How do I qualify for Off-Island Referral?
Coverage under NHI for off-island medical care are approved by the Medical Referral Committee and certified by the Healthcare Fund Administrator. A care that is approved for off-island referral means that Palau local hospital and clinics lacks the ability to provide adequate treatment.
Referral Process
- Primary physician determines that your care cannot be adequately treated in Palau and care must be done at an off-island tertiary facility.
- Primary physician presents referral case to the Medical Referral Committee for off-Island referral care.
- The Healthcare Fund Administrator reviews the case and approve or deny based on NHI off-island referral guidelines. Cases are reviewed according to the NHI schedule of benefits and Benefit Interpretations as approved by the Healthcare Fund Governing Committee. For more information on NHI Schedule of Benefits and Benefit Interpretations, click here
- All approved referral cases are forwarded to the Healthcare Fund Office for processing and determination of referral location (Taiwan or Philippines). Click here to see list of all approved medical providers off-island
- HCF Administrative Assistant will contact all approved referral patients for consultation and briefing of NHI guidelines and referral processes.
- Approved referral patients must pay 20% copayment, which is determined after receiving estimate cost treatment from off-island providers. Copayment is either 20% of the cost estimate or the maximum out of pocket expense (OOP) which is based on annual household income.
- Copayments are paid at the Social Security Administration Office. Patient will be given an invoice for copay collection.
- HCF Administrative Assistant to coordinate with Airline agent for booking to referral location (Taiwan or Philippines).
- For Taiwan, HCF will book airline tickets for both patient and escort with China Airlines. HCF will pay for the patient’s airfare expense and escort will self-pay airfare cost by providing a form from China Airlines to Bank of Guam for payment. China Airlines will confirm booking and advise HCF staffs.
- For Philippines, HCF will book airfare tickets for both patient and escort. HCF will purchase airfare expense for patient only. Family escort will self-pay airfare cost directly with United at local office.
- HCF Administrative Assistance to schedule final briefing for patient and escort a few days before departure to referral location. Click here for briefing guidelines
What about Airfare Coverage?
Airfare Travel Benefit:
For approved off-island referrals, NHI reimburses for the cost of one round-trip economy class airline ticket for the covered individual at the lowest published economy fare on the date of travel.
Airfare Travel benefit is covered for one member per benefit period, unless approved by Plan Administrator.
Transportation Benefits under NHI:
One round-trip economy class airline ticket for approved member.
Stretcher seats covered at the request of attending physician with written justification. Oxygen is covered only if medically necessary.
Medical Attendant covered only if medically necessary with written justification. NHI only covers for the cost of one medical attendant.
Family attendant covered only for a minor under age of 18. Coverage is for a parent or guardian who accompanies the minor at the time of medical evaluation. NHI only covers for the cost of one family attendant.
First Class/Business Class Airfare maybe purchased in lieu of stretcher or if at the time the only available fare to date.
What NHI does NOT cover:
Airfare benefit for referral follow up care, continuation of treatment, second opinion is not covered under the Plan.
Medical Repartriation of mortal remains from off-island referral site to primary residence.
Airfare benefit for any Preventive or Wellness Exam or if member is not traveling under NHI responsible for the amount by which the cost of the "First Class Ticket" exceeds the cost of the "economy fare ticket". Restriction may be waived if UR determines financially for HCF to purchase First Class/Business in lieu of more expensive option Stretcher seats, with approval of attending physician.
Airfare costs that were self-paid are not reimbursable under any circumstances.
