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The United States Department of State (USDoS) is pleased to welcome you to the Accident and Sickness Program for Exchanges (ASPE) Health Benefit Plan. As an Exchange Participant, you receive a limited health care benefit plan designed by USDoS and administered by Seven Corners, Inc. This plan IS NOT an insurance policy.
The ASPE is a self-funded, limited, health care benefit plan designed to pay covered medical expenses for eligible Exchange Participants. Covered medical expenses are subject to limitations, and pre-existing conditions are not covered.
This guide is an overview of the health care benefits you are provided while serving on your USDoS funded program. It also explains how payments are made for your covered medical expenses. It is your responsibility to read and under- stand what medical expenses are covered and not covered by the ASPE health care benefit plan. Life-threatening medical emergency Dial 911 from any telephone. Find a doctor or hospital Log on to www.usdos.sevencorners.com or call Customer Service toll free at 1 .800.461 .0430 Show Your ID Card to the provider This lets them know where to send your medical bills.
Questions about ASPE or medical bills Call Customer Service toll free at 1 .800.461 .0430, or send an email to Customer Service at [email protected] or go to Need a medical or prescription claim form Call Customer Service toll free at 1 .800.461 .0430 or download forms at www.usdos.sevencorners.com (One form is provided in the back of this guide) Contact Seven Corners toll free at 1 .800.461 .0430 ASPE requires all of its members (exchange participants) to pay a $15.00 co-pay for all office visits, ER, urgent care and hospitalizations. The provider will require the co-pay at the time of visit. As a reminder the co-pay amount will be pre-printed on your ASPE ID card.
Seven Corners must be contacted at 1 .800.461 .0430 to confirm coverage and benefits as soon as non-emergency hospitalization is within 48 hours of the first working day following an emergency admission when your physician recommends any surgery including outpatient prior to any treatment for dental pain Life-threatening medical emergency Contact your local emergency service or go to the nearest hospital. This lets them know where to send your medical bills.
Find a doctor or hospital Getting reimbursed for medical care Need a medical or prescription claim form Questions about ASPE or medical bills Easy way to contact Customer Service from outside the US 24/7/365 is by calling collect at +01 .317.818.2867, you will need assistance from the local operator to make this free call. You can also visit AT&T direct at to determine the AT&T toll free access code for your specific country. This code should be dialed followed by our toll free number 1 .800.461 .0430.
Contact Seven Corners collect at +01 .317.818.2867 C o - P a y ASPE requires all of its members (exchange participants) to pay a $15.00 co-pay for all office visits, ER, urgent care and hospitalizations. The provider will require the co-pay at the time of visit. As a reminder the co-pay amount will be pre-printed on your ASPE ID card.
Seven Corners must be contacted: to confirm coverage and benefits as soon as non-emergency hospitalization within 48 hours of the first working day following an emergency admission when your physician recommends any surgery including outpatient prior to any treatment for dental pain The USDoS health benefit program is administered by Seven Corners, Inc. As a specialist in claims and billing administration, you can be assured of quick and personalized service. Customer Service representatives are available to answer any questions you may have regarding the medical provider network, pharmacy program, medical bill payments or covered benefits.
Business Hours: 8:00 am to 6:00 pm Monday–Friday (Eastern Standard Time) (Only emergency phone calls will be answered after business hours) Call toll free: 1 .800.461 .0430 Seven Corners utilizes AT&T Direct for its toll-free 800 numbers. Virtually anywhere in the world you can dial an access code, and then dial 1 .800.461 .0430 and be connected to Seven Corners. For a complete listing of access codes please visit: Call collect: +01 .317.818.2867 outside the US Seven Corners can also be reached by contacting your local operator and placing an international collect call. Advise the operator you are calling collect to +01 .317.818.2867. All collect calls are accepted by Seven Corners.
Attn: Customer Service Carmel, IN 46082-3724 It's easy to access information about your health plan Once you log into www.usdos.sevencorners.com, through the Seven Corners' customized website designed you can select a special service called MyPlan, which especially for USDoS members. You can have instant access is an area where you can access secure information for to ASPE health care plan information anytime day or night.
you specifically. While this guide was meant to provide you with comprehen- 1. Claim Information—If you have a question about sive information about your benefit plan, you should always whether a claim has been paid to a provider or refer to the website for the most up to date information if Seven Corners has received your claim for reim- bursement to you, you can log in and find all of the medical service bills received by Seven Corners The USDoS customized website is located at: and the status of payment of those bills.
