Missionary
MISSIONARY
Medical Aid Plan
Description and Summary of Coverage
(Effective 1/1/2012)
A. Principle and Purpose of the Missionary Medical Aid Plan
1. Avant Ministries is a religious not-for-profit organization, not an insurance company.
2. This is an in-house cooperative medical aid program providing coverage
for overseas missionaries, missionaries on home assignment in U.S., home
missionaries andfull time employees.
3. The medical coverage is funded by a stipulated monthly allocation
included in the missionary support schedule. The allocation is based on
claims experience and reviewed at least once a year.
4. The fund is self-administered and controlled by the Executive Committee
of Avant Ministries.
B. Eligibility
All active members of the religious order are eligible for family coverage immediately upon appointment and once required support is at 50% for two consecutive months. The 50% of required support level for two consecutive months is based on actual support coming into Avant.
In countries other than Canada, all long-term missionaries are required to enroll in the plan. However, if also required to pay into a foreign plan, Missionary Medical Aid Plan (M.M.A.P.) will pay the foreign premium up to 1/2 the amount of the support allocation for medical aid. All claims should first be submitted to the foreign plan before final review of M.M.A.P.
Full time employees, serving at the International Service Center, are eligible for medical coverage at the first of the month following their date of hire, unless they have waived their right to receive coverage as part of the hiring process. If you are still active on prior medical coverage and would like to delay your effective date on Avant’s plan, please contact the Medical Benefits Administrator.
For the purposes of Avant’s Medical, Dental and Optical benefits, a full-time employee is defined as an employee being paid for an average of at least 30 hours/week (this includes hours worked, as well as holiday, vacation and sick time). This is a total of 1560 hours per year.
Member employees are eligible for family coverage.
Non-member employees are eligible for individual coverage; they are not eligible for family coverage. For individual coverage, no family member is eligible to be on the plan. Individual married female employees of Avant are eligible for maternity coverage upon completion of 1 year of employment. If the married female employee had maternity coverage through their previous medical coverage, and if there has been no break in coverage, then Avant would waive this one-year waiting period.
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If you have had 12 months of continuous medical, dental and/or optical coverage up to the date you will begin coverage through Avant, you will need to provide a Certificate of Creditable Coverage (from your current insurance provider) to Avant, so that there will be no break in coverage.If you have not had 12 months of continuous dental or optical coverage, there will be a one-year waiting period.The documentation can be sent via email, fax, or regular mail. Email: , Fax:(813) 441.7210, Mail: Avant Ministries, Attn: Terresa Jones, 10000 N Oak Trafficway, Kansas City, MO 64155.
Exceptions to the above:
1. Affiliate and short term workers are eligible to participate and are required
to have medical coverage but it can be obtained elsewhere.Summer workers are not eligible and are required to obtain medical coveragethrough other sources.
2. Retired or disabled missionaries are not covered under this plan.
3. Missionaries on leave of absence are not covered.
4. Covered staff who enter the plan with pre-existing conditions will becovered by the plan except for any claims relating to the condition, unless transferring in under HIPAA regulations.
C. Dependent Coverage
Medical coverage for a child will continue until the child is no longer a dependent or the child reaches the age of twenty-six, (the day of their birthday) whichever comes first. For purposes of the medical plan, dependents are defined as unmarried children who are either born into a family or have been legally adopted, and are still living at home or enrolled full-time in a college undergrad program. Children who have moved away from parents and are not in college are no longer considered dependents and are not eligible to remain on the plan. (It is the responsibility of the parent to notify Avant of a child becoming independent.)
Health Expense Coverage for your fully handicapped child may be
continued past the maximum age for a dependent child if the child has
not been issued a personal medical conversion policy.
Your child is fully handicapped if he or she is not able to earn his or her
own living because of a mental or a physical handicap which started prior
to the date he or she reaches the maximum age for dependent children;
and he or she depends chiefly on you for support and maintenance.
Coverage will cease on the first to occur of: cessation of the handicap,
failure to give proof that the handicap continues, or failure to have any
required exam.
D. Deductible Requirements
The copay is $40 for each visit to a doctor, hospital, chiropractor, or
licensed counselor. There is a maximum of $500 deductible per person or
$1,000 per family in a calendar year. Expenses are considered according to
the date of treatment, not the date paid or date submitted.
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E. Covered Expenses
1. All members while receiving treatment in the U.S. (other than Alaska) must use providers and facilities within a Network as selected by Avant.
2. Covered expenses shall be the reasonable, usual, and customary charges
in the area where incurred for the following: services, supplies, andtreatment when medically necessary and when ordered by a licensedphysician or surgeon, or other licensed psychiatric care or healthcareprovider as stipulated in this plan.
3. Licensed physicians and surgeons services are covered whether rendered
in the doctor’s office, or in the hospital.
4.Hospital charges: room and board, services, supplies while confined when
medically necessary.
6. Surgery: performed by a legally qualified physician or surgeon.
Weight losssurgery will not be covered.
7. Medical treatment: by a legally qualified physician.
8. Private nursing: if in an intensive care unit, by a registered nurse
who is not a member of immediate family or household.
