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UPDATE regarding NEW (FOPS: Friends of Padre Simon) Health Plan with Options for Life and Dental Insurance.
Mar 9 (1 day ago)
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Correspondence Email Address:
Sunday 09 March 2014
RE: FOPS Health Plan Update Memo / DRAFT VERSION 09MARCH2014
Our committee spent most of the past week in meetings, and all day Thursday in Guayaquil.
We spent most of the day Friday on telephone conferences.
We spent all afternoon yesterday, meeting to formulate this transmission herewith. We are sharing what is appropriate to share at this point.
Since we still need the final documents and review thereof:
Now, our goal is to update you, as much as possible. We are still waiting for final version of documents, as we caught a few errors in the version that we received on Thursday night. The Spanish Version will of course be the legal document. However, for convenience sake, we have personally contracted with a reputable translator to translate these documents as they come to us and are approved.
A. The insurer for (1) Group Primary Health Coverage, and (2) Group Secondary Catastrophic Health Coverage, and (3) Optional Group Life Insurance, and (4) Optional Group Dental Insurance IS:
note: We have spoken to medical doctors and others in the healthcare field, and they have all spoken very highly about BMI. Apparently, BMI, has a wonderful reputation nationally and internationally, with providers, and customers.
B. The Broker who will offer customer service is VITAL. They have two offices, they are in the World Trade Building in Guayaquil, and also at OMNI Hospital in Guayaquil. We have spent much time with the broker and his staff (Bilingual / Spanish and English Speaking). We have been impressed with them as professionals. We have a commitment from them, that a young professional, by the name of Jorge Chavez (Bi-lingual / Spanish and English Speaking), will serve as the direct Account Executive for our Group. Many of us know Jorge Chavez, because he spoke at some of the informative lunch meetings which were held on the Peninsula regarding the "Manta Salud" Group. VITAL has even agreed to consider our suggestion of quickly putting in place, a North American telephone number, so that those of us with Magicjack, etc, can reach Jorge through this method.
C. Fundacion Kairos
"Padre Simon, el amigo del millon" is the Non Government Organization (NGO) who will "process and sponsor" our group plan, in compliance with rules and regulations of Ecuador. Padre Simon, the Executive Director, hopes for our help in spreading the mission and vision of Fundacion Kairos throughout Ecuador and beyond. He asks that IF we can help him do so, with any of our "time, talent, and or treasure", he would be most appreciative of our efforts on behalf of the many people whom his institution(s) serves.
Minimally, he asks for our good wishes and most importantly, our prayers. Fundacion Kairos is the entity that allows us to have a "dependency relationship", which is required for any group health plan in Ecuador. Padre Simon, eventually is interested in the idea of establishing regional advisory committees of group members (for those who would like to become more actively involved). One example, would be for our Plan Group, to coordinate and sponsor periodic Blood Drives, throughout Ecuador, in the regions where we reside. Padre Simon has been honored by President Correa. He has also been awarded (twice), the highest honor that ROTARY CLUB INTERNATIONAL gives out.
Questions and Answers ("from our current understanding without benefit of final documents in hand").
Many of the questions have been sent in by various people to the email address: FOPS.HEALTHPLAN@GMAIL.COM
Our volunteer committee is attempting to answer them as best as we can, in this transmission. We are basing our information on what we have been told, by reliable sources (in our opinion). We even had a Medical Doctor sit through one of our meetings, voluntarily, to help us, with this process.
Much time in our most recent meetings have been dedicated to our questions and those that have been submitted by interested parties (prospective group members). We feel that we are representing the interests of everyone, as best as humanly possible. We now have between 200 and 300 prospective enrollees.