2. Eligibility Information—If you are interested to see when you might have had breaks in coverage or Access a list of all doctors and hospitals in the dates you are eligible for coverage. the Medical Provider Network 3. Printable ID cards—If you misplace the ID card Access a list of pharmacies in the Pharmacy Network provided to you, you can download a temporary Download necessary forms for pharmacy and ID card that has your personal information on it. medical claim reimbursement 4. Secure Customer Service email—you can send an View a list of frequently asked questions regarding email and attach any information you have questions on that you received or viewed on MyPlan. This is Access this benefit guide electronically a secure and encrypted email connection. Review a glossary of medical terms Because you are viewing personal health information Access MyPlan. A password secure area where you through MyPlan, a username and password are required. can get personal and private health care information It is easy to activate a MyPlan account, simply follow the specifically for you.
steps on the website.
Click on the "Setup New Account" link Enter your MyPlan ID (ID card number) and PIN Number (first time login—use your date of birth) Once your MyPlan ID and PIN Number have been confirmed, you will be instructed to pick a username and password that you will enter every time you want to login to MyPlan (see general login screen). The username and password will now be your key to enter the MyPlan site.
Remember to bookmark the MyPlan login page for future ease of use. On the effective date of the grant as printed on If your medical condition requires you to return to your your ID card.
home country, your ASPE health benefits will terminate upon arrival. If the grant is reinstated because your health permits the return to the host country, then ASPE health benefits will On the last date of your grant as printed on your ID card. also be reinstated upon departure from your home for the country of assignment.
Only you (the grantee) are covered under the ASPE health care benefit plan. ASPE does not cover dependents Example: If you are a US citizen and your host country is (spouses or children).
France you are covered by ASPE for the dates on your ID card (the dates of your grant). If you decide to go on personal leave from your host country (France) and go to Egypt for a vacation you are in your home country or country of you are not covered by ASPE. In addition if you become ill or regular domicile; have an accident while on personal leave, and then return to you are on personal leave; your host country, your accident or illness will be considered you travel outside the country of assignment a pre-existing condition and will not be covered by ASPE.
without pre-approval from USDoS; During extended stopovers en route to or from Example: If you are on a grant in the United States and your country of assignment; or decide to vacation or holiday in Canada or Mexico, or any During orientations in your home country.
other country outside the United States you are not covered by ASPE. If you become ill or have an accident while outside the United States and then return to finish your grant, your accident or illness will be considered a pre-existing condition and will not be covered by ASPE.
If you are not located in the system at Seven Corners, contact your Program Agency. As an Exchange Participant enrolled in the ASPE health Accident and Sickness Program for Exchanges benefit plan, you will receive an identification card to be used $15.00 co-pay for office visits* as proof of health care benefits when you need services. Simply show your identification card to the hospital or doctor at the time of service. You should carry your ASPE identification card with you at all times while you on your grant. Whether you are inside or outside the United States the ASPE ID card provides important information in case you need emergency treatment.
In addition, the ASPE ID card includes the address providers need to file medical bills for payment.
If you have not received an ID card please contact your program agency before contacting Seven Corners. In the US the identification card is also your prescription drug card for use when filling prescriptions. You will need to show this card at the pharmacy, so carry it with you at all If your ID card is lost or misplaced, you can obtain a temporary ID card immediately to ensure no disruption in service. Call toll free: 1.800.461 .0430 Call collect: +01.317.818.2867 outside the US Go online at www.usdos.sevencorners.com and Or write to: ASPE Health Benefits Attn: Customer Service Carmel, IN 46082-3724 You are responsible for a $15.00 co-pay for all office All covered expenses incurred as a result of the same or visits, ER, urgent care, and hospitalizations. The provider related cause (including complications) shall be considered will require the co-pay at the time of visit. As a reminder the as resulting from one Injury or Sickness. To be sure medical co-pay amount will be pre-printed on your ASPE ID card. services are covered, Seven Corners must be contacted: The maximum amount you will pay in co-pays is $500.00 to confirm coverage and benefits; per benefit year. If during your grant period you reach that as soon as non-emergency hospitalization amount, you will be refunded any co-pays in excess of $500.00 once you submit your receipts as proof of payment.
