers, any approach to charge benchmarking would be quite constrained.
Another source of data is provider billing records, which has its own set of benefits and drawbacks; in this case, the charge data is regarded as a suitable basis for fee benchmarking. What source did they use to obtain their fees? How did they come to be in the first place? Their fees may simply reflect the contractual agreements they have with their particular payers.
There are various questions you should ask the vendor when selecting a UCR data collection for your organization:
There are still some hazy areas, such as how those providers compare to the broader market for that procedure in that geographic location, even if you work from a large enough data set to enable statistically reasonable and valid estimations.
Perhaps the information gathered came from a non-MD source (s). What data integrity thresholds were used? (Some costs may have been deemed too high or low and hence deleted.) Perhaps all of the information came from a single payer or supplier. Any of these circumstances could bias the fees one way or the other.
Both providers and patients are questioning the fairness of the UCR pricing idea as well as the authenticity of the underlying data that underpins the payment rates as the discussion about pricing, value, and transparency continues.
What is 80th UCR?
It’s a mystery how insurance companies come up with their UCR charges, although most of them are set at the 80th percentile. That means that in a given area, 80 percent of medical providers charged the same as or less than the insurance company’s UCR cost.
How are usual customary and reasonable services UCR determined?
While the phrases “usual and customary” (“UC”) and “usual, customary, and reasonable” (“UCR”) are frequently used interchangeably by publications and organizations, they have very distinct meanings.
The charges on a provider’s chargemaster are known as “usual and customary charges.” A chargemaster is a list of standard costs for certain services that apply to all patients, regardless of payment method.
The greatest usual and customary charge that a payor thinks appropriate is referred to as “usual, customary, and reasonable.” Charges for UC are set by providers and applied universally. Each payor determines what the UCR pricing for a certain service in that market is.
Another term to remember when talking about UCR fees is “authorized amount.” The permitted amount is the entire amount determined by a health plan to be paid to a provider for a service. The entire cost is equal to the sum of the plan’s and the patient’s responsibilities. The provider’s charge will be the authorized amount if it is equal to or less than the plan’s UCR charge. If the provider’s fee exceeds the plan’s UCR, the plan’s UCR will be the allowable amount.
There are some services and geographic marketplaces where the UCR approach cannot be used. RPC employs various methods to calculate an acceptable payment amount in those instances.
What is 90th percentile UCR?
Definition: The cost of a procedure based on what providers in your area charge on average for that operation. A third party calculates the UCR value as a percentile based on claims for that procedure in your area (specified by the first three digits of your provider’s zip code). To further explain this, let’s utilize a normal Beam plan. For many of our plans, the 90th UCR is standard. This means that the UCR value for a procedure will be established so that 90% of providers in your area charge the same or less. This is the maximum amount Beam will pay for an out-of-network provider’s covered service.
Example*: Because UCR can be confusing, let’s return to the tooth extraction example. To keep things simple, let’s say your insurance still pays for the surgery at 80%. Your plan uses the 90th UCR instead of MAC, which means that 90 percent of dentists in your zip code would charge that amount or less for the treatment. In this scenario, we’ll say the price is $110. Beam would cover $88 of the $110, or 80% of it. If your deductible has already been met and your dentist charges $125, you will be responsible for the remaining $37.
Let’s imagine a dentist costs $100 for a tooth extraction, which is cheaper than the UCR price of $110. We would cover a portion of the office charge because it is less than the UCR fee. We’d pay for 80% of the $100 cost ($80), and you’d be responsible for the remaining $20.
- For Beam designs, the 90th UCR is normal. Plans can, however, be upgraded to the 95th UCR.
- FAIR Health, a third-party entity, provides Beam with UCR claims data. We don’t perform any costing in-house.
- For groups in distant areas with few in-network dentists, UCR plans are typically the best option.
What is UCR payment?
The “UNIFIED CARRIER REGISTRATION” program requires individuals or businesses who operate commercial motor vehicles in interstate or international commerce to register with a participating state and pay an annual fee based on the size of their fleet.
What is UCR acceptance rate?
Admissions to the University of California-Riverside is more selective, with a 66 percent acceptance rate. An SAT score of 1060 to 1290 or an ACT score of 22 to 29 is required for admission to the University of CaliforniaRiverside. However, one-fourth of approved applicants received scores that were higher than these ranges, while the other quarter received scores that were lower. The deadline for applications is November 30, and the application cost at the University of California-Riverside is $70.
What is the main goal of the UCR?
The program’s primary goal is to produce a credible set of crime statistics for use in law enforcement administration, operation, and management; nonetheless, its data has evolved into one of the country’s most important social indicators throughout time.
What’s a MAC and what do they do?
A Medicare Administrative Contractor (MAC) is a private health-care insurer that has been given regional jurisdiction to handle Medicare Part A and Part B (A/B) medical claims, as well as DME claims, for Medicare Fee-For-Service (FFS) patients. CMS enlists the help of a network of MACs to operate as the principal point of contact between the Medicare FFS program and the health care providers who participate in it. MACs are multi-state, regional contractors in charge of both Medicare Part A and Part B claims administration. MACs are used for a variety of tasks, including:
- Provider reimbursement services and expense reports for institutional providers are handled.
CMS was directed to replace Part A Fiscal Intermediaries (FIs) and Part B carriers with MACs under Section 911 of the Medicare Prescription Drug Improvement and Modernization Act (MMA) of 2003. All MAC contracts are procured by CMS in accordance with the Federal Acquisition Regulation. Over time, many aspects of the Agency’s original strategy for implementing Section 911 of the MMA changed. In the Archives, you may learn more about the strategy.
Currently, the program has 12 A/B MACs and 4 DME MACs processing Medicare FFS claims for almost 56 percent of all Medicare beneficiaries, or 36 million Medicare FFS patients.
The MACs served more than 1.1 million health care providers registered in the Medicare FFS program in Fiscal Year 2021 (FY2021).
In FY2021, the MACs processed more than 1.1 billion Medicare FFS claims, including 221 million Part A claims and 956 million Part B claims, and paid out $424 billion in Medicare FFS payments.
A/B MACs
A/B MACs provide institutional providers, physicians, practitioners, and suppliers by processing Medicare Part A and Part B claims for a given geographic area or “jurisdiction.” Visit this page to learn more about A/B MACs. What exactly are the MACs?
Home Health and Hospice Areas (HH+H)
Home health and hospice claims are processed by four A/B MACs in addition to traditional Medicare Part A and Part B claims. Please note that the four HH+H zones do not correspond to the four A/B MACs’ jurisdictional areas. At Who are the MACs, you may learn more about HH+H areas and the MACs that are responsible for them.
DME MACs
DME MACs process Medicare claims for durable medical equipment, orthotics, and prosthetics (DMEPOS) for a designated geographic region or “jurisdiction,” and service DMEPOS vendors. Visit Who are the MACs to learn more about DME MACs.
Relationships between MACs and Functional Contractors
The complete FFS operational environment is administered by MACs in collaboration with multiple functional contractors. View the MACs diagram to learn more about the links between MACs and functional contractors: Read about what functional contractors do at Functional Contractors Overview (PDF) and The Hub of the Medicare FFS Program (PDF) (PDF).