San José, Costa Rica, since 1956

Changes in Medical Insurance Policy

“PLAN 16” isthe medical insurancepolicy INShas been sellingsince 1990, and alot of people in theforeign communityhave obtainedcoverage throughthe CanadianClub, The AmericanLegion, andthe ARCR.Late NovemberINS advisedthat, starting with the renewal on Jan. 1,2005, some new rules apply to this policy.Some of them look good, some not sogood – but, on balance, the changes ironout some of the “bugs.” At the same time,the premium rates, which are in colones,have increased by about 20%, which isreasonable – it’s just a tad above whatinflation will probably rack up to in calendaryear 2004.Outlined below are the nuts and boltsof Plan 16. After each paragraph, are commentsregarding the changes.Who can be insured? Anyone up toage 100, regardless of legal status in CostaRica. Applicants over 69 must undergo anexamination by an INS doctor. It takes INSabout three weeks to study applications:you may not pay until your application isaccepted.The policy goes with the calendar year:if someone applies and is accepted partway through the year, the yearly premiumis prorated. No changes.What does the policy cover ? It coversexpenses due to sickness, accident, orchildbirth. Outpatient services are paid forup to 10% of the insured amount, per year.The rest of the policy, the other 90%, isfor hospitalization, surgery, pre- and postoperativecare, private room, food, supportsystems, intensive care, rehab., ambulances,home care, therapy, meds, etc.In case of death, 50% of the insuredamount is paid to a named beneficiary.Please note that there is no payment forcheckups or “preventive maintenance.” Nochanges.What does it exclude? Pre-existingconditions, non-prescribed expenses, AIDS,VD, medical expenses as a result of cataclysmicevents, injuries from fightingexcept in self defense, tournament sports,martial arts and other dangerous activities.accidents when under the influence ofalcohol or drugs, mental or nervous disorders.,checkups, allergies, stress, plasticsurgery. Only accident-related eyeglasses,dentists’ bills or reconstructive surgery arepaid. Some ailments (e.g. glaucoma,cataracts, ENT, women’s reproductiveorgans, breasts, asthma, hernias, pregnancy,prostates, stones, osteoporosis) have a12-month moratorium, during whichclaims are not allowed.Here we see a change: glaucoma andcataracts were not previously subject to themoratorium.How much does it cost? You canchoose between three levels of insurance.The insured amount refers to the maximumamount INS will pay for your health in thecalendar year. Premiums depend on thelevel of insurance, and on age and sex ofthe insured. Some samples of yearly premiums:LEVELS:¢4 million¢6 million¢8 millionMen Women30 – 34 19 – 2589,000 370,000106,000 434,000115,000 490,00045 – 49 55 – 59172,000 436,000208,000 488,000232,000 526,00060 – 64 70 – 75322,000 779,000402,000 896,000466,000 985,00070 – 75 Minors Up to 18587,000 115,000758,000 137,000908,000 152,000These rates reflect the 20% increase –however, it is not exactly 20%, as figureshave been rounded.Group policies for companies costabout 12% less. Associations or clubs,(ARCR, American Legion, etc.) get about6% off. Cost of renewal may increase ifthere is a high claim/premium ratio.Another change here: discounts for grouppolicies used to be greater.How does the policy work? In case ofambulatory care (when hospitalization isnot needed), you must pay for your careand later submit an INS claim form signedby you and your main doctor, attachingoriginal receipts and corresponding prescriptionsfor medicines, treatments, andlab tests. Your agent will push your claimthrough INS, which usually pays afterthree-six weeks, based on usual and reasonablecharges. If you require hospitalization,a week before you go into the hospital,through your agent you should obtain a“preauthorization” from INS, which willnegotiate prices with your care giver.When released from the hospital, youmust show your insurance card and payonly the deductible. If you didn’t get the“preauthorization,” you pay the entire billand make a claim as described above.Important changes here: a network ofproviders used to accept patients’ insurancecards and collect only the deductiblefrom them. And the network providerswere supposed to abide by a price listimposed by INS.Now, there are no network providers,there is no official price list, payment ofclaims is based on “usual and customaryprices,” and insurance cards can only beused for ailments requiring hospitalizationin cases where prior approval (“preauthorization”)has been obtained from INS.Deductibles? The general deductibleis 25%. In some cases, like claims fromabroad, or if you buy a patent medicinewhen there is available a generic equivalent,the deductible can be 30%.More changes: general deductible usedto be 30%; there was no differencebetween patent and generic medicines; andthere was no deductible on surgeon’s fees.Contact David Garrett at 233 2455 The purpose isto give the reader a better understandingof insurance in Costa Rica. The opinionsand viewpoints expressed are those of thewriter, and do not necessarily represent theofficial position of the National InsuranceInstitute (INS). INS and Garrett & Asoc.will be closed Dec. 17 -Jan. 3, 2005.

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