within 48 hours of the first working day following ASPE will cover the remaining expenses at 100% up an emergency admission; to your Policy Maximum if the medical condition is not when your physician recommends any surgery including outpatient; If you use a provider outside the Medical Network, prior to any emergency treatment for dental pain, or; you may have to pay additional charges if the Provider bills for emergency evacuation, repatriation and more than the Usual, Customary, and Reasonable Rate. (See glossary for further explanation) In the U.S. call: 1 .800.461 .0430 Outside the U.S. call collect: +01 .317.818.2867 $50,000 or $100,000 depending on your exchange The ASPE health benefit plan will pay 100% of all Covered Expenses listed below in the Schedule of Benefits. Payment will not exceed the Maximum Benefit limit shown on the Paid by USDoS at 100%, up to $10,000 Schedule of Benefits. Paid by USDoS at 100%, up to the amount approved by 1. it does not exceed your program's Maximum Benefit; USDoS after medical review.
2. you have been continuously covered under the ASPE benefit plan; 3. the sickness or injury occurred in your assigned You are responsible for a $15.00 co-pay per office host country, or; visit, ER, urgent care and hospitalization. 4. it is a covered service.
When an Exchange Participant ends their program, treat- Hospital Room and Board Charges—Payment will be lim- ment for a covered Injury or Sickness is covered up to one ited to the hospital's normal charge for semi-private calendar year from the date of onset. This coverage does not apply to Acupuncture, Chiropractic, Massage Therapy or Maternity care—-those benefits terminate at the end of the Home Health and Skilled Nursing Services—Covered if enrollment period regardless of other conditions of this the medical condition is not pre-existing and the cost of the policy. Covered Expenses are subject to the pre-existing service is less than an inpatient stay.
Laboratory Tests and X-rays—Covered if recommended Accident or Injuries—Including to mouth and teeth are and performed by a licensed provider for diagnostic purposes covered under medical benefits. due to symptoms, illness or injury.
Acupuncture—When prescribed and performed by a Massage Therapy—when prescribed by a licensed physician or physical therapist to treat a covered injury or physician or chiropractor and performed by a state licensed sickness. Limited to 25 visits per benefit year. Acupuncture massage therapist. Limited to 6 visits per benefit year, benefits terminate at the end of the enrollment period massage therapy benefits terminate at the end of enrollment regardless of other conditions of this policy.
period regardless of other conditions of this policy.
Ambulance—Professional ambulance service.
Maternity—Medical expenses for maternity care, includ- ing childbirth. Maternity benefits terminate at the end of the Chemotherapy and Radiation Therapy—Services for enrollment period regardless of other conditions of this policy.
medical conditions. In addition to the medical expenses for maternity care for the Exchange Participant, the medical expenses of the child Chiropractic—Care is limited to 25 visits per benefit year.
newly born during the grant period are covered for the first Chiropractic benefits terminate at the end of the enrollment 31 days up to the assigned maximum benefit. For coverage period regardless of other conditions of this policy.
beyond the 31-day period, an Exchange Participant must obtain commercial health insurance coverage for the new- Diagnostic Care—Fees for diagnosis and treatment by born dependent at personal expense. The ASPE health a physician, surgeon, registered nurse, professional anes- benefit plan does not pay the expenses of a newborn to a thetist, including physical therapy related to a covered Injury dependent of an Exchange Participant. The Exchange Partici- pant is advised to obtain commercial insurance to cover ma- ternity care of the dependent and dependent's newborn. Durable Medical Equipment (DME)—Rental charge for Durable Medical Equipment, or the purchase of this equipment, Medevacs Outside of the US—Contact Customer Service whichever is less. Prostheses and Orthopedic Appliances are collect at +01 .317.818.2867 to arrange transportation and covered only if required as the result of an accident. If pros- medical care as well as pre-approval. If pre-approval is not thesis or an orthopedic appliance is required for a condition obtained through Customer Service and transportation and that is not pre-existing, coverage determination will be made coordination of care is not provided through Seven Corners, by USDoS on a case-by-case basis. Supporting documentation travel services will not be covered. must be forwarded to Seven Corners for review. The ASPE program will pay the actual expense incurred as Prescription Drugs—When prescribed by a licensed a result of a covered Injury or Sickness for medical evacuation physician. Refer to Prescription Drug Program section of of Covered Person, including physician or nurse accompaniment this guide and/or the website for more information. to the nearest suitable medical facility. This evacuation will be paid only upon USDoS/Seven Corners approval.