9. Ambulance: if certified by a physician as required to rapidly transport a disabled patient to obtain urgently needed care.May be by air within same country with a maximum cost of $20,000 to be reimbursed. One way only and for patient only.The cost of supplemental evacuation coverage up to $2,000 per year per family. If the member is in a location where the benefit explained above is not adequate to cover the potential costs may be reimbursed from ministry work funds through normal Avant expense reports.
10.Anesthetics and oxygen and administration thereof.
11. Physiotherapy, laboratory work, radium therapy.
12. Crutches: braces, prosthetics necessitated by injury or disease occurring
while insured. Does not include replacement or maintenance.
13.DME: Rental or purchase of durable medical equipment as required by
physician.
14.Blood: Blood or plasma, except as offset by donations. In some cases,
donationsof blood may be required.
15. Physical: Complete physical every two years, or annually if medically necessary. The $40 copay will apply.
(Westrongly suggest that physical be taken on field if good doctors are
available and ifcost would be less than in the States.)
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16. Prescriptions will be covered under the Prescription plan as follows:
90% will be paid if member buys a generic drug from one of the providers
or buys the prescription from a provider outside of the U.S.
75% will be paid if member buys a brand name drug from a list that will
be provided (they call it formulary drugs)
60% will be paid if member buys a brand name drug not on the list (these
are called non-formulary drugs)
50% will be paid on prescriptions bought from a provider not in the Network
Shipping and handling from mail order prescriptions will be included as
part of the cost of the prescription if this makes the total less expensive
than buying locally at retail.
The definition of prescription is understood to be drugs that cannot be
secured in any other manner. The prescription receipt which includes the
prescription number must be submitted. (A cash register receipt will not
be acceptable.)
Insulin, although available over the counter, will be covered as any other
prescription including necessary syringes and blood/sugar testing equipment.
The Avant Rx plan does not cover anti-rejection medication for a transplant patient. There will be a $10 per card replacement charge for anyRx card.
17. Psychiatric: Office or hospital psychiatric care or services of a licensed
psychologist ormember of Christian Psychological Services will be reimbursed after the$40 per visit copay, subject to $2,500 annual maximum of coveredexpenses for out-patient care and $7,000 annual maximum for in hospitalcare.
18. Chiropractic: Treatment by a licensed chiropractor acting within the scope of
hislicense. Outpatient treatment by doctor other than a chiropractor will alsofall under these limits if treatment falls under area normally performed bychiropractor (including adjustments, traction, thermo massage, whirlpooltreatments, acupuncture, and other similar treatments). After $40 per visitcopay, M.M.A.P. will pay up to $1,000 per year, and thereafter pay80% of each claim after the copay.
19. Maternity: Maternity coverage will be treated as any other illness. This
coverage includes married female staff employees who are on the plan. The plan will include coverage for pre-natal and delivery claims performed by a licensed midwife. It will also cover facility charges for delivery in a licensed birthing center.(See Exclusions Section G, Page 5, Item #6)
Testing for infertility is covered. Treatments for infertility are NOT covered.
Unless high risk – sonograms are limited to 3.
Sonograms to discover the baby’s sex are not covered.
Network providers and facilities are to be used or claims will be paid at 80% by the medical plan.
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20. Special coverage consideration: for out-patient hospital and clinic services
when treatment alone requires stay in motel at location of treatment.
M.M.A.P will be governed by the following:
a. 50% of cost for hotel, motel, or any Avant-owned Guest House withlimit of 21 days, subject to $40per day copay.
b. Treatment must be verified in writing by a doctor, M.D., licensed
chiropractor or osteopath.
21. Hearing Aid Coverage: Will pay for 80% of cost of examination and
purchase of hearing aid device up to a limit $3,500 in a three-year period.
Repairs and maintenance are not covered.
22. Well woman exam: Women age 18 or older may have a well woman
exam performed once a year subject to the $40copay. This routine
exam includes a breast and pelvic examination, mammogram, and/or pap
smear.
23. Shoe inserts: if prescribed by a doctor, are covered up to $500 after a $40
deductible. Shoes are not covered, even if prescribed by a doctor.
24. Corneal transplants: after $40copay.
25. Autism/Aspergers: will be treated as a Mental Health / Behavior Disorder.
As such, it will be subject to the plan limits for outpatient psychiatric care.
26.Assistant surgeon fees: We allow up to 25% of the usual & customary
surgical charge.
27. Physical Therapy: We allow up to 100% of the usual & customary charge after the $40 copay. Member must have a referral from a licensed doctor for the plan to cover.
F. Dental and Optical Coverage
Dental and optical coverage will begin, subject to the following limits,one year after the initial enrollment in the medical plan unless there isuninterrupted previous coverage.If you have not had 12 months of continuous dental or optical coverage, there will be a one-year waiting period.
- Dental: Will pay 90% of dental claims up to $1,800 per individual per calendar year. (Dental surgery for removal of wisdom teeth will be treated as amedical claim.) Beautification procedures are not covered.
- Optical: Will pay 90% of optical claims up to $500 for eyeglasses, contacts, andexam per individual per calendar year. All eye exams will fall under this limit.
- Lasik: surgery covered at 50% after $40copay.
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G. Exclusions
1. Exclusions include charges for services and supplies that are not
medically necessary for the diagnosis and treatment of an illness or injury,or charges which are not usual, reasonable or customary. A necessaryservice or supply is considered necessary only if it is broadly acceptedprofessionally as essential to the treatment of the illness or injury.
2. 20% of any claim in the U.S., outside of a network, is member responsibility.
3. Any beautification procedures or treatment including bleaching and
capping of teeth for cosmetic purposes.
4. Transportation to receive treatment except ambulance.
5. Injury and disease which existed before becoming insured. Unless
uninterrupted coverage exists when enrolling in plan.
6. Maternity benefits for an unmarried member or unmarried dependent as this
violates our religious conviction on moral code of conduct.
7. Breast pump or any supplies needed that are a personal choice of the couple.
8. Shots, medical exam, etc. needed for obtaining a visa should not be
submitted as medical claims but rather turned in as a work fund expense.
9. Private duty nursing care other than in an intensive care unit.
10. Maintenance dialysis treatment due to kidney failure.
11. Organ transplants.
12. Vitamins, food supplements, and nutritional supplements.
13. Bone marrow transplants.
14. Books and literature.
15. Hearing aid repairs and maintenance.
16. Shoes for foot problems.
17. Ear piercing
18. Cosmetic surgery
19. Invitro Fertilization (IVF), shots or injections to increase fertility, or other
similar treatments for infertility.
20. Spouse and Children of employee with individual coverage not covered.
21.Weight loss surgery of any kind not covered
22. Any claims submitted more than six months afterthe date of service will not
be covered.
23. As a church that values life and with a religious conviction against abortion, Avant does not cover abortions except in the case of a pregnancy where there are grave medical conditions which threaten the life of the mother
24. As a church and religious order that has moral purity code of conduct, Avant does not cover birth control for unmarried participants unless the birth control medication is prescribed for other medical conditions
H. Burial Aid Coverage
Dependent children are not covered under the life insurance program but are covered under the Avant Medical Aid Plan. The amount is $500 from birth to 6 months. $5000 from 6 months to age 23.
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I. Termination Provision
1. M.M.A.P. will provide coverage only through the date of termination and
cannot extend coverage to non-members after termination.
2. Retiree will be terminated under this plan on the effective date of
retirement. They will have option to transfer to supplemental coverage,
Plan #200, if they qualify according to the provisions in the policy manual.
J. How and When to Present a Claim
1.In the U.S. The Plan requires all members to use the network of providers
(Except in Alaska). When outside of network the plan pays 80% of full benefit. (DENTISTS are not in network!)
a.Inside K.C. area use providersthat participate withFreedom Network
Select.DO NOT PAY any medical bills out of pocket!
Please make sure all network providers bill the P.O. Box address foundon the back of your card.
b.Outside of K.C.areause providers that participate with Multiplan,
PHCSor Beech Street networks.DO NOT PAY any medical bills out of pocket!Please make sure all network providers send their bill to the P.O. Box address foundon the back of your card.
2. OverseasClaims must be filled in completely on the proper Avant claim form
found on the Website. Include all receipts pertaining to that individual’s
claim.Receipts need to accompany the claim forms submitted for payment. Please send in one document
a.The deductible and uncovered portion of a claim will be charged to the
missionary’s personal account. Claims that have been paid by themissionary will be reimbursed to his or her personal account unlessotherwise requested.
b.The physician’s signature is not required but itemized original bills must
be provided for expenses claimed (may send copies of original bills).
c.Provide all information requested on Medical Claim Form found on the website.All boxes must be completed!
d.TRANSLATION of receipts into ENGLISH IS REQUIRED. If they are printed as unreadable, please circle the date, name of patient and amount.
e. Use exchange rate in effect at the time the medical care was received.
Late Filing
You may file claims as often as you please, but no later than six months
after the date of service. Any claims submitted more than six months after
the date of service will not be covered.
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Subrogation provision
If the Plan pays a benefit which was the result of another party’s fault,
Avant expects, and you agree to permit recovery by the Plan against such
party at fault. Such recovery will be from any and all payments you or a
covered dependent may have received as compensation from such fault.
The right of recovery of the Plan must be honored notwithstanding the
manner or form of the actual settlement. The Plan Supervisor will not pay
any benefits until the covered person has fully cooperated by providing
information and executing documents. Specifically, the Plan Supervisor
may require, as a condition to the payment of any benefits, that any
covered person direct such person’s attorney in any legal action instituted
by such person to represent both interests of such person and the
interests of the Plan. The Plan reserves the right to appoint an attorney in
its own right as an alternative to its using such person’s attorney. FOR
EXAMPLE: If you broke your leg because of faulty front steps at A’s home,
or because of an auto accident where the other person, A, was at fault,
the cost of settling your leg would be paid by the Plan. However, the Plan,
in turn would expect recovery from the homeowner’s or automobile
policy issued to A. Acceptance of this booklet constitutes agreement on
your part to cooperate and to permit the Plan to fully recover the benefits
paid as a first priority obligation from any settlement you or your covered