clements group health plan – tba - baymac · 1 confidentiality notice: this document is intended...

Clements Group Health Plan – TBA

Presented by: Smita Bhargava Senior Vice President August 4th 2019

1 Confidentiality Notice: This document is intended to be viewed only by the individual to whom it is addressed. It may contain information that is proprietary, privileged and confidential. Any dissemination, distribution or copying of this document or any information contained in it, is strictly prohibited without our prior permission.

About Clements Worldwide

Clements Worldwide is the leading provider of insurance to international organizations, schools and other industries worldwide. We were founded in 1947 and are one of the oldest international insurance brokerage firms in the world. Our approach is solution-based not product-driven. Our goal is to understand your business and help build a custom insurance program to identify critical exposures and control, finance and manage risk. Clements Worldwide (Clements) is dedicated to meeting the business insurance needs of the international community at home and abroad for over 70 years. We are dedicated to continuing to be the most trusted and specialized provider of insurance solutions for international organizations, including international schools and universities, NGOs and faith-based groups, U.S. Embassies etc. Of note, Clements has been a recipient of the Independent Insurance Agents & Brokers of America’s (IIABA) Best Practices Award for the last 11 consecutive years, from 2008-2018. We are also an Accredited Business (A+ rating) with the Better Business Bureau. With approximately 85% of Clements’ revenues derived from proprietary solutions, Clements is in effect operating on behalf of key underwriters, such as Lloyd’s of London, AIG and many other carriers. This places Clements further up the insurance value chain than a traditional brokerage, wherein claims adjudication, policy servicing and sales and marketing tasks are all carried out by the company. Clements is headquartered in Washington, D.C., U.S. and has wholly-owned subsidiaries in London, England, in the shadow of the Lloyd’s of London building, and in the financial district in Dubai, UAE. Our Credentials

• Launched as the first expatriate program for the American Foreign Service in 1947 and insures six out of every ten American Foreign Service Officers worldwide

• Provide coverage in over 170 countries

• Clements is a coverholder for Lloyd’s of London for 13 products and also has exclusive programs designed though the U.S. and other carriers worldwide

• Preferred provider of International Insurance solutions for many international organizations and expats globally

Baymac – Clements Partnership

Baymac has partnered with Clements Worldwide since 2013 to provide world-class insurance solutions, underwritten by Lloyd’s of London, to its members and Aviation focused organizations globally. The partnership offers comprehensive, cost-effective and customizable insurance solutions for individual members and organizations. These programs are specifically designed to meet the needs of professional pilots, cabin crew, and other staff and their families globally.

Joint Expertise


We insure more than 1000+ companies globally including UN, US Government, US Embassies, NGOs, Ecommerce organizations, Global Mobility fi rms, Aviation companies etc. Within the aviation industry, we work with various airlines, pilot recruitment agencies and professional aviation membership groups for a wide range of covers including group and personal Health insurance, Loss of Income, and Life.

OTHER INSURANCE PRODUCTS FOR AVIATION ORGANIZATIONS

Employee Benefits

• Group Life • Group Accidental Death & Dismemberment • Group Travel Accident • Critical Illness • Group Loss of Income Policies • Group Health • Kidnap & Ransom • Emergency Evacuation & Salary Continuation


Servicing Team :

Smita Bhargava Senior Vice President

+1.202.741.1573 [email protected] Clements Worldwide

Dan Edmonds Director – Partner Solution


Jasmine Newman Assistant Account Manager – Partner Solutions


Mary Venable-Payne

Manager – Client Services


Denise Valentine Claims Concierge


Patricia Cupid Claims Concierge


Nikkia Summers Claims Concierge


Gavin Lambert Account Executive

+1 (832) 2245524 [email protected] Baymac

Suma Mekalathuri Manager Administration

+971 55 111 3674

[email protected] Baymac

mailto:[email protected]





The Clements Group Health – Executive Summary

• A unique Health Insurance program designed to currently meet the needs of our expat and international staff of International organizations .

• This is an Employer driven plan and not an underwriter driven plan. The plan is extremely flexible. Coverage can be added, deleted and changed. Clements wants every plan we provide to meet the individual needs of our clients.

• In regards to our experience, Clements is one of the leading multi-line insurance providers for international insurance . We create, design, implement and manage insurance programs on behalf of our clients and underwriters. We have been a managing general agent since 1947 (MGA) and have clients in over 170 countries. It is important to note that Clements created and owns “Scholars”. Therefore, it is highly customizable for each client.

• Stability of rates even at renewals unlike other plans where rate increases can sometimes be steep. For years

renewal rates have been in the single digits for most of our clients.

• We are able to maintain stable rates as we have a fairly large book of business with our underwriters. Because of the pooling of medium-sized risks with larger risks, we can offer the medium-sized accounts reduced rates but also stability and cushioning from steep rate increases.

• Our program is insured with “A” Class Security from Lloyd's of London. This gives us unique flexibility in structuring and offering a cost effective and quality program for our clients.

• Smooth implementation and orientation process.

• Monthly conference calls with key staff and other employees to discuss any claims and other coverage questions.

• The plan provides the largest international medical direct bill network.

• When we take over a medical program, one of our main objectives is for us to lead and manage the implementation process. We believe it is our responsibility and not our clients to ensure the staff is fully educated on the medical benefits, enrollment procedures, web site utilization and claims processing. We will work with you to ensure we maintain strong lines of communication with the organizations , Clements Worldwide and HTH (claims administrator).

• The plan provides the largest international medical direct bill network. We strongly recommend our clients

utilize this service so they do not have to be reimbursed for their medical bills. However, if they do decide to pay up front and then seek reimbursement, our turnaround time is excellent; once we have all the required documentation. We can send reimbursement by check, wire and coming soon by ACH (must have a US bank account). We can wire reimbursement in over 30 different currencies. We are constantly enhancing our online / web capabilities, user interface, claims service improvements etc.


• We are the Managing General Underwriter for the Clements Group Health plan and as such have flexibility and control on it renewal, servicing, admin and claims handling. This has been our business model for several programs / products.

• This benefits our client as it allows to request claims exceptions and main high standard of servicing. This kind of flexibility will not exist with direct insurers.


Clements Group Health Package 2019 Program highlights

o Insurer - A class security from Lloyd's of London. o Passive War, Terrorism, Strikes, Riots coverage included at no cost o One of the largest network international medical direct bill network

180 countries 160 Regional Physician Advisors Over 20,000 vetted providers worldwide Contracted community is made up of 7,000 physicians and 2,000 facilities in over 190

countries 200 Contracted infectious disease specialists ; 575+ Travel Clinics

o US Network Aetna with over 650,000 in-network providers in US.

o Tropical and Infectious Diseases: HTH Physician Advisor for Infectious Disease - Director of Infection at UCLH & Head

of Hospital for Tropical Diseases, London 24/7 Tropical disease specialist advice RPAs include recognized global experts in Rabies, Diarrhea and Vaccinations 200 Contracted infectious disease specialists 575+ Travel Clinics

o Web based Claims Portal Online Claims submission Deductible tracking / accumulators Print medical ID cards Admin Access for Group HR or key contact for ID cards, census change requests etc. Check status of pending & paid claims Prescription Mail-order Review & print Explanation of Benefits (EOB’s) Review coverage & benefits Pre-certification Search for hospitals and physicians Translate Medical Phrases, Drugs & Medical terms Access over 44,000 participating pharmacies Travel Health & news

o Mobile Claims Filing and App – mPassport (available for free on App Store, Google Play and Amazon)

Submitting a Direct Pay request (subject to provider participation) Filing electronic claim Review of Un-submitted eClaims Network providers Other Travel tools and critical information

o Clements in-house Claims Concierge Services: Webinars on claims Regular monthly calls with HQ and Regional offices for claims settlement pulse. Assisting Members with Claims and benefit queries Helping members with denied or pended claims


Understanding Explanation of Benefits Resolution of issues if any – Dr / Providers communication, HTH liaison, updates on

claims status Call and / or In person meetings with clients and insured members worldwide

throughout the year – Group and one-on-one meetings Bi-weekly review of all claims reports internally by the claims concierge team to

ensure pro-active action – denied, pended, high dollar denied claims, high out of pocket / out of network reports.