Repatriation of Mortal Remains—In the event of a cov- ered Exchange Participant's death, the ASPE health benefit Men's Health Benefits—Are covered after completing plan will pay for actual charges incurred up to the Maximum six months of eligibility, for men 50 and older one (1) annual limit of $10,000.00 for services related to the preparation prostate exam including a PSA.
and transportation of the body. This benefit does not include the transportation expenses of anyone accompanying the Mental or Nervous Disorders—Treatment of Mental and body or any personal effects. Seven Corners should be Nervous conditions are payable subject to the following contacted in the event of a grantee's death.
Inpatient Care: Lifetime maximum benefit is thirty (30) Utilization Management Program—The health benefit days of hospital confinement; plan includes a utilization management program to review Outpatient Care: Lifetime Maximum benefit is thirty the Exchange Participant's medical care to identify conditions (30) visits. Outpatient Mental or Nervous benefits that may adversely affect their completion of an exchange terminate at the end of the enrollment period program. The ASPE utilization management program is regardless of other conditions of this policy.
administered by Registered Nurses and Board Certified Authorized providers of care: A licensed physician, Physicians and is focused on Individual case management licensed clinical psychologist or a master of social of potentially catastrophic cases.
work (MSW) may provide services that are medically necessary for mental and nervous disorders.
Women's Health Benefits—Covered after completing six months of eligibility for women 18 and older one (1) annual Physical Therapy—Services provided by a licensed GYN health exam per benefit year that includes one (1) pelvic physician or a licensed physical therapist when prescribed examination, Pap smear, breast examination and lab work by a physician or chiropractor and directly related to the related to ONLY GYN health when performed at the time of complications associated with a covered Injury or Sickness annual GYN exam. If follow-up diagnostic Pap smears are incurred during the period of coverage.
medically necessary, they will be covered. Contraceptive management and HPV vaccinations are covered only when Physiotherapy—A physical or mechanical therapy, performed at the annual GYN health visit. In addition one (1) diathermy, ultrasonic, a heat treatment in any form, baseline mammogram for women 35 and older and one (1) manipulation or massage, when ordered by a licensed annual mammogram for women 40 and over; one (1) Bone physician or chiropractor. (See massage therapy benefit Mineral Density (BMD) screening test for all women over age on page 10). 65, estrogen deficient women and women at clinical risk for osteoporosis when performed as part of the annual GYN exam. A repeat BMD test is covered every two years.
Pre-existing Conditions are not covered. You are urged Chiropractic—This program does not cover chiropractic to retain or obtain your own health insurance to cover services before or after the enrollment period.
ongoing or potential medical requirements relating to Claim Submission—After 1 year from date of service.
Congenital Anomalies—Treatment of congenital anomalies, and the conditions arising or resulting directly As stated throughout the guide, the ASPE Benefit Plan does not cover pre-existing conditions. A pre-existing condition is any condition which: Contraceptive Injections a. originated prior to your effective date of coverage; b. you received consultation from a physician about— Cosmetic Surgery—Expenses incurred for elective plastic prior to your effective date of coverage; or cosmetic surgery. Plastic surgery is only covered if service c. you received treatment or medication for—prior to is a direct result of a covered Injury that necessitated medical your effective date of coverage; or treatment within 24 hours of the accident.
d. would have caused any prudent person to seek medical advice or treatment, prior to your effective Dental—No dental services are covered. Only treatment for date of coverage.
emergency alleviation of pain will be paid, in which case dental treatment shall be limited to $1,000 per benefit year.
Note: ASPE does not define pregnancy as a pre- existing condition. Dependents—Coverage for accompanying spouses and dependent children must be purchased separately.
Other Services/Expenses in addition to pre-existing conditions that are not covered include the following: Expenses incurred for the treatment of an Injury or Sickness more than one calendar year after the time of Abortion—A surgical procedure used for the purpose the Injury or onset of the Sickness.
of birth control and/or an elective termination of pregnancy.
