There are multiple insurance requirements which may impact a scholar or employee. These are:
J Visa Insurance Requirements (22 CFR 62.14)
Everyone in J-1 or J-2 visa status must have emergency medical insurance from the program beginning date to program ending date indicated on their DS-2019 form, regardless of whether or not they are physically located in the U.S. all of that time. The insurance must meet or exceed the following minimal requirements for coverage:
- Medical benefits of at least $100,000 per accident or illness;
- Repatriation of remains in the amount of $25,000;
- Expenses associated with the medical evacuation of exchange visitors to his or her home country in the amount of $50,000;
- Deductibles not to exceed $500;
- The policy may require a waiting period for pre-existing conditions that is reasonable as determined by current industry standards;
- The policy may include provisions for co-insurance under the terms of which the exchange visitor may be required to pay up to 25% of the covered benefits per accident or illness;
- The policy must not unreasonably exclude coverage for perils inherent to the activities of the exchange program in which the exchange visitor participates;
- Any policy, plan, or contract secured to fill the above requirements must, at a minimum, be:
- Underwritten by an insurance corporation having an A.M. Best rating of “A−” or above; a McGraw Hill Financial/Standard & Poor's Claims-paying Ability rating of “A−” or above; a Weiss Research, Inc. rating of “B + ” or above; a Fitch Ratings, Inc. rating of “A−” or above; a Moody's Investor Services rating of “A3” or above; or such other rating as the Department of State may from time to time specify; or
- Backed by the full faith and credit of the government of the exchange visitor's home country; or
- Part of a health benefits program offered on a group basis to employees or enrolled students by a designated sponsor; or
- Offered through or underwritten by a federally qualified Health Maintenance Organization or eligible Competitive Medical Plan as determined by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services.
These insurance requirements are intended to cover most relatively minor emergency medical situations, but not chronic conditions, routine care or tests, children’s wellness visits, maternity, birth control, or immunizations. Scholars in J-1 status and their families may find that they require more comprehensive insurance coverage either to meet the other regulatory requirements noted below or their individual healthcare needs.
Scholars in J-1 status, who will be employed by FSU for 30 hours per week or more, are eligible to enroll themselves in the State of Florida group insurance coverage, but will experience an unavoidable gap between their arrival and their ability to enroll in the coverage. Therefore, those scholars must purchase 90 days of temporary insurance coverage that meets or exceeds the requirements listed above. Within those 90 days, the scholar will arrive at FSU, check-in with the CGE, apply for a federally issued Social Security number (if they do not already have one from previous U.S. employment), complete payroll paperwork and any required background check procedures, and await issuance of the Social Security number (usually 2-4 weeks from the date of application). When the Social Security number is received and the payroll appointment is completed, the scholar can enroll in a Standard HMO or Standard PPO plan (the high deductible plans do not meet the J visa regulations), and the insurance can begin on the first day of the next month after enrollment. Scholars must begin their insurance enrollment no later than 60 days from their start of employment, or they will miss the opportunity to enroll until open enrollment begins for the following year’s coverage.
The insurance enrollment is NOT automatic and hiring department cannot enroll scholars in the state group insurance. The scholar must research their options and enroll themselves and their dependents at http://www.hr.fsu.edu/?page=benefits/insurance/insurance_home. The employer only pays a portion of the premium. The employee pays $50 per month for individual coverage or $180 per month for family coverage. Scholars in J-1 status must also purchase separate medical evacuation and repatriation of remains coverage to meet the J visa requirements. The State group insurance does not cover these required benefits, but there are many online insurers that provide this separate coverage at a very affordable rate.
Scholars who are not paid by FSU must purchase insurance for themselves and their J-2 dependents for the entire duration of their program before their arrival in the U.S. There are many online insurance companies which can be found by searching “Travel Medical Insurance for the U.S.”. FSU employees are not authorized or licensed to give any recommendations or suggestions for a particular insurance agent, company, or plan. But, the Exchange Visitor Advisor at the CGE can review plans for compliance with the J visa regulations, prior to the scholar enrolling or purchasing coverage.
The FSU Health Center’s comprehensive insurance plan can also be purchased by only the visiting scholar (no dependents) for the following coverage dates only – August 15 to August 14 of the following year, August 15 to December 31, or January 1 to August 14.
Visiting scholars and their dependents who find, after their arrival in the U.S., that they need more comprehensive coverage, coverage for a pre-existing condition, or coverage that meets the Affordable Care Act, may be able to find plans that meet the medical portion of the above J-1 requirements through the Healthcare Marketplace – www.healthcare.gov, but will need to ensure that the deductible is no more than $500 and the co-insurance is no more than 25%. Separate medical evacuation and repatriation coverage will need to be purchased with this option, as the Marketplace plans do not cover these requirements. The Marketplace plans have strict enrollment windows and will bill for the remainder of the calendar year in which enrollment in the plan occurs.