1. Many people have asked questions that are related to the Past Salud Group out of Manta (PSGOOM).
We would like to state that our goal must be to proceed onward and upward. However, we know that many people are feeling the stress of suddenly being uninsured. Our volunteer committee is personally feeling the added stress and responsibility (on a full time basis, it seems) to secure the best plan and to perform as much due diligence as possible, with a very short window of time, to do so. We do feel it is appropriate to clarify the following information (as we understand it), which we think is leading to confusion among people who were members of the "PSGOOM", based on many questions that we have received.
"Too many claims". Many people have submitted questions about whether the same "problem" (too many claims, etc) will affect this new group, which we are about to offer, thereby putting it at risk of early termination by insurer. The answer is "NO". If our new group with BMI has a similar Experience Rating of 49% (Information Source = Salud SA), which was the actual Experience Rating of "PSGOOM", we will be in great shape. A 49% experience rating was told to us by SALUD and now by BMI, to be VERY GOOD. Further, Salud told us that the "PSGOOM" very good experience rating had nothing to do with the reason that they terminated the "PSGOOM". Salud told us that they discovered that the "PSGOOM" did not comply with laws and or regulations relative to a compliance issue. So, just to clarify, the "PSGOOM", according to Salud, was not terminated because of "too many claims". Rather, we were told by Salud, that the claim experience rating was "very good". Further, BMI has agreed that the experience rating of the "PSGOOM" was very good, and they are considering that fact, in their pricing structure.
"Unfortunate Timing". Many of us first heard about a "problem" in Ecuador regarding expatriates filing too many claims, on February 9, 2014. We learned this through a posting on "email@example.com" by the "PSGOOM" Group Administrator that referenced this "problem". On February 10, 2014, we learned that Salud had canceled our coverage, through the same source. We all assumed (wrongfully) that the reason was excessive claims. A group of us visited SALUD SA offices to question what was going on. In addition to clarifying the real reason for termination (Compliance Issue), we were told by Salud, that the "PSGOOM" Group Administrator was officially put on notice in writing on 17 January 2014, that the referenced group was to be terminated in 30 days. We are only sharing this information, because we are upset and disappointed that the "PSGOOM" Group Administrator apparently knew of the group status, on 17 January 2014, but did not relay information about the termination until 10 February 2014. We are upset and disappointed, because had we known, when we feel that we should have known, we could have had the benefit of much more time to put in place what we are trying to do at an exhausting pace, now. Further, we would have preferred to know the actual reason for termination (Compliance Issue), rather than the implication that Salud terminated us for excessive claims. We apologize to the many new people interested in this FOPS HEALTH PLAN OFFERING(S), for having to hear about the above information, which did not apply to them. Onward and upward...
2. What are the levels of coverage and how does age affect premium or coverage level?
You can choose your level of PRIMARY BASIC COVERAGE, at $25,000, or $50,000, or $75,000. EACH OF THESE LEVELS ARE PER EVENT (which is much better than a Per Year Coverage). You can enroll up to age 79 years 0 months.
There is no price differential based on age.
Up to age 70, the coverage levels remain at 100%.
From Age 71 to Age 75, the coverage level = 50%.
From Age 76 to Age 80, the coverage level = 20%
Example. A 79 year old person, who selects the $75,000 level of coverage, will be covered at the level of $15,000 PER EVENT, [which is 20%] (no restriction on the number of events per year).
With this group plan, coverage ends at a person's 80th birthday. Incidentally the same age and coverage scale above, applies to the Group Life Insurance, which is an option being offered.
In addition to the above Primary Basic Coverage, this plan includes a Secondary Catastrophic Care $250,000 per event level of coverage, with a $20,000 deductible. This deductible would be through a coordination of benefits, being paid out of your Primary Basic Coverage.
3. What is the level of coverage, in percent at whatever level we choose?
As we understand it, there are actually three answers.
If you go to an IN or Out of Network Provider, you will be covered at 80% (You may choose your own provider).