Expenses incurred within your home country or country Acupuncture—This program does not cover acupuncture of regular domicile, unless: before or after the enrollment period.
it is necessary and authorized treatment received after the individual has proven Sickness or Injury in the country Alcohol, Drug Abuse or Detoxification Treatment— of assignment; or is related to a pre-approved medevac, Expenses incurred resulting from the use of alcohol or and which would have otherwise been covered had the intoxicants, or any illicit drugs or abused drugs by the expenses occurred in the country of assignment.
Exchange Participant, (abused drugs include prescription drugs that may be used illicitly); expenses incurred due Expenses in excess of Usual, Customary and Reason- to substance abuse treatment.
able Charges (UCR).
Experimental Procedures—Services or supplies which Maternity—This program does not cover maternity are experimental or investigative in nature; including any before or after the eligibility period.
treatment, procedure, facility, equipment, drugs, drug use, devices, or supplies that are not recognized as accepted Newborn Expenses for coverage beyond the 31-day medical practice; and any such items that require federal period—For coverage beyond the 31-day period an Exchange or other governmental agency approval not received at the Participant must obtain commercial health insurance cover- time services were rendered.
age for the newborn dependent at their personal expense.
The ASPE Health Benefit Plan does not pay the expenses Eyes—Services in connection with eye examination, of a child newly born to a dependent of an Exchange eyeglasses or contact lenses except as required for repair Participant. The Exchange Participant is advised to obtain caused by a covered Injury limited to $300 maximum.
commercial insurance to cover maternity care of the dependent and dependent's newborn.
Feet—Expenses incurred in connection with weak, strained or flat feet, corns, calluses or toenails, shoes and Non-Medically Necessary Services and Supplies— other supportive devices for the feet. This does not apply The diagnosis or treatment of a covered Sickness or Injury, to infections of the toenails or feet and does not apply to of which are not recommended by an attending physician.
casts, splints or braces for treatment of injuries.
Nasal—Surgical correction of deviated nasal septum, Hearing—Services in connection with hearing aids, including submucosal resection.
except as required for repair or equivalent replacement when caused by a covered injury.
Perilous Activity— 1. Flying, except: a. as a passenger on a regularly scheduled airline; b. as a passenger on a chartered carrier for pur- poses of an approved grant program activity; c. as a passenger in the Military Airlift Command Infertility—Expenses incurred for services related to the of the US or similar air transport services of diagnostic treatment of infertility or other problems related other countries.
to the inability to conceive a child, unless such infertility is a 2. Playing, practicing, or participating in intercollegiate, result of a covered Injury or Sickness.
club (professionally organized) or professional sports, or during travel for such purposes, e.g. skateboarding, Injury or Sickness sustained or contracted during any snowboarding, BMX racing, X-games (extreme sports). period of unofficial travel outside the country of assignment.
If your participation in a professional sports event is part of your grant the perilous activity clause does 3. Operation of a vehicle while not properly licensed to Sexual Transformations, Sexual Impairment or do so or riding in a noncommercial vehicle operated Sexual Inadequacy Treatment by a person not licensed to do so in the jurisdiction in which the accident takes place.
Transportation—Expenses incurred for taxicabs or other 4. Operation of a vehicle while under the influence of transportation to and from the doctor's office or other place drugs or alcohol.
of treatment, except if an approved medical evacuation 5. Dangerous activity not directly related to the fulfill- ment of grant objectives, e.g. bungee jumping, scuba diving, skydiving, rock climbing (indoor/ Temporomandibularjoint Disease (TMJ)—Medical or outdoor), hang gliding, operation of an all terrain dental services or supplies for the treatment of TMJ.
vehicle (ATV) or motocross bike. If your grant requires that you travel to areas Vaccinations except those pre-approved. Contact Seven requiring an ATV or snowmobile then item 5 Corners for information.
does not apply. War—Loss due to war, declared or undeclared, while in Personal Comfort Items—Any personal comfort item the service in the Armed Forces of any country. (purchased or rented) such as a dehumidifier, humidifier, air cleaner.