Conditions & Assumptions:

1. This is a Non-Binding indication which is subject to no known or reported losses and material change

in information as of the date of binding. 2. Group Census assumptions:

a. Average Age – 40 b. Expats only c. Nationalities vary from Brazilian, Mexican, European, Filipino, Russian and Australian, some with

families, some single. d. Minimum size – 30

3. All covered members must elect the same plan. 4. Minimum participation clause – N/A as optional opt-in plan. 5. Evidence of Insurability will not be required 6. These rates are only valid if accepted within 30 days of the date of this offer. 7. This quote is based on the information and census provided and is subject to Application being completed and

signed by the company. Any substantial discrepancy in that information may void this offer. 8. All members are assumed to be actively at work on the effective date and working a minimum of 21 hours

per week. 9. Plan excludes any long term employees and coverage in USA/Canada. 10. Final approval and rates will be subject to actual enrollment, plan offerings and census clarification. 11. A signed application and enrollment forms are necessary for the group to be considered. 12. Quote is subject to viable address for policy issuance. 13. All taxes are in addition to the below quoted rates.

Benefits & Features

1. Key Condition – Top-up coverage a. Policy is on top-up basis providing coverage over and above the Employer’s provided primary

Group Medical Plan . b. The coverage provided is on Difference-in-condition and Difference-in-limit basis. c. In the event where this policy pays first and the claim is recoverable under Employer’s primary

plan, recoveries will be subrogated to your employer provided primary plan. 2. Policy effective date – TBA 3. Premium Payment – Options for Annual, Semi-Annual, Quarterly and Monthly 4. Various Deductible options as quoted 5. Coverage Territory – Worldwide excluding USA/Canada. Only incidental emergencies will be covered in

USA/Canada. 6. Coinsurance:

a. 100% of R&C outside the US b. 90% of R&C inside the US & in network


c. 70% of R&C inside the US but out of network 7. Plan types:

a. Custom – All members 8. Employee coverage category :

a. Custom –Employees with family 9. Pre-existing conditions are covered with proof of prior credible coverage for 12 months. 10. All other standard Clements Health Program medical benefits, policy provisions and administrative practices

will apply. 11. Sanctions Clause to apply.

Quote Subjectivities :

1. Completed application 2. Final Census of covered members and dependents with Date of Birth, Nationality, Country of Residence,

Country of Assignment. 3. Completed Application, Enrollment form, census 4. Copy of primary employer provided Health insurance copy. 5. Quote will be subject use of viable address for policy issuance . 6. If placed using Trust, then Trust charges of 1.50% to apply in addition to the quoted premiums . 7. Quote is also strictly subject to US and European Sanctions Clause.


Foreign Group Health Plan Rates 2019 Medical Rates – Rates indicated below are per person per month

Plan Design Plan A Annual Policy Limit US$ 5,000,000 Plan Type Pre-existing conditions excluded. Coverage Territory Worldwide excluding USA/Canada Deductible $500 per policy year Family max – Deductible 3 x Coinsurance – US-in-network /US- out-of-network/ overseas

90/80/100

Out of pocket maximum $5,000 Family max – out of pocket 3 x Well Child Care Yes Adult Physical $250 Mental & Nervous covered - $25,000 maximum Maternity $15,000 maximum including complication Continuation No Hospital Indemnity - $50 per day / max $1,000

No

Alternative therapies 250 USD maximum per policy period . Acupuncture, Naturopathy , Osteopathy , Magnetic Therapy, Herbal Therapy, Massage Therapy, Aroma Therapy and Vitamin Therapy.

Prescription Co-pay - generics/ brand/overseas

$10/$20/Nil

Pre-existing Conditions – Covered Excluded. Covered only with proof of prior equivalent credible coverage for 12 months

Vision Included Dental Optional as quoted


Rates 2019 – Monthly rates per person – $500 deductible / Excluding USA/Canada – Based on minimum group size of 30

Illustrative Monthly Premium Rates: Rates per Person

Plan A Dental

Monthly Total

Custom Employee only: 0 $194.25 $34.00 $228.25 Employee + 1: 0 $388.50 $68.00 $456.50 Employee + 2 or more: 0 $679.88 $108.80 $788.68 Estimated Monthly Premium- Employee Only 0 Estimated Annual Premium – Employee only

Rates 2019 – Monthly rates per person – $1,000 deductible / Excluding USA/Canada - – Based on minimum group size of 30

Illustrative Monthly Premium Rates: Rates per Person

Plan B Dental

Monthly Total

Custom Employee only: 0 $174.83 $34.00 $208.83 Employee + 1: 0 $349.65 $68.00 $417.65 Employee + 2 or more: 0 $611.89 $108.80 $720.69 Estimated Monthly Premium- Employee Only 0 Estimated Annual Premium – Employee only

** Subject to Baymac membership .

• Group Discounts for group size more than 30 • 31-50 – 8% • Over 50 – 15%

• All applicable taxes will be in addition to the premium above. • Payment Plan options – Annual, Semi-annual, Quarterly or Monthly. These installment plans do not attract

any additional rates.


• Additions and deletions – Pro-rata – If added or deleted prior to 15th of the month, then full monthly premium will apply. If added on or after the 15th of the month, no premium will apply.

Other Clauses

SANCTION LIMITATION AND EXCLUSION CLAUSE No (re)insurer shall be deemed to provide cover and no (re)insurer shall be liable to pay any claim or provide any benefit hereunder to the extent that the provision of such cover, payment of such claim or provision of such benefit would expose that (re)insurer to any sanction, prohibition or restriction under United Nations resolutions or the trade or economic sanctions, laws or regulations of the European Union, United Kingdom or United States of America. JC2010/014 11/08/10


Summary of Custom Plan Benefits - Worldwide excluding USA/Canada

CUSTOM PLAN

Benefit Plan Features Within the United States, US territories and possessions including Puerto Rico and Canada

Overseas

In-Network Benefit Level

Out-of Network Benefit Level

Outside the United States, US territories and possessions including Puerto Rico and Canada

Policy Year Maximums Emergency - $150,000 per policy year per person Incidental Emergencies only

$5,000,000 per policy year per covered person

Coverage Territory Worldwide excluding USA/Canada Pre-existing Conditions Proof of prior credible coverage required for previous 12 months for Pre-

Existing Conditions to be covered as per the policy terms and conditions. Congenital Conditions Covered upto a maximum of $100,000 per insured person Deductible* and Co-insurance – See Note below Note - *The deductible is applied once per policy year before claim payment is made. United States

In Network United States Out-of-Network

Overseas

Individual US$500 per person per policy year

US$1,000 per person per policy year

US$500 per person per policy year

Family US$1,500 per policy year

US$3,000 per policy year

US$1,500 per policy year

Total Out of Pocket Expense

US$5,000 per individual; nil per family



Common Accident: If two or more Covered Persons are injured in the same accident and incur Covered Expenses for those injuries in the policy year in which the accident occurs, not more than one Deductible will be deducted from the total Covered Expenses incurred for them during the rest of that policy year. Co-insurance 90% of Reasonable

and Customary charges incurred within the Preferred Provider Network

70% of Reasonable and Customary charges for Covered Expenses (up to the Out-of-Pocket Limit) incurred outside the Preferred Provider Network

100% of Reasonable and Customary charges incurred overseas .

100% of the balance of Reasonable and Customary charges for Covered Expenses incurred within the United States, US territories and possessions which exceed the Out-of-Pocket Limit for the remainder of the policy year. This provision does not include expenses to which specific limitations apply.


Hospital Emergency Room - Within the United States, US territories and possessions including Puerto Rico and Canada $50 Co-Payment per visit, if not admitted as an in patient 100% of Reasonable and Customary Covered Expenses within seventy-two (72) hours of Injury or Medical Emergency (no Deductible) 80% of Reasonable and Customary Covered Expenses after seventy-two (72) hours of Injury or Medical Emergency (after Deductible) Hospital Emergency Room - overseas $0 Co-Payment per visit, if not admitted as an in patient 100% of Reasonable and Customary Covered Expenses within seventy-two (72) hours of Injury or Medical Emergency (no Deductible) 100% of Reasonable and Customary Covered Expenses after seventy-two (72) hours of Injury or Medical Emergency (after Deductible) Emergency Medical Transportation Benefits** - Deductible does not apply United States


Overseas

Ambulance, Local Emergency Transportation** Up to a policy year Maximum of $25,000

100% of Reasonable Expenses



Emergency Reunion (10 days limit) ** Up to a policy year Maximum of $10,000




Remote Medical Transportation (Emergency Medical Evacuation Services) Up to Policy Limit




Repatriation of Bodily Remains** Up to a policy year Maximum of $25,000




Transportation to Residence in Country of Assignment Up to a policy year Maximum of $10,000




Key Services See Tables Below for additional limits that apply United States


Overseas

Physician Office Visits 90% of Reasonable 70% of Reasonable 100% of Reasonable


(Non-Surgical) Expenses after Deductible

Expenses after Deductible


In-Patient Services 90% of Reasonable Expenses after Deductible

70% of Reasonable Expenses after Deductible


Out-Patient Services 90% of Reasonable Expenses after Deductible



Preventative care Services – Deductible does not apply United States


Overseas

Routine Physical Exams (Adult and Children) Maximum limit per person per policy year – $250 One examination per year Adult Males – a standard physical assessment which may include Colorectal Cancer Screening & Prostate screening and any related lab fees. Adult Females - a standard physical assessment which may include Mammograms, one PAP smear & Colorectal Cancer screening and any related lab fees. Colorectal Cancer Screening means and may include - 1. An annual fecal occult blood tests (three (3) specimens). 2. A flexible sigmoidoscopy 3. A colonoscopy 4. A double contrast barium enema See additional Colorectal Cancer Screening benefit for insured persons of fifty (50) years of age or older and those forty (40) years of age or older with family history or elevated risk.

Not covered Not covered 100% of Reasonable Expenses Deductible does not apply.


Colorectal Cancer Screening Colorectal Cancer Screening means and may include - For insured persons of fifty (50) years of age or older: 1. An annual fecal occult blood tests (three (3) specimens). 2. A flexible sigmoidoscopy every five (5) years. 3. A colonoscopy every ten (10) years. 4. A double contrast barium enema every five (5) years. In addition, these benefits may be provided for insured persons of forty (40) years of age or older who are considered to be high risk for colon cancer because of: 1. Family history of familial adenomatous polyposis; 2. Family history of hereditary nonpolyposis colon cancer; 3. Chronic inflammatory bowel disease; 4. Family history of breast, ovarian, endometrial, colon cancer or polyps; or 5. A background, ethnicity or lifestyle is determined to be at elevated risk.

Not covered Not covered 100% of Reasonable Expenses Deductible does not apply.

Immunizations and vaccinations - $400 maximum per insured

Not covered Not covered 100% Reasonable Expenses Deductible does not apply.

Well Child Care (Newborns) Maximum of 6 examinations within the first year of life Also includes routine / diagnostic tests and immunizations



Mental Illness – Deductible applies United States


Overseas

Maximum Benefit – Mental Illness

US$25,000 per policy year maximum

In-patient Not covered Not covered 100% *

Out-Patient Services including Video-Counselling Remote Therapy (phone, online, skype etc.) The geographical location of the provider determines the coverage tier.

Not covered Not covered

100% *

Alcohol and Substance Abuse rehabilitation - In-patient

Not covered Not covered 100% *

Alcohol and Substance Abuse rehabilitation - Out-patient

Not covered Not covered $500 per person and $1,500 per family

Family Counselling – lifetime maximum

Not covered Not covered $100 per person and $300 per family

Bereavement counselling for an insured family member incurred within six (6) months of the insured person’s death – lifetime maximum

Not covered Not covered

100% *

Other Benefits United States


Overseas

Pre-Admission Testing 90% of Reasonable Expenses after Deductible



Second Surgical Opinion 90% of Reasonable Expenses after Deductible



Outpatient Skilled Nursing Care (U.S. Only) Two (2) hours per day, fifty (50) visits per policy year maximum

Not covered Not covered Not covered

Private Duty Nursing (Outside USA Only) Eight (8) hours per day, thirty (30) days per policy year maximum

N/A N/A 100% of Reasonable Expenses after Deductible

Home Health Care Two (2) visits per day, four (4) hours per visit, ninety (90) visits

Not covered Not covered 100% of Reasonable Expenses after Deductible


per policy maximum Standard Medical Expenses 90% of Reasonable




Rehabilitative Therapy, Physical/Occupational/Speech Therapy/Medicine and Other Specified Therapies Twenty (20) visits per injury/illness per policy year maximum

Not covered Not covered [100%] of Reasonable Expenses Deductible does not apply.

Chiropractic Care [$30] maximum benefit per visit, one (1) visit per day, [$1,000] maximum limit per policy year

Not covered Not covered 100% of Reasonable Expenses. Deductible does not apply.

Reconstructive Surgery 90% of Reasonable Expenses.

70% of Reasonable Expenses.

100% of Reasonable Expenses.

Complimentary / Alternative Medicine $250 maximum per policy period Acupuncture, Naturopathy, Osteopathy, Magnetic Therapy, Herbal Therapy, Massage Therapy, Aroma Therapy and Vitamin Therapy


Maternity Care Prenatal, postnatal, complications, birth centers, nurse midwives – up to a maximum of US$15,000 per insured person

Not covered Not covered 100% of Reasonable Expenses upto a maximum of US$15,000 per insured person

Hospice Care Facility US Only Limited only to USA; one hundred eight (180) day maximum limit

Not covered Not covered Not Covered

Organ Transplants** $500,000 per Covered Person per lifetime, $25,000 maximum for costs incurred.


Congenital Conditions $100,000 maximum per lifetime of the policy


Hearing Aid maximum Up to $1,000 per hearing aid unit necessary for each hearing impaired ear every 2 years for a dependent child under age 24 Per policy year.

Not covered Not covered 100% of Reasonable Expenses . Deductible does not apply.

Temporomandibular Joint Dysfunction and Related Disorders

$1,000 maximum benefit per Policy Year


Hospital Indemnity Not covered Bridge Cover Maximum of 3 months from the date of termination Continuance Coverage Not Covered Prescription Drugs Out-patient Prescription Drugs 100% of all Covered Expenses after applying the co-payment

Retail Pharmacy (Rx) in US Not covered Retail Pharmacy (Rx) Overseas Deductible applies Generics and Brand Name: Nil co-payment per 30-day supply 3 months’ supply max. Contraceptive Benefit in US Not Covered Contraceptives Benefit Overseas Deductible applies US$ Nil Co-payment per 30 day supply $250 annual maximum for all forms of contraceptives and/or related consultations and procedures associated with contraceptive management, insertion and/or removal where applicable. 3 month supply max. Mail Order Pharmacy (Rx) in US Not Covered Mail Order Pharmacy (Rx) Overseas Deductible does not apply Generics and Brand Name: Nil co-payment per 30-day supply 6 months supply max. 100% of the delivery cost is provided under the Mail-order Customs charges may apply and are the responsibility of the insured persons

Additional Optional Benefits – Not covered Dental Expense

$25 Policy Year Deductible, $75 per family - $750 per year maximum benefit All Benefits are – Policy Year Class I - Plan pays 100% of expenses for preventive care, without a deductible.

Class II - Plan pays 80% of expenses for basic restorative care, the deductible applies.

Class III - Plan pays 50% of expenses for major restorative services, the deductible applies.

Class IV - Plan pays 50% of expenses for orthodontic dental services, the


deductible applies.

Vision Expense $150 maximum for routine eye exams per 24 months $100 maximum for correctives lenses per 24 months Not subject to deductible and co-insurance All Benefits are – Policy year

Travel Benefits Not Covered


B.1. Additional Conditions and Definitions applicable to the Custom Plan benefits Additional Benefit Limitation applicable to Covered Expenses incurred in the United States (including Puerto Rico) and Canada – Benefits will be payable for Covered Expenses incurred in these countries, but only for Incidental Emergencies that occur only while taking a trip to these countries for reasons other than to secure medical attention.

Additional Definitions applicable to Custom benefits – For the purposes of this Certificate of Insurance, Incidental Emergency means the occurrence of an accident or the sudden and unforeseen onset of an illness for which neither causes nor conditions existed before the trip.

For the purposes of this Certificate of Insurance, trip means a visit of sort duration and the total number of days accumulated on trips in any twelve (12) month period shall not exceed thirty (30) days.

Eligibility – Persons who are otherwise eligible, but are citizens of the United States, US Territories and Possessions and Canada, are not eligible to be enrolled for Custom benefits.

Additional Exclusion – Benefits will not be payable for either pre-existing conditions or the aggravation of existing conditions while in the United States, US Territories and Possessions and Canada.]

* Benefits will be payable for Covered expenses incurred in the USA, US Territories and Possessions & Canada, but only for incidental emergencies that occur only while taking a trip to these countries for reasons other than to secure medical attention. Benefits will not be payable for either pre-existing conditions or aggravation of existing conditions while these countries. ** Pre-certification required.


Medical Evacuations HTH Worldwide, the Scholars claims administrator, handles the entire medical evacuation from communicating with the doctors to setting up the actual flight. HTH has 40 regional doctors that coordinate with the person’s attending physician. An air ambulance is utilized if needed and the person is taken to the best medical facility to handle the illness or injury. Emergency Family Reunion coverage is included if a family member is needed to accompany or meet the insured person. Pre-Existing Condition Pre-existing conditions are covered when a person can provide proof of prior insurance coverage or as specified above in the quote. If the company is rolling over from another plan to the Scholars program, they would send census with the insured persons’ listed and copy of an invoice for the prior coverage. If not proof can be shown, then there is a 12 month waiting period before pre-existing conditions can be covered.

Rating The Scholars rating process takes into consideration the average median age of the group, the number of people to be insured and the claims history.

Adoption The definition of adoption under this policy is very broad. A child can be in the process of an adoption or just under legal guardianship to be covered. An enrollment form is needed within 30 days and documentation such as power of attorney or processing papers is required. Pre-Certification Pre-certification can be done directly on our website and a response takes no longer than 24 hours. There are staff members on call 24/7 to review pre-certifications including a medical doctor. If a more immediate pre-certification is needed, then the hospital, patient or family member can pre-certify via phone. HTH Worldwide accepts collect calls. The medical conditions that required pre-certification are any surgeries, whether inpatient or outpatient, maternity plus others. See the summary of benefits above at the * areas to the left to determine additional conditions, It is very important to pre-certify as failure to do so can result in reduction of benefits or the claim being denied.


Additional Program Information

Participating Entities • Insurer – Lloyd’s of London

• Managing Agent and Program Holder – Clements Worldwide

• Third Party Claims Administrator – HTH Worldwide

o U.S. Claims Administrator – AmeriHealth (AHA) Online Services / Claims Portal at - - www.Clementsgrouphealth.com

1. Online Claims submission 2. Deductible tracking / accumulators 3. Print medical ID cards 4. Admin Access for Group HR or key contact 5. Check status of pending & paid claims 6. Prescription Mail-order 7. Review & print Explanation of Benefits (EOB’s) 8. Review coverage & benefits 9. Pre-certification 10. Search for hospitals and physicians 11. Translate Medical Phrases, Drugs & Medical terms 12. Access over 44,000 participating pharmacies 13. Travel Health & news

Website Review We have set-up a demo user area on our website so that potential clients can review the features. Please log onto www.clementsgrouphealth.com Website: www.clementsgrouphealth.com Member Name: Clements Group Health Demo Member ID: 501839422 Username: [email protected] Password: demo123 Please note: not all functions may be available as the demo person is not yet a true insured. Mobile Claims Filing and App – mPassport (available for free on App Store, Google Play and Amazon)

Submitting a Direct Pay request (subject to provider participation) Filing electronic claim Review of Unsubmitted eClaims Network providers Other Travel tools and critical information

http://www.clementsgrouphealth.com/





Claims servicing

1. All claims can be submitted via online submission, e-mail and mail 2. Once logged in , the member can view the status of their claim, request pre-certification etc. online. It

is a very user friendly website. At policy inception, we will provide ID cards to every member and they can use that to register on the website.

3. Our average Turnaround time on claims settlement is 15 days on clean claims i.e. full information submitted on claims.

4. Claims status can be viewed online at any time. 5. Pre-certifications is fast and easy and can be requested online through the website. It is generally

approved within 48 hours unless additional information is required. 6. Our Claim Form is in English but if medical receipts are submitted in any other languages, then those

get translated. 7. We can make claims payment by check, wire or ACH (for US Bank Accounts) . We do encourage

members to request wire payments as that’s fast and easy to track internationally. 8. The direct pay list is large and can be viewed on our website. Where direct pay provider is not

available we can arrange Guarantee of Payments. 9. Direct pay network with specific recruitment of facilities where possible. 10. 24 X 7 Customer service center – Not a Call Centre but staff with plan awareness 11. HTH’s Medical staff is available 24 hours a day, 7 days a week for emergencies. 12. Response to e-mails within 48 hours of receipt 13. Toll free number provided for persons in USA and Canada. HTH accepts collect calls from anywhere

in the world from insured persons and providers. 14. Simplified claims reimbursement process 15. Monthly Newsletters with focused information on Claims Aspects 16. Member Surveys across our insured lives globally for plan and service improvement and adjusting to

our member’s needs.

Clements in-house Claims Concierge Services:

• Regular monthly calls with HQ and Regional offices for claims settlement pulse. • Assisting Members with Claims and benefit queries • Helping members with denied or pended claims • Understanding Explanation of Benefits • Resolution of issues if any – Dr / Providers communication, HTH liaison, updates on claims status • In person meetings with clients and insured members worldwide throughout the year – Group and

one-on-one meetings • Bi-weekly review of all claims reports – denied, pended, high dollar denied claims, high out of pocket /

out of network reports. • Pro-active approach to identifying claims issues • Our goal is to play an active role in making the claims experience as smooth and seamless as

possible for our clients.

Customer Service Guidelines and Procedures

Customer Service Commitment 1. Respond to emails and/or Customer Service phone calls within 24 hours. HTH’s Medical staff is available 24 hours


a day, 7 days a week for emergencies. 2. Toll free number provided for persons in USA and Canada. HTH accepts collect calls from anywhere in the world

from insured persons and providers. PPO Network Services Providers Provide access to largest PPO network in U.S. – Aetna with over 650,000 in-network providers in US. International Network Services Providers HTH International and Domestic Provider Communities bring together thousands of carefully selected general and specialty physicians, dentists, and other health providers in over 190 countries. Their contracted community is made up of 7,000 physicians and 2,000 facilities. These providers have agreed to bill HTH directly, so members do not need to fill out claims forms or wait for reimbursement.

• 180 countries

• 160 Regional Physician Advisors

• Over 20,000 vetted providers worldwide

• Contracted community is made up of 7,000 physicians and 2,000 facilities in over 190 countries

• 200 Contracted infectious disease specialists ; 575+ Travel Clinics


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www.clements.com

For more information contact: Smita Bhargava

Senior Vice President +1.202.340.1305

[email protected]

clements group health plan – tba - baymac · 1 confidentiality notice: this document is intended...

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