Expatriate Insurance North Point IT Corp

Proposed Group Insurance Medical Plan Effective Date: 01/01/2020

Choice Plus Expatriate Insurance - 30/3000/80% Plan
Plan Name
1007A MOD
Medical Expenses
Active full-time Expatriate employees of working a minimum of 30
Eligibility Provision
hours per week.
Dependent Spouse; domestic partner; children under the age of 26.
Lifetime Maximum Unlimited

Plan Highlights Outside the U.S. U.S. In-Network U.S. Out of Network

Deductible (Single/Family) $3,000 / $6,000 $3,000 / $6,000 $7,000 / $14,000

Out-of-Pocket Maximum (Includes Deductible.
$6,900 / $13,800 $6,900 / $13,800 $18,000 / $36,000
Combined International & U.S. In-Network)
Coinsurance
80% 80% 50%
(covered expenses after deductible)
Rx / Pharmacy – Mail Order Pharmacy coverage is $15/ $40/ $75 (2.5x
80% 50%
included in the United States. MO)

Preventive Care
Physician Office Services:
Includes: routine physical examinations, well baby 100% not subject to 100% not subject to
50% after deductible
and well child care, immunizations and hearing deductible deductible
screenings.
Lab, X-ray or other preventive tests:
Include: Screening mammography, screening 100% not subject to 100% not subject to
colonoscopy or sigmoidoscopy, cervical cancer 50% after deductible
deductible deductible
screening, prostate cancer screening and bone
mineral density tests.
Frequently Accessed Services
100% not subject to 100% after a $30
Primary Physician Office Visit 50% after deductible
deductible Copay
100% not subject to 100% after a $60
Specialist Physician Office Visit 50% after deductible
deductible Copay
100% not subject to 100% after a $75
Urgent Care Center Services 50% after deductible
deductible Copay
100% not subject to 100% after a $300 100% after a $300
Emergency Services – Outpatient
deductible Copay Copay

Hospital – Inpatient Stay 80% after deductible 80% after deductible 50% after deductible

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Expatriate Insurance North Point IT Corp
Proposed Group Insurance Medical Plan Effective Date: 01/01/2020
Additional Core Benefits
100% not subject to 100% after a $30
Acupuncture - $2,500 per year 50% after deductible
deductible Copay

Ambulance Services (Air and Ground) 80% after deductible 80% after deductible 80% after deductible

Durable Medical Equipment

(limited to a single purchase of each type every 3 80% after deductible 80% after deductible 50% after deductible
years)
Hearing Aids - $5,000 per year and are
limited to a single purchase (including
80% after deductible 80% after deductible 50% after deductible
repair/replacement) per hearing
impaired ear every three years.

Home Health Care (up to 120 visits per year) 80% after deductible 80% after deductible 50% after deductible

Hospice Care 80% after deductible 80% after deductible 50% after deductible

100% not subject to 100% not subject to

Lab, X-Ray and Diagnostics – Outpatient 50% after deductible
deductible deductible
Lab, X-Ray and Major Diagnostics – CT, PET, MRI,
80% after deductible 80% after deductible 50% after deductible
MRA & Nuclear Medicine – Outpatient

Pregnancy-Maternity Services 80% after deductible 80% after deductible 50% after deductible

Prosthetic Devices - A single purchase of each type

80% after deductible 80% after deductible 50% after deductible
of prosthetic device every three years.
100% not subject to 100% after a $30
Rehabilitation Services 50% after deductible
deductible Copay
Physical Therapy up to 20 visits up to 20 visits up to 20 visits
Occupational Therapy up to 20 visits up to 20 visits up to 20 visits
Manipulative Treatment up to 20 visits up to 20 visits up to 20 visits
Speech Therapy up to 20 visits up to 20 visits up to 20 visits

Skilled Nursing Facility (up to 120 days per year) 80% after deductible 80% after deductible 50% after deductible

Surgery - Outpatient 80% after deductible 80% after deductible 50% after deductible

Temporomandibular Joint Disorder 80% after deductible 80% after deductible 50% after deductible

Medical Evacuation and Repatriation

Emergency Evacuation 100%

Emergency Family Reunion 100%

Medical Repatriation 100%

Repatriation of Remains 100%

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Expatriate Insurance North Point IT Corp
Proposed Group Insurance Medical Plan Effective Date: 01/01/2020
Mental Health and Substance Use Disorders / Neurobiological Disorders

Inpatient 80% after deductible 80% after deductible 50% after deductible

100% not subject to 100% after a $30

Outpatient 50% after deductible
deductible Copay
Vision Benefits
100% not subject to 100% after a $30
Eye Exam – 1 exam every 2 years 50% after deductible
deductible Copay
Vision Materials ($250 maximum reimbursement per
Excluded Excluded Excluded
year)
Additional Member Benefits and Tools

Medical Assistance:
- Medical evacuations and
repatriations
- Return of minor children
during evacuation
- Transportation to join a
hospitalized patient
- Medical provider and dental Travel Assistance:
referrals - Destination Intelligence
- Monitoring of treatment - Help with emergency travel planning
Assistance Services - Relaying of medical and - Transfer of funds
insurance information - Lost document assistance
- Facilitation of hospital - Legal referrals
payment - Emergency translation
- Updates to family and
employer
- Hotel arrangements
- Medication and vaccine
transfers
- Replacement of corrective
lenses and medical devices

Included for members is five hours of face-to-face counseling and re-

integration support for employees and their families returning to their
International Employee Assistance Program
home country. Members also have access to unlimited telephonic
counseling and a specialist network of counselors 24/7/365.

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Expatriate Insurance North Point IT Corp
Proposed Group Insurance Medical Plan Effective Date: 01/01/2020
Additional Member Benefits and Tools Continued
■ “Livewell” is our online portal which provides members with ready
access to an extensive array of health content, screeners, tools,
resources and self-help programs.
■ Rally is our wellness portal we offer to members where they can
take an online health survey and access personalized activities,
individual goals and more.
■ Our new Health Management Program provides personal support if
Digital Tools and Wellbeing Services
members or their family members are living with chronic health
conditions or have a child with special needs. The program provides
direct access to a clinician with whom a relationship is built to help
manage: medication management, durable medical equipment and
supplies assistance, dietary management, assistance in finding
specialty providers for complex issues and action planning for urgent
needs.

■ Pre-departure outreach calls and emails including an assessment

Onboarding Services for Members
for the employee and spouse and a follow-up outreach call and
assessment six to eight weeks into the assignment
■ Custom webinars (either live or recorded) for employees – these
can be provided to the employer to save on intranet sites
■ Evaluation of ongoing clinical needs for enrollment into our Health
Management programs
■ Follow-up emails and assessments
■ Online health risk assessment

Optional Coverage
Enhanced Physical Examination / Ningen Dock (up
Excluded Excluded Excluded
to $0,000 per lifetime)
Private Room - Hospital (Inpatient Stay) Excluded Excluded Excluded
Infertility Services (up to $10,000 per lifetime) Excluded Excluded Excluded
Obesity Surgery (up to $0,000 per lifetime) Excluded Excluded Excluded
Private Duty Nursing (up to visits per year) Excluded Excluded Excluded
Vision Therapy (up to visits per year) Excluded Excluded Excluded
Prior authorization may be required for certain benefits.
Proposal Enrollment Medical Rates
Employee Only 6 $314.59
Employee + Spouse 3 $692.09
Employee + Ch(ren) 0 $597.71
Family 1 $975.22
Total 10
Monthly Premium $4,939.01
Annual Premium $59,268.09
This premium includes state and federal taxes and fees.
This is a high level benefits overview. Refer to actual plan documents, including benefits summary, for more detailed benefit
descriptions.
The rates quoted here are based on the assumptions detailed in the General Financial Assumptions pages. Changes to these
assumptions may result in an adjustment to rates or revocation of the quote.