Weight Loss Programs including Gastric Bypass and/or Political Demonstration—Injuries due to participating in any demonstrations against the government of your host Workers Compensation—Expenses covered under any country while you are on an ECA grant in your host country.
occupational benefit plan, Workers Compensation Act or similar law, automobile medical payment or no-fault plans, Professional Medical Services—Rendered by a member public assistance programs, government plan, any other of the Exchange Participant's immediate family or anyone valid/collectible group insurance, or any primary insurance.
who lives with the Exchange Participant.
ASPE will pay medical expenses not paid by such primary insurance due to application of deductibles or limitations Routine Physical or Health Examinations—"Routine on benefits, provided that such expenses would otherwise exams" include but are not limited to health exams for be covered by the provisions of this Program.
school, immunizations, vaccinations, etc.
Services or Supplies—For any Injury or Sickness received prior to the Exchange Participant's effective date under the ASPE health benefit plan, or which are not actually incurred while this Program is in force.
ASPE health care benefit plan contains a Medical Provider To locate a provider or hospital in the USDoS Medical Network inside the US. A Medical Provider Network is a net- Provider Network: work, or group, of doctors and hospitals that have entered Go to www.usdos.sevencorners.com and select the into an agreement with Seven Corners to accept discounted tab marked medical provider. fees for medical services. The Medical Provider Network is a Perferred Provider Network (PPO). Claims for services The website will provide you with the most up to date provided by a Preferred Provider are mailed directly to Seven information about Medical Network Providers in your area. Corners at the address on the back of your identification card.
If you do not have access to the Internet or want to discuss If you receive your medical services from one of the your provider choice with Customer Services, you can call doctors and hospitals in the Medical Provider Network your customer service toll free in the US at 1.800.461 .0430.
benefits will be paid at the negotiated provider contracted Do not wait to find a provider for Emergency Care. rate if they are a covered benefit. Also, if you use a provider Go straight to the nearest ER. Emergency care is defined in the Medical Provider Network the provider can not bill you by Seven Corners as a need for hospitalization, trauma for any covered benefits except the $15.00 co-pay for office (i.e., broken bones, accidents), acute and spontaneous visits, ER, urgent care or hospitalizations.
non-controllable pain, blurry vision, intense headache, chest pain, shortness of breath, unmanageable high fever, open wounds, or any life-threatening situation. If you do not receive care from a provider in the Medical If you have a life-threatening emergency, please call Provider Network, benefits will be paid at standard Usual, your local emergency service or go to the nearest hospital. Customary and Reasonable Charges (UCR) for the area in which If you are unsure where the nearest hospital is located, care was delivered if they are a covered benefit. If the provider Seven Corners staff can assist.
bills more than UCR, you will be responsible for any charges over and above the UCR, as non-preferred providers are not under negotiated contracted rates.
If you pay for your medical services out-of-pocket or are billed at the time of service you will need to submit a claim for payment or reimbursement. (See page 30, Payment of Medical If your home address is over 35 miles from the nearest Claims) for more information.
medical network provider, you are exempt from the provider network guideline. You are free to see any provider of your choice. You will need to call Seven Corners Customer Service to coordinate this exemption.
Using a Medical Provider Network means lower out-of-pocket expense for you. In the US, for all States except New York and New Jersey In New York and New Jersey when you call a doctor's and Utah when you call a doctor's office for an appointment office for an appointment or present your ID card to a or present your ID card to a provider, it is important for you provider, it is important for you to say: "My healthcare coverage utilizes the Beechstreet "My healthcare coverage utilizes the ChoiceCare PPO PPO Network. Are you a Beechstreet Provider?" Network. Are you a ChoiceCare Provider?" Exchange participants on grants outside the US may If a provider has not agreed to participate in the Seven go to any provider they want. Seven Corners offers a Medical Corners network, Seven Corners will still attempt to negotiate Network outside of the US but the non-US Medical Network a direct pay or guarantee of payment agreement with the work slightly different than the US Medical Networks. provider so you will not have to incur all of the out-of-pocket Non US doctors and hospitals are contracted to provide expenses at the time care is received.
access to USDoS participants based on payment of Usual and Customary Rates for Local Nationals. Seven Corners has To locate a provider or hospital in the USDoS Non-US built Usual and Customary Rate tables for specific regions Medical Network: outside of the United States. There are two types of Non US Call toll free: 1.800.461 .0430 (see page 4) Medical Network Providers which are defined below: Call collect: +01.317.818.2867 outside the US Direct Pay Providers—Direct Pay Contracted Providers Emergency—In the case of an emergency during which are defined as providers that Seven Corners has reviewed the member is outside the United States our Assistance and determined that the provider meets all the necessary Department should be contacted immediately. We ask that requirements for quality care based on their country licens- you gather as many details as possible for our Assistance ing authority. Additionally, these providers have agreed to staff during this call. Our office can be reached 24/7/365 a payment fee schedule which is not more than the rates days a year by calling 1.800.461 .0430 or collect local nationals pay and they have agreed to accept payment +01.317.818.2867. You may dial this number direct directly from Seven Corners without billing the participant or you may contact your local operator and request to first. Participants may not be required to pay out of pocket make a collect call to this line. The caller may also visit: when accessing these providers for covered services. Seven Corners wire transfers payment to provider's bank to determine the AT&T toll-free access code for your specific account in the currency of the providers' choice or can mail country. This code should be dialed followed by our toll-free the provider a check.
number, 1.800.461 .0430. Emergency care overseas is defined by Seven Corners Referral Provider—Referral Providers are defined as as a need for hospitalization, trauma (i.e., broken bones, providers that Seven Corners has reviewed and has deter- accidents), acute and spontaneous non-controllable pain, mined the provider meets all the necessary requirements blurry vision, intense headache, chest pain, shortness of for quality care based on their country licensing authority.
breath, unmanageable high fever, open wounds, or any Seven Corners has loaded these providers in a database, life-threatening situation. and has sent them information on joining the Seven Corners Seven Corners is available to support you with an emer- Direct Pay Network, but they have not yet agreed to join the gency number and guide you to a Direct Pay or Referral Provider, Direct Pay usually due to lack of large numbers of participants but clearly we want you to seek immediate care at the nearest in their area. As participant numbers in the area grow or facility. In emergency situations where care is needed imme- providers are accessed, Seven Corners continues negotia- diately, you are not required to call Seven Corners.
tions with those providers in an attempt to move them into If you have a life-threatening emergency, please call our Direct Pay Contracted Provider list. your local emergency service or go to the nearest hospital.
If you pay for prescription drugs out of your pocket, you can complete the Prescription Reimbursement Standard A copy of this form is provided in the back of this guide, and additional forms are available through one of the following ways: The integration of CVS/Pharmacare and Caremark combines Go to www.usdos.sevencorners.com and download our services into one organization, CVS Caremark. Although the Prescription Reimbursement Standard Claim Form the name has changed, you still have access to all prior Call Customer Service: 1 .800.461 .0430 features utilized. Present your ID card to have your prescriptions filled.
The ASPE benefit plan provides a US paid prescription drug program with a Pharmacy Network to be used in combi- Your health care plan requires that all maintenance nation with your health benefits. Through the nationwide medications or medications taken on an ongoing basis must Pharmacy Network community and chain pharmacies, and the be purchased though the Direct Mail Service.
mail service pharmacy option, you have the broadest choice of Direct Mail Service provides a convenient way for you to pharmacies to choose from to satisfy your prescription drug have your medication delivered right to your home or office.
Mail Service should be the first choice for people using main- Your identification card contains all the information that tenance medications. These are medications taken on an your pharmacist needs. Simply present your ID card to have ongoing basis such as asthma, heart and cardiovascular your prescriptions filled at any one of the Pharmacy Network conditions, diabetes, and oral contraceptive medications.
providers in your area. The pharmacy will then electronically With the Mail Service Pharmacy, you are authorized a 90-day transmit a claim for that medication and within minutes have supply of your medications each time it is refilled.
approval for filling the prescription. To start using Direct Mail Service you'll need a prescrip- The Pharmacy Network includes over 60,000 pharmacy tion from your doctor for the medication. Ask your doctor to locations nationwide. authorize a 90-day supply and four refills. Be sure to also obtain a prescription for an initial fill at your local pharmacy if you need to use the medication right away or don't have Go to www.usdos.sevencorners.com or go directly existing supplies of your medications. to www.pharmacare.com Call Pharmacy Member Services at 1.800.777.1023.
Confidential Mail Service Enrollment Form is provided In the unlikely event that a pharmacy in your area is in the back of this guide, and additional forms are available not part of our Pharmacy Network then please ask your through one of the following ways: pharmacist to request a participation agreement by calling Go to www.usdos.sevencorners.com to download PharmaCare's Network Service Department at the Confidential Mail Service Enrollment Form 1.800.237.6184 ext. 7555.
Go to www.pharmacare.com, select direct mail service and enroll online Call Customer Service: 1.800.461 .0430 Carrs Quality Centers Costco Pharmacies Leader Drug Stores Costco Pharmacies CuraScript Pharmacy Costco Pharmacies Gemmel Pharmacy Group Leader Drug Stores Hi-School Pharmacy Fry's Food & Drug Horton & Converse Leader Drug Stores Leader Drug Stores Medicap Pharmacies Medicap Pharmacies Publix Super Markets Payless Drug Stores NeighborCare Pharmacies PharmaCare Specialty Pharmacy Payless Drug Stores PharmaCare Specialty Pharmacy Smith's Food & Drug Raleys Drug Center Ralph's Pharmacies TrueCare Pharmacy Save Mart Supermarkets Brookshire Grocery Co.
Scolari's Food & Drug Co.
Harp's Food Stores Leader Drug Stores Medicap Pharmacies Costco Pharmacies Columbus Health Services Pharmacy Providers Costco Pharmacies Leader Drug Stores NeighborCare Pharmacies TrueCare Pharmacy Payless Drug Stores Leader Drug Stores PharmaCare Specialty Pharmacy Medicap Pharmacies Valu Merchandisers/ PharmaCare Specialty Pharmacy SafeScript Pharmacy SUPERVALU Pharmacies The Pay-Less Pharmacy Group Winn Dixie Stores Medicap Pharmacies Payless Drug Stores Costco Pharmacies Food Lion Pharmacy Harris Teeter Pharmacy Kash N Karry Food Stores Leader Drug Stores Leader Drug Stores Smith's Food & Drug Medicap Pharmacies Yoke's Washington Foods Navarro Discount Pharmacies NeighborCare Pharmacies NeighborCare Pharmacies Pavilion Plaza Pharmacies PharmaCare Specialty Pharmacy Carle Rx Express Pharmacy ShopRite Pharmacy Sedano's Pharmacies Costco Pharmacies TrueCare Pharmacy Winn Dixie Stores Dierberg Family Markets Dominick's Finer Foods BJ's Wholesale Club BJ's Wholesale Club Columbus Health Services Costco Pharmacies Costco Pharmacies Giant of Maryland Leader Drug Stores Food Lion Pharmacy Leader Drug Stores Medicap Pharmacies ShopRite Pharmacy J.H. Harvey Co.
Leader Drug Stores Mercy Health System Medicap Pharmacies Nash Finch Company PharmaCare Specialty Pharmacy NeighborCare Pharmacies Leader Drug Stores Winn Dixie Stores PharmaCare Specialty Pharmacy PharmaCare Specialty Pharmacy Rinderer's Drug Stores Costco Pharmacies Schnucks Pharmacy BJ's Wholesale Club PharmaCare Specialty Pharmacy SUPERVALU Pharmacies Costco Pharmacies TrueCare Pharmacy CuraScript Pharmacy Valu Merchandisers/ Costco Pharmacies Leader Drug Stores Costco Pharmacies Leader Drug Stores Dillon's Pharmacy Medicap Pharmacies Costco Pharmacies SafeScript Pharmacy Leader Drug Stores Thrifty Drug Stores Medicap Pharmacies TrueCare Pharmacy Winn Dixie Stores Leader Drug Stores NeighborCare Pharmacies Martin's Super Markets PharmaCare Specialty Pharmacy Medicap Pharmacies Pharmacy Providers of Oklahoma Community Pharmacies Hannaford Brothers NeighborCare Pharmacies Price Chopper/Hen House Leader Drug Stores TrueCare Pharmacy Pharma-Card Mgmt. Services Valu Merchandisers/ Schnucks Pharmacy SUPERVALU Pharmacies TrueCare Pharmacy BJ's Wholesale Club Costco Pharmacies Food City Pharmacies Costco Pharmacies Leader Drug Stores Food Lion Pharmacy NeighborCare Pharmacies Giant Food Stores Keystone Med-Chest Payless Drug Stores Leader Drug Stores Leader Drug Stores Medicap Pharmacies SUPERVALