Even as the Middle East has become a major business and tourist hub, U.S. companies that send executives to the area or hire local workers still express dissatisfaction with the insurance markets.

In response, U.S. carriers have begun partnering with local insurers in the region to expand coverage, and improve quality and efficiency of care for expats, local nationals and third-country nationals working the Middle East.

One example is UnitedHealthcare International, a UnitedHealth Group company that earlier this year joined forces with Dubai-based Al Sagr National Insurance Co. Through the alliance, they offer international insurance coverage to employers with employees in the Middle East.

"As [our client-] employers have globalized, they have asked us to globalize with them and provide modern health benefits with a focus on wellness and customer service," says Simon Stevens, executive vice president of UnitedHealth Group and president of its global health division.

Several large U.S. carriers have steadily expanded their international insurance programs for employers that required specialized global coverage for their expat assignees.

"With any outbound U.S. expatriate, in the vast majority of cases, regardless of where they're going to, the U.S. employer is going to set up a specialized expatriate plan. Normally, [U.S. companies] would insure these plans with the international division of a U.S. carrier, which maintains the U.S. compliance aspects that need to be considered and provides access to a large, well-established network back in the United States," says Peter Hindmarsh, president of Gold Circle Benefits, Inc.

Usually expatriate plans cover medical, dental, vision and pharmacy on a worldwide basis, and may also offer benefits such as life, accidental death and dismemberment, and disability insurance.

Most U.S.-based companies use the international offerings from a U.S. carrier because they prefer to comply with U.S. benefit laws. "Most employers stick to the most conservative route and make sure that their contracts comply with ERISA," says Hindmarsh. "[Employers] rarely use a local plan to cover expatriates in most host destinations, as these local plans are not U.S.-compliant. They also only provide local benefits, not worldwide coverage, and often local plans have lower levels of benefits than U.S. plans provide, and therefore they are less comprehensive than the U.S. expatriate expects."

UnitedHealthcare's new solution ensures expats receive the quality of care to which they are accustomed. Because individual countries in the region have their own regulatory systems, UnitedHealthcare and a few other U.S. carriers in the market can provide an umbrella plan that smoothes compliance issues no matter where the employee is traveling and needs care.

UnitedHealthcare's Global Solutions specifically serves members in the Kingdom of Saudi Arabia, the United Arab Emirates, the Hashemite Kingdom of Jordan, Qatar, the Sultanate of Oman, the Republic of Lebanon, the Kingdom of Bahrain, and Kuwait.

Instead of piecing together a patchwork quilt of offerings in different countries, coverage for U.S. multinational employees in the Middle East stays intact no matter where they are.

"Part of the reason we think this is such an important step forward is that it will provide more employers in the region a seamless offering [of coverage,] so that there will be a single customer experience instead of them having lots of different relationships in each of those markets," Stevens says.


Compliance changes within the Middle East

Historically, Middle Eastern countries were unconcerned that international insurance companies covered expats working in the region. However, as more third-country nationals entered the area to work, often as low-level contractors or laborers without local health care coverage, they began to put stress on state-run emergency care facilities because they didn't have adequate medical insurance.

In order to curb overutilization of emergency care, Abu Dhabi and Saudi Arabia have passed local laws mandating that anyone residing in their region must have a minimum level of insurance with a local insurer. Further, compulsory health insurance may soon become law throughout the United Arab Emirates.

Even though U.S. expats aren't necessarily the reason for these laws, they still may need a local insurer to be compliant. Thus, U.S. carriers have partnered with local insurance carriers to provide local insurance contracts within the same global benefit plan an expat expects.

"The partnering with local insurance carriers helps with service as well as compliance," says Hindmarsh.

U.S. expatriates gain access to local networks through a local carrier partnership, which helps smooth claim processing.

Although the legislation in the Middle East is relatively recent and not yet widespread, the international divisions of large U.S. carriers, such as Cigna and Aetna, have developed partnerships with local insurers for over five years.

"United Healthcare's Global Solutions product is a relatively new entrant to the U.S. expatriate benefits market. While the concept of partnering with local insurers is not something that's new in the industry, it is an important step for United Healthcare in developing a robust product to compete against Cigna, Aetna, MetLife, and the others," says Hindmarsh. The back office administration of these integrated products is also complex and UnitedHealthcare hopes the arrangement can streamline some of these procedures.

The UnitedHealthcare Global Solutions service provides fully integrated reporting with domestic benefits in the U.S. as well. Stevens explains that often expat employees will require U.S. care coverage if they have dependents back home or return for medical treatments.


Expats seeking 'best of the best'

While working abroad, U.S. expats in the Middle East generally have more comprehensive coverage than other local and third-country nationals, and usually seek easy access to care, as quality is not necessarily a problem.

If they need to visit a particular care facility, expats don't want to pay upfront and seek reimbursement. In various parts of the world, expatriate carriers have begun partnering with local insurers to allow expats to access local networks, or they have established direct arrangements with local hospitals/providers so they can arrange direct payment.

Ultimately, a local network becomes invaluable for expats if they can avoid all hassles and not have to pay out of pocket for care.

"This provides an integrated plan covering the whole of the region [with] single plan design, coverage options [and] wellness programs. It makes it much easier from a benefits administration point of view than one that has typically been available to people in the past," says Stevens.

Generally, the UnitedHealthcare coverage is employer sponsored and funded coverage, though there may be some cost sharing. If an employee falls ill while working abroad and is not receiving effective treatment, it could jeopardize the entire abroad project. Thus, it's important for key individuals to have complete coverage in international operating locations, says Stevens.

"On an expatriate assignment, it's considered one of the standard best practice items to provide international health care. I think there is an expectation [with an expat] that 'I'm going to be getting the best of the best,'" says Becky Woods, manager of client services at Expaticore Services LLC.

In addition to simplified pay structures, expats also want access to better facilities. While quality of care is developing rapidly in the Middle East, it's not yet at the same high level of care as in the United States. Expats often want recommendations of where to get care from their carriers.

These employees "are facing an uncertain environment where the quality of health care within the country [where they are working] varies dramatically. Any help with choosing the [care] provider or hospital would certainly be appreciated by an expat," Hindmarsh says.

By having a strong local partner, U.S. carriers can provide a deeper knowledge base for the status of care in the region, as well as how to smooth as many bumps as possible.


Wellness spreads around the world

Wellness programs for expats in the Middle East have evolved over recent years. However, "over the past three to four years they have developed more robust programs to take [an American] mentality on health care internationally," Hindmarsh says of carriers in the global health care market.

Generally, expats tend to be reactionary when seeking care and often will wait until their sick, he explains. However, some individuals with chronic conditions or who have dependents utilize the chronic disease management programs and wellness education.

"It's not as prevalent as in the U.S., but it is generally available to them passively. Employers are trying to encourage it and expand it over time," he adds.

Some carriers and employers are using technology to engage workers. Employees can find health information on their smartphones and tablets, as well as locate care facilities.

Technology such as mobile apps and comprehensive websites are rolling out in the area, says Hindmarsh, though they are not as robust as health technology in other parts of the world. All the carriers have websites and provide country guides that detail the quality of care in, and recommend providers for, specific countries.

Some carriers provide pharmacy translation tools for expats. For example, the expat could look up and communicate a generic drug substitute while speaking to a local pharmacist.

"At UnitedHealthcare International, we see U.S. and global employers increasingly wanting the same kind of sophistication for their international benefits that they see from companies like UnitedHealthcare domestically in the U.S. [They] recognize, of course, that all health care is local, and you have to tailor it for the specific circumstances in that country and for that population one is providing services for. The days are over when expat insurance was seen as a bolt-on, without the level of integration of technology, care coordination and prevention," Stevens says.


Expats head home

Expats in the majority of countries affected by unrest in the Middle East or the Eurozone crisis report seeing deterioration in the political, social and economic climate of the country they live in, according to the 2011 Expat Explorer Survey conducted by HSBC. Despite this, there is a divide between those who wish to relocate and those who want to stay in their country of residence.

Expats in Egypt (100%), Spain (97%), Bahrain (94%) and Italy (88%) all say that the economic situation is weak or has deteriorated. Among those who say this, those in Bahrain and Egypt are much more likely to be actively looking or considering relocating (57% and 53% respectively). In contrast, expats in the Eurozone are less likely to be looking or considering relocation (Italy 22% and Spain 21%) despite economic turmoil.

More than 3,385 expats from 100 countries responded to the survey.

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