President and Fellows of Harvard College Harvard Global Research and Support Services, Inc. (HGRSS) 2019 Global Benefits Guide

Transcription

1 President and Fellows of Harvard College Harvard Global Research and Support Services, Inc. (HGRSS) 2019 Global Benefits Guide

2 Medical Schedule of Benefits International In-Network U.S. Out-of-Network U.S. Deductibles Individual / Family $0 / $0 $0 / $0 $750 / $2,500 Coinsurance 100% 100% 80% Out-of-Pocket Maximum Individual / Family $0 / $0 $0 / $0 $2,500 / $7,500 Eligibility: Employee All active regular Employees, as defined by the Employer, of any Participating Employer who normally work at least 17.5 hours per week (excluding overtime) or whose annual base rate of pay is at least $15,000 with an assignment duration of one year or greater, and who are U.S.-based employees on temporary assignment outside the U.S.; or non-u.s.-based employees on temporary assignment in the U.S.; or non- U.S.-based employees working temporarily in an assignment country, who are neither nationals of the assignment country nor the U.S. Dependent Employee Contribution Lifetime Maximum In-patient Hospital Daily Room and Board Spouse, Same or Opposite Sex Domestic Partner, Child(ren) under age 26 Contributory Unlimited Plan Coinsurance Avg. semi-private (Private room is covered outside the U.S. if no semi-private room equivalent is available.) ICU/CCU 2x avg. semi-private (2x Private room is covered outside the U.S. if no semi-private room equivalent is available.) Out-patient Hospital Plan Coinsurance Plan Coinsurance Plan Coinsurance Physician Office Visits Plan Coinsurance 100% after $20 copay Plan Coinsurance (Deductible waived) Specialist Office Visits Plan Coinsurance 100% after $20 copay Plan Coinsurance (Deductible waived) Lab / X-ray Plan Coinsurance Plan Coinsurance Plan Coinsurance Prescription Drugs Retail Plan Coinsurance 100% after $7/$20/$45 copay (Deductible waived) Plan Coinsurance Mail Order 100% after Not Available $14/$50/$110 copay Not Available (Deductible waived) Mental Illness/Substance Abuse Inpatient Plan Coinsurance After Deductible Plan Coinsurance 100% after $20 copay Plan Coinsurance Outpatient (Deductible waived) Emergency Room Plan Coinsurance 100% after $75 copay 100% after $75 copay (Deductible waived) (Deductible waived) Ambulance Plan Coinsurance 100% (Deductible waived) Well Baby/Child Care 100% (Deductible waived) 100% (Deductible waived) Plan Coinsurance for children to age 18 Effective Date: January 1, 2019 Page 2 of 12

3 Adult Preventive Care for eligible persons age 18 and older Immunizations (Including Travel) Mammograms Women s Preventative Care Prostate Cancer Screenings Gynecological Cancer Screenings Colorectal Cancer Screenings Lead Screenings Temporomandibular joint dysfunction (TMJ) Applied Behavior Analysis for treatment of autism spectrum disorder Infertility Physical / Occupational / Speech Therapy Spinal Manipulation / Acupuncture / Acupressure Home Health Care Skilled Nursing Facility Inpatient Physical Rehabilitation Facility Hospice Care Allergy Treatment / Testing Durable Medical Equipment Diabetes Supplies Scalp Hair Prosthesis Hearing Aids for dependent child(ren) Vision Exam Lenses, Frames, Hardware 100% (Deductible waived) 100% (Deductible waived) Plan Coinsurance 100% (Deductible waived) 100% (Deductible waived) for eligible females o Age 35 through 39: one baseline exam o Age 40 through 49: one baseline exam ever one or two years, based upon recommendation of a Physician o Age 50 or older: one per year o Based on Physician s evaluation that physical conditions, symptoms or risk factors indicate a probability of breast cancer higher than the general population: one exam 100% for eligible females o Annual well-woman visits (including prenatal visits) o Screening for gestational diabetes; women who are 24 to 28 weeks pregnant and at the first prenatal visit for those who are at high risk of development of gestational diabetes o Screening and counseling for interpersonal and domestic violence annually o FDA-approved contraception methods & contraceptive counseling as prescribed; including birth control & sterilization o Breast-feeding support, supplies and counseling o HPV DNA testing every three years for women 30 years & older o Sexually-transmitted infection counseling annually o HIV screening & counseling annually 100% (Deductible waived) once per year for eligible men age 50 and older 100% (Deductible waived) once per year for eligible females 100% (Deductible waived) for eligible persons age 50 or older 100% (Deductible waived) Plan Coinsurance up to $1,000 per lifetime Plan Coinsurance up to $36,000 maximum per calendar year to age 21 Plan Coinsurance for Diagnosis only Plan Coinsurance up to a combined 60 visits per calendar year Plan Coinsurance up to 18 visits per calendar year Plan Coinsurance up to 120 visits per calendar year Plan Coinsurance up to 120 days per calendar year Plan Coinsurance up to 120 days per calendar year Plan Coinsurance up to $10,000 per lifetime Plan Coinsurance Plan Coinsurance Plan Coinsurance Plan Coinsurance up to $500 per calendar year Plan Coinsurance once per ear every 3 years up to $1,000 up to age % once every 12 months (Deductible waived) 100% up to $200 once every 24 months (Deductible waived) Effective Date: January 1, 2019 Page 3 of 12

4 Global Emergency Assistance Employee Assistance Program 24-hr, 7 days per week assistance services including telephonic translation, medical and legal referrals, evacuation/repatriation, dependent return, and concierge-level travel assistance. Covered at 100% (Deductible waived) up to $25,000 for Repatriation of Remains, $250,000 per occurrence for Medical Evacuation, $10,000 per occurrence for Emergency Family Travel and $10,000 per occurrence for Return of Dependents 24-hr, 7 days a week unlimited telephonic support for members including consultation, counseling and provider referral. In-person counseling for members up to 6 visits per year. 24-hr, 7 days a week unlimited telephonic support for managers including problem employee and crisis consultation. Effective Date: January 1, 2019 Page 4 of 12

5 Dental Schedule of Benefits Eligibility: Employee All active regular Employees, as defined by the Employer, of any Participating Employer who normally work at least 17.5 hours per week (excluding overtime) or whose annual base rate of pay is at least $15,000 with an assignment duration of one year or greater, and who are U.S.-based employees on temporary assignment outside the U.S.; or non-u.s.-based employees on temporary assignment in the U.S.; or non- U.S.-based employees working temporarily in an assignment country, who are neither nationals of the assignment country nor the U.S. Dependent Employee Contribution Deductible Preventive Basic Spouse, Same or Opposite Sex Domestic Partner, Child(ren) under age 26 Contributory $50 Individual /$150 Family 100% (Deductible waived) for Diagnostic services including oral examination, diagnostic x-rays and periodontal maintenance. 75% for Basic Restorations, Endodontics, Periodontics, Fillings, Root Canal, Scaling, Root Planing and repairs to Bridgework and Dentures. 75% for Major Restorations, Dentures, Bridgework and Crowns Major Orthodontics 50% for children to age 19 Annual Maximum $3,000 Orthodontic Deductible $0 Lifetime Orthodontic Maximum $1,500 Effective Date: January 1, 2019 Page 5 of 12

6 Life and AD&D Schedule Eligibility: All active regular Employees, as defined by the Employer, of any Participating Employer who normally work at least 17.5 hours per week (excluding overtime) or whose annual base rate of pay is at least $15,000 with an assignment duration of one year or greater, and who are U.S.-based employees on temporary assignment outside the U.S.; or non-u.s.-based employees on temporary assignment in the U.S.; or non-u.s.-based employees working temporarily in an assignment country, who are neither nationals of the assignment country nor the U.S. Employee Contribution Non-Contributory for Basic Life / Contributory for Supplemental Life Employee Basic Life Benefit: 0.5 X Base Annual Earnings rounded to the nearest $1,000, if not a multiple of $1,000 up to a maximum of $1,250,000 Employee Supplemental Life Benefit: 1,2,3,4 or 5 X Base Annual Earnings rounded up to the nearest $1,000 if not a multiple of $1,000 up to a maximum of $1,250,000 Accelerated Benefit Option Up to 80% of your Basic Life/Supplemental Life amount not to exceed $500,000 Age Reductions: Termination: Disability Provision: Benefits reduce by 35% at age 67, an additional 35% at age 70, and an additional 35% every 5 years thereafter. Benefits terminate at retirement. Upon termination, an employee may elect to convert their life coverage to an individual life policy without having to supply medical evidence of insurability. The employee must submit a written application and the first premium must be paid within thirty-one (31) days after the insurance terminates. Extended Death Effective Date: January 1, 2019 Page 6 of 12

7 Dependent Life Schedule Eligibility: Employee Contribution: Dependent Life Benefit: Dependent Spouse or Dependent Children of Employee enrolled in Supplemental Life Contributory Spouse: Increments of $25,000 up to a maximum of $100,000 not to exceed 50% of employee s supplemental Life benefit Dependent Children: from 14 days to 26 years: Flat $5,000 or $10,000 Guaranteed Issue: Spouse: $50,000 Child: $5,000 Age Reductions: Benefits reduce by 35% at age 65 and an additional 15% at age 70 and terminate upon retirement Effective Date: January 1, 2019 Page 7 of 12

8 Long Term Disability Schedule Eligibility: All active regular Employees, as defined by the Employer, of any Participating Employer (excluding overtime) or whose annual base rate of pay is at least $15,000 with an assignment duration of one year or greater, and who are U.S.-based employees on temporary assignment outside the U.S.; or non-u.s.-based employees on temporary assignment in the U.S.; or non-u.s.-based employees working temporarily in an assignment country, who are neither nationals of the assignment country nor the U.S., on U.S. payroll who normally work at least 17.5 hours per week. Employee Contribution Contributory Disability Definition: 24-month own occupation, any occupation thereafter Benefit Percentage: 60% Maximum Monthly Benefit: US$ 15,000 Elimination Period: 180 Days Pre-Existing Exclusion: 6 / 12 / 24 Benefit Duration: Reducing Benefit Schedule Age 61 or younger or older Maximum Benefit Period To age 65, or to SSNRA, or 3 years 6 months, whichever is longer To SSNRA, or 3 years 6 months, whichever is longer To SSNRA, or 3 years, whichever is longer To SSNRA, or 2 years 6 months, whichever is longer 2 years 1 year 9 months 1 year 6 months 1 year 3 months 1 year Cost of Living Adjustment: Offsets: Return to Work Incentive: Vocational Rehabilitation: Rehabilitative Employment: Mental Illness/Drug Addiction/Alcoholism: Waiver of Premiums: Minimum Monthly Benefit: Survivor Benefits: Recurrent Disability: Social Security Normal Retirement Age (SSNRA) means your normal retirement age under the Federal Social Security Act, as amended. N/A Primary & Family Government Social Plans and other offsets defined in the policy Included Included Included 24-month limitation. Included N/A 3 Months lump sum 6 Months Effective Date: January 1, 2019 Page 8 of 12

9 Exclusions and Limitations Medical Exclusions Covered Medical Expenses will not include, and no payment will be made for expenses incurred: 1. for services or supplies to the extent that benefits are available for the services or supplies elsewhere under the Policy or under any other plan of group insurance, group prepayment coverage or other arrangement of coverage for individuals in a group to which the Participating Employer contributes or makes payroll deductions whether or not an Insured Person is covered for such benefits; 2. for services or supplies for which benefits are not payable because of deductible or co-payment provisions under the Policy or under any other plan of group insurance, group prepayment coverage or other arrangement of coverage for individuals in a group to which the Participating Employer contributes or makes payroll deductions; 3. for, or in connection with cosmetic surgery unless the Insured Person is injured as a result of an accident that occurs while he or she is covered for Medical Benefits under the Policy, which results in damage to his or her person requiring the cosmetic surgery; 4. for hearing aids or examinations for prescription or fitting of hearing aids unless specifically provided for elsewhere in the Policy; including any surgical procedures which are done primarily to correct a hearing loss; 5. for, or in connection with treatment of the teeth or gums unless such expenses are incurred for (a) charges made for or in connection with dental work necessitated by Accidental Injury to natural teeth sustained while the Insured Person is covered for Medical Benefits under the Policy for services provided within 90 days of the accident, or (b) charges made by a Hospital for Room and Board or Miscellaneous Services and Supplies; 6. for which benefits are not payable according to the section of the Policy entitled General Limitations. Prescription Drug Exclusions In addition to the provisions of the Policy titled Medical Exclusions and General Limitations, the following will apply to Prescription Drug Benefits: No Prescription Drug Benefits are payable for: 1. Drugs for Infertility treatment; 2. Drugs given while Confined in a Hospital, nursing home or similar place that has its own drug dispensary 3. Therapeutic devices or appliances, including colostomy supplies and support garments, regardless of intended use. (This exclusion does not apply to insulin syringes with needles, blood testing strips - glucose, urine testing strips - glucose, ketone testing strips and tablets, lancets and lancet devices which are covered.) 4. Injectable drugs (This exclusion does not apply to insulin or self-administered injectables which can be injected subcutaneously which are covered.); 5. Progesterone suppositories; 6. Appetite suppressants and other weight loss products; 7. General and injectable vitamins (This exclusion does not apply to prenatal vitamins, vitamins with fluoride and B-12 injections which are covered.); 8. Drugs dispensed in any amount which exceed the supply limits; 9. Replacement drugs resulting from a lost, stolen, broken or destroyed Prescription Order or Refill; 10. Unit dose packaging of drugs; 11. Drugs available over-the-counter that do not require a Prescription Order or Refill by federal, state or similar law before being dispensed and any drug that is therapeutically equivalent to an over-the-counter drug; 12. Drugs for tobacco dependency or smoking cessation. 13. Drugs for, or in connection with cosmetic surgery unless the Insured Person is injured as a result of an accident that occurs while he or she is covered for Medical Benefits under the Policy, which results in damage to his or her person requiring the cosmetic surgery. Effective Date: January 1, 2019 Page 9 of 12

10 Dental Exclusions Covered Dental Expenses will not include, and Dental Benefits will not be payable for, the following charges: 1. charges for crowns for teeth that are restorable by other means or for the purpose of periodontal splinting; 2. charges for procedures relating to the change of vertical dimension; restoration of occlusion; bite registration; bite analysis; or which are cosmetic in nature; 3. charges for initial placement of full dentures, partial dentures or bridges if it includes the replacement of teeth all of which were missing on the date the Insured Person became covered under this plan. This exception will not apply if the prosthesis replaces a functioning tooth that was removed while covered; 4. charges for replacement of bridges, partial dentures, full dentures, inlays and crowns unless on the date of the replacement it has been at least five years since the bridge, denture, inlay or crown was first inserted. This exception will not apply if the replacement is made necessary by: (i) the removal of a functioning natural tooth; or (ii) Covered Dental Injury to sound natural teeth; provided the removal or Injury occurred during the 12 months preceding the replacement;. 5. charges for replacement of bridges, partial dentures, full dentures, crowns or inlays if they can be repaired; 6. charges for implants and related services; 7. charges for orthodontic treatment unless otherwise provided in a section of the Policy entitled "Orthodontics Benefits"; 8. charges for appointments which are broken or otherwise missed; 9. for which benefits are not payable according to the section of the Policy entitled "General Limitations". Vision Care Exclusions No benefits are payable for: 1. charges for more than one examination in any 12 consecutive month period; 2. charges for more than one pair of lenses in any 24 consecutive month period; 3. charges for more than one set of frames in any 24 consecutive month period; 4. charges for sunglasses, unless prescribed to be worn at substantially all times; 5. charges for examinations required by an Employer in connection with employment; 6. charges for any item or service not listed in the Schedule of Vision Care Services and Supplies; 7. charges for services or supplies to the extent that benefits are payable for the services or supplies elsewhere under the Policy; 8. charges for which benefits are not payable according to the section of the Policy entitled "General Limitations". Emergency Medical Evacuation Exclusions and Limitations In addition to the provisions of the Policy titled Medical Exclusions and General Limitations, the following will apply solely to the benefits afforded under the Emergency Medical Evacuation Benefits: No benefits are payable for: 1. Claims arising from depression or anxiety, mental or nervous disorder, alcohol or drug abuse addiction or overdose; 2. Claims arising from elective cosmetic or plastic surgery, except as a result of an accident; 3. A Pre-existing Condition as defined in the Policy; 4. an Insured Person traveling against the advice of a Physician; 5. Claims directly caused by or directly resulting from: a. any business or financial contractual obligations of the Insured Person or Insured Person s Immediate Family Member; b. Change of plans or disinclination of the Insured Person or Insured Person s Immediate Family Member to travel. Effective Date: January 1, 2019 Page 10 of 12

11 General Limitations No benefits will be payable under the Policy for any of the following: 1. charges incurred for, or in connection with an Injury arising out of, or in the course of, any employment for wage or profit, including self-employment; 2. charges incurred for, or in connection with a Sickness for which Insured Person is entitled to benefits under any worker's compensation or similar law; 3. charges for care or treatment of any Sickness or Injury that results from war, declared or undeclared, or any act of war, or committing or attempting to commit an assault or felony or from any intentionally self-inflicted Injury; 4. charges incurred for treatment to the extent that payment under the Policy is prohibited by any law of the jurisdiction in which the Insured Person resides at the time the expenses are incurred; 5. charges which the Insured Person is not legally required to pay or for charges which would not have been made if no insurance coverage had existed; 6. charges for services and supplies which are in excess of the lesser of: (a) the Reasonable and Customary Charge; or (b) the actual charge; 7. charges for services and supplies that are not Medically Necessary; 8. charges for vitamins or food supplements or for experimental drugs or drugs limited by law to investigational use and any charges for the administration of such substances; 9. charges for or in connection with experimental procedures or treatment methods not approved by the American Medical Association, the American Dental Association or the appropriate medical or dental specialty society; 10. charges for treatment, services or supplies received in a Hospital owned and operated by any government; 11. charges for private duty nursing services in a Hospital or any other facility; 12. charges in connection with a change in gender; 13. charges incurred by an Insured Person as an organ donor; 14. charges incurred for, or in connection with Custodial Care, education or training; 15. to the extent that the Insured Person is reimbursed, entitled to reimbursement, or is in any way indemnified for those expenses by or through any public program. For the purpose of this paragraph, any individual who, at any time, was entitled to enroll in all or any portion of the medical care program under Title XVIII of the Social Security Act of 1965, as amended (Medicare) but who did not so enroll will be considered to be entitled to reimbursement in an amount equal to the amount to which he or she would have been entitled, if any, if he or she were so enrolled; 16. charges for services rendered by a member of the Insured Person s Immediate Family; 17. charges for a surgical procedure that does not correct the condition of Infertility but is used to induce Pregnancy, such as in-vitro fertilization, artificial insemination or similar procedure; 18. charges for reversal of a voluntary surgical sterilization (charges for voluntary surgical sterilizations are covered). The provision above which indicates that no payment will be made for expenses incurred in connection with Injury arising out of, or in the course of any employment for wage or profit will not apply with respect to any partner, proprietor, or corporate officer who is not himself or herself covered under worker's compensation or similar law. No payment will be made under the Policy for expenses incurred by an Insured Person to the extent that he or she is reimbursed, entitled to reimbursement or in any way indemnified for those expenses by any personal Injury protection benefits payable under the mandatory portion of any group or individual automobile insurance policy written under the "nofault" insurance provisions of the law of any jurisdiction. Effective Date: January 1, 2019 Page 11 of 12

12 Life Limitations Benefits will not be payable for any loss caused in whole or in part by, or resulting in whole or in part from, the following: 1. suicide or any attempt thereat by the Insured Person within two years of the effective date of such Insured Person s coverage under the Policy; 2. the commission of or attempt to commit a felony; 3. the participation in a riot or insurrection; or 4. the declared or undeclared war, or any act of declared or undeclared war. 5. an insured s death caused as a result of radiological, nuclear, chemical, or biological weapons or events LTD Limitations This policy does not cover any disability due to: 1. war, declared or undeclared, or any act of war; or 2. intentionally self-inflicted injuries; or 3. active participation in a riot; or 4. you are not under the Regular Care of a Physician; or 5. disability is caused by your commission of, or attempt to commit, a felony, or to which a contributing cause was your being engaged in an illegal occupation; or 6. a disability for which Workers' Compensation benefits or similar law, are paid or may be paid, if duly claimed. DISCLAIMER This schedule of benefits is intended as a guideline and does not modify in any manner the terms and conditions specified in the policy document. In case of discrepancy between this document and the actual policy contract, the terms and conditions of the policy contract shall prevail. It should always be used in conjunction with the actual policy contract. Effective Date: January 1, 2019 Page 12 of 12