If you go to a Special Preferred Provider, you will be covered at 90% (Currently: 8 hospitals in Guayaquil and 5 Hospitals in Quito)
If you go to VERIS or MEDICGLOBAL or AVANTMED or MEDILINK or CLINICA USFQ or CONSORCIO BIODILAB, you will be covered at 100%. We understand you only pay $4.00 (and these providers will direct bill, BMI for anything above $4.00)
4. Is there International Coverage?
As we understand it, there are two answers.
For the first 30 days of an out of country (out of Ecuador) trip, you will be covered up to $10,000 AT RATES OF THE DESTINATION COUNTRY, and you will only have to pay a $150 deductible per trip. In other words you will not be responsible for 20% of payment. 100% coverage, less $150 deductible.
If your incident happens after the 30th day of your trip, you will have your chosen coverage limit, and coverage will be based on Out of Network, at customary rates for Ecuador.
5. What about Pre-Existing Conditions and any Waiting Periods?
As we understand it, for those people that enroll during the INITIAL PERIOD OFFERING (timeframes should be defined early this week);
(a) There will be no Medical History Questionnaire &/or Pre-Existing Condition Declaration.
(b) There will be no Waiting Periods on anything.
(c) Therefore, from Day one of Coverage, your chosen Coverage Level will apply (examples: Emergencies, Doctor Visits, Surgery, Hospitalization, and even to cancer treatment).
Important Note: People who may sign up in the future, after this INITIAL PERIOD OFFERING, will be subject to filling out a Health Declaration or Questionnaire, and based on the answers and explanations thereof, they may or may not be accepted for coverage.
6. Can we join in the future, rather than now?
There are benefits of joining now, during the INITIAL PERIOD OFFERING, that are not being offered to people who enroll at a later date.
As we understand it, people who enroll after the INITIAL PERIOD OFFERING, will be subject to: Medical History Questionnaire &/or Pre-Existing Condition Declaration; and Waiting Periods.
Please see Question #5 above.
7. What is the yearly deductible?
As we understand it, the annual deductible amount is $120. (per year, NOT PER INCIDENT).
8. Does this plan cover maternity?
9. What is the age limit for children to be covered on a family plan?
As we understand it, children may be covered up until their 24th birthday; as long as they are not employed.
10. Does this plan cover Preventive Care or Wellness?
We have learned that other than basic preventive care, such as annual mammography, pap test, prostate check, etc; that healthcare insurance companies do not cover comprehensive preventive care or wellness. However, we spoke personally with the Head of Group Plans at BMI and presented him with volumes of documents listing benefits of preventive wellness care. We talked about the advantages not only to the patient, but also to the insurance company, relative to early detection, treatment and hopefully cure. This BMI executive, told us in a very sincere manner, that if our new group, has a good experience rating (similar to that of the "PSGOOM" and demonstrates future growth in enrollment; he will seriously look into adding preventive wellness care, after our one year anniversary; with the thought of BMI striving for "Best Practices" status. Hopefully, this will happen, and a trend will be set, to benefit all those in Ecuador.
11. Does this plan cover "life style" induced conditions and medications for those conditions?
As we understand it, some life style induced conditions are covered and others are not. We are aggressively seeking greater detail with respect to this question. However, we have been told that high blood pressure and hypertension are covered, as is heart disease, diabetes, & high cholesterol. Mental health is NOT covered.
12. How long are the initial rates guaranteed and can people make a commitment for less than one year?
Initial rates are guaranteed for a period of one year from our anniversary date (to be determined very soon).
Each person enrolled must commit to 12 months of coverage, with certain qualifying exceptions.
We were told on Friday, that the Life Insurance Rates previously quoted were based on a low average age, and therefore will be higher in final version. Our committee documented in writing to all concerned in the negotiation, that everyone knew that this group would likely be comprised mostly of expatriates, and therefore, many people in retirement years. BMI responded that in the final version, they will offset any increase in the previously quoted life insurance rates, with an equal reduction in the Primary Basic Coverage Rates. We are waiting for the final numbers, prior to updating the Draft Version Fundacion Kairos New Plan Offering, including:
A. Group Primary Health Coverage at "PER EVENT" Levels of $25,000 or $50,000 or $75,000.
B. Group Secondary Catastrophic Health Coverage of $250,000 PER EVENT with a $20,000 Deductible (which through coordination of benefits, deductible would be paid out of Group Primary Health Coverage.
C. Optional: Group Life Insurance at Coverage Levels of $25,000 or $50,000 or $75,000 or $100,000
D. Optional: Group Dental Insurance (we are expecting full details of this optional coverage early this week)
13. Can individual members be terminated from the group, with or without cause?
As we understand it, the answer is absolutely not.
14. Is there a list of clinics to which we can go where there are cost advantages for patients and/or simplified claims processing?
Refer to Question and Answer #3.
If you go to VERIS or MEDICGLOBAL or AVANTMED or MEDILINK or CLINICA USFQ or CONSORCIO BIODILAB, you will be covered at 100%. We understand you only pay $4.00 (and these providers will direct bill, BMI for anything above $4.00). Incidentally, one person on our committee is familiar with VERIS at Mall del Sol. We are told that most if not all, VERIS locations, have at least one English speaking person who will help to coordinate any appointments and
If you go to a Special Preferred Provider, you will be covered at 90% (Currently: 8 hospitals in Guayaquil and 5 Hospitals in Quito). We further understand that with your BMI Enrollment ID Card, you should not have to pay any guaranty or use your own credit card, if admitted to these hospitals for at least 24 hours.
15. Can we choose any doctor or clinic?
As we understand it, yes.
16. What about emergency room coverage or being admitted to a hospital?
As we understand it, if you are admitted to a hospital (overnight or more than 24 hours), the copay will be 20% (or 10% at Special Preferred Provider Hospitals)
If you are at a hospital for less than 24 hours, such as an emergency room visit, this is considered ambulatory care, and you would be expected to pay upfront, and file your claim for reimbursements.
17. Is there an English speaking person, who will help us with the claims process?
Copied from "B" above:
The Broker who will offer customer service is VITAL. They have two offices, they are in the World Trade Building in Guayaquil, and also at OMNI Hospital in Guayaquil. We have spent much time with the broker and his staff (Bilingual / Spanish and English Speaking). We have been impressed with them as professionals. We have a commitment, that a young man, by the name of Jorge Chavez (Bi-lingual / Spanish and English Speaking), will serve as the direct Account Executive for our Group. Many of us know Jorge Chavez, because he spoke at some of the informative lunch meetings which were held on the Peninsula regarding the "Manta Salud" Group. VITAL has even agreed to consider our suggestion of quickly putting in place, a North American telephone number, so that those of us with Magicjack, etc, can reach Jorge through this method.
...Thank you for your continued interest and patience. We hope to have more information sent to you early in the week...
Special Request (at your option): If you are seriously interested in this option, we would like to begin a database of those who will need an INITIAL PERIOD ENROLLMENT PACKET (via email). If so, please send us an Email (SUBJECT = ENROLLMENT) with the following information:
Individual Coverage (If Applicable):
Full name exactly as is listed on your Cedula or Passport.
Date of Birth.
Family Coverage (If Applicable):
Full name of Titular (Head of Household) as is listed on Cedula or Passport.
Date of Birth.
Dependent 1: Full name exactly as is listed on Cedula or Passport and Date of Birth. Relationship to Titular (Head of Household): Ex. Spouse / Child
Dependent 2: Full name exactly as is listed on Cedula or Passport and Date of Birth. Relationship to Titular (Head of Household): Ex. Spouse / Child
Etcetera (Same information for each additional Dependent)
Correspondence Email Address: FOPS.HEALTHPLAN@GMAIL.COM
Im interested in hearing about the Fops plan. I have IESS, but FOPS is Friends of Padre Simon whom Ive known for over a decade. It is connected I believe in some way with Kairos foundation.