Affordable Care Act
Those who are residents for tax purposes (not the same as the immigration status) may be subject to the Affordable Care Act requirements. To determine your tax residency status, go to http://www.arcticintl.com/quick-spt-test.asp . The state group insurance available through FSU employment of at least 30 hours per week (http://www.hr.fsu.edu/?page=benefits/insurance/insurance_home) complies with Affordable Care Act, as does the insurance offered through the FSU Health Center and through www.healthcare.gov. Residents for tax purposes who are not compliant with the Affordable Care Act can become subject to a tax penalty when filing their tax return. More information regarding the applicability of a tax penalty can be found here (link to the attached pdf) or by consulting with a qualified tax professional. Those in J-1 and J-2 visa status may be subject to both the J-1 visa requirements for insurance and the Affordable Care Act requirements and will need to be careful to meet all provisions of both.
FSU Insurance Requirements for Enrolled Students
Anyone in F-1, F-2, J-1, or J-2 status who enrolls in classes must meet the Florida State University insurance requirements for international students listed at http://www.studentinsurance.fsu.edu/insurance.html under Requirement to Show Proof. These requirements are higher than the J-1 visa requirements, and for some benefits, higher than the Affordable Care Act requirements. A J-2 dependent enrolled in classes may be subject to all three of the above insurance regulations and will need to be careful to comply with all provisions of the three separate sets of requirements. Those in other visa classifications who are enrolled in FSU classes will need to comply with the “domestic” requirements listed at the link above under Requirement to Show Proof. As an enrolled student, a J-2 or H-4 dependent would become eligible for their own coverage under the FSU Health Center’s insurance plan, but may already have comparable coverage under their spouse’s state group insurance.
What to Consider When Choosing Coverage
Premium vs. Benefits – Many people opt for the “cheapest” insurance plan available. It is important to keep in mind, though, that a low premium usually means less coverage for any medical care that may become necessary. A higher premium means that the insurance company has more money to pay medical bills, and the insurance benefits provided are usually better. Most people think that they simply will not need to use their U.S. insurance, so they need not pay attention to the benefits when choosing a plan. In an unexpected and severe medical emergency, having a higher level of coverage will mean less financial stress at a particularly stressful time.
Eligibility – Be sure to pay attention to who is eligible for coverage under the plans you are considering. Does the policy cover only international students enrolled in classes, scholars engaged in research, or anyone who is visiting the U.S. from another country? Will the plan cover someone in a dependent status without the primary status holder being covered? Does the policy have any U.S. citizenship or permanent residency requirements? Does the policy require a physical exam or other determination of health status prior to issuance of the policy? How long will the application process take to determine eligibility? Insurance companies often ask for verification of eligibility (such as proof of enrollment in classes for a student insurance policy) before paying a claim for payment of a medical bill, and they will deny a claim if the policy holder is found to be ineligible for coverage.
Renewal options - Check to see if the plan can be continuously renewed, if you anticipate an extension of your visa status. Some plans do not allow renewal. So, each time the policy is re-purchased a period of non-coverage for pre-existing conditions begins again. This means that if a student’s dependent becomes pregnant at the end of one period of paid coverage, the continuing care, the birth, and the newborn care will not be covered under the new period of coverage. The condition will be considered pre-existing. Choose plans that allow for renewal, and be sure to renew within the specific period outlined in the insurance plan details in order to maintain continuous insurance coverage during an extension period.
Pre-existing conditions exclusions – Many travel insurance plans can exclude pre-existing conditions. These are generally defined as any condition which manifested or was diagnosed prior to the beginning of the insurance policy. So, if a doctor determines that a patient may have had untreated diabetes for a year before the student began their insurance coverage, all treatment for that condition will be the student's responsibility for at least the first six months of the insurance policy, if not more. Be sure to read carefully and understand all language regarding pre-existing conditions, and if your family members have a condition which will require continuing care during their stay, avoid switching insurance plans. Look for plans which do not exclude pre-existing conditions in order to have the most comprehensive coverage available.
Exclusions - Be sure to understand all exclusions detailed in your insurance policy’s benefits brochure. Many plans exclude activities like any sports activities, even amateur or casual participation, climbing, or snorkeling. This means that any injury resulting from participation in these activities will not be covered at all. Some plans exclude children's ear infections, immunizations, pregnancy, birth control, treatment of back or joint pain, treatment of jaw pain, or treatment of foot conditions. Some plans completely exclude coverage for chemo-therapy or radiation therapy, commonly required for treatment of cancer. Be aware of these exclusions and make the best decision based upon your family's potential healthcare needs. Plans with minimal exclusions provide the most comprehensive coverage.
Benefit limits - Be aware of the limits placed on certain services. Plans which appear to provide the same maximum coverage amounts may limit the amounts they pay for an ambulance, daily hospital charges, a surgeon, anesthesia, CT Scans, X-rays, laboratory tests, emergency room care, for example. If a plan pays for only $1,000 of the cost of a CT Scan, you would be expected to cover the entire remaining amount, which could be another $1,500. A healthcare provider will probably not be able to tell you the cost of individual services, because an outside billing office generally determines those charges based upon a number of criteria.
Provider Network - Be sure that you look at the provider network used by the plan. This is the list of doctors, hospitals, specialists, and laboratories that have contracted (at some point) to provide service for the insurer. You will want to make sure that there are available providers in a multitude of specialties and facilities in Tallahassee and that these listed providers are still accepting your insurance plan or are still part of that provider network. Many doctors move, do not renew the contract, or contract with other agencies which disallow their participation in any other network. So, it is always best to check directly with the doctor's office. If you prefer a certain doctor, be sure that your doctor is in the network. Out-of-network care often involves a higher deductible and co-payment. Plans with extensive networks of providers will give you more comprehensive coverage and will reduce your out-of-pocket expenses for healthcare.
Usual and Customary - If you choose a provider which is out-of-network, or if there is no in-network provider in the specialty area you need, the insurer will pay their percentage of what they feel is "usual and customary", or the an amount similar to what they pay other such providers in the same geographic area or in a similar geographic area. If the amount charged by the doctor is more than what is considered "usual and customary", you will be charged the difference, in addition to your normal deductible and co-pay.
Deductible – This is the first amount of healthcare charges which are the responsibility of the insured person. Be sure you understand whether you have a deductible which covers the whole year or is charged each time you have a healthcare claim. If you have a $250 deductible, $250 will be deducted from what is billed to the insurance company and you will pay that full amount, plus any co-insurance. Emergency Room visits often incur an additional deductible or co-pay charge, which is charged to the insured. Higher deductibles are used to keep the plan premium amount lower by both discouraging use of the insurance for minor illnesses or injury and by passing along some healthcare cost to the insured person.
Co-insurance - This is a percentage amount which is billed to you, in addition to your deductible amount. This amount is typically around 20% of the bill which remains after your deductible. Sometimes different treatments or diagnostic procedures will have different co-insurance amounts. Co-insurance helps keep an insurance policy’s premium lower by having those who use more medical services pay more of the healthcare costs. This benefits those who do not frequently use the insurance plan, but may impose a large financial burden on those with serious injuries or illnesses.
Co-pays – This is a flat rate for certain services, usually doctor’s visits. Typically, there is no additional charge after the co-pay is paid. Some insurance plans have an all co-pay structure, such as Capital Health Plan or some plans offered through www.healthcare.gov. Co-pays provide a predictable cost for healthcare services incurred.
Out of Pocket Maximum – If your plan has an out-of-pocket maximum, this is the highest amount you can be charged for all of your medical care in one year. This will generally include your deductible and all co-insurance. So, if your plan has a $10,000 out of pocket maximum, and you have an unexpected hospital stay costing $100,000, rather than owing 20% of that bill in co-insurance, you would owe only $10,000.
Costs - Be sure that you understand what costs you will incur if you must be treated. Here is an example for a minor unexpected accident or illness:
$900 - Ambulance
$500 - Emergency Room Services
$250 - Doctor's Bill
$900 - CT Scan/X-rays
$250 - Follow up Doctor's Visit
Total medical bill: $2800
Insured pays deductible: $250
Insured pays additional emergency room deductible: $200
Insured pays 20% of remaining amount: $470
Total billed to insured person: $920
Insurance is essentially a discount off of your total healthcare costs. Be sure that you understand each potential cost to you with the plan you choose.
If it seems worthwhile to go with a plan that provides less comprehensive coverage but lower premiums, keep in mind what you might actually pay more overall in the end, should you need emergency medical services.
Claim procedures - Be sure that you understand what is required in order to file a claim. Will the healthcare provider present a bill to the insurer? Are you responsible for the entire bill in the beginning and must apply for reimbursement at a later date? What is the standard time for reimbursement? When must bills be submitted? Many plans require that bills be submitted within 30-60 days of the injury or illness, but many doctors and healthcare providers do not provide a bill that quickly. In that case, you will have to make calls to get the bill more quickly, or the claim will likely not be paid. Keep copies of all bills and claims submitted, in case you are billed more than once before the insurer pays. Be sure to ask questions and seek advice, especially if anything seems incorrect. The U.S. does not have a coordinated system of healthcare and mistakes and miscommunication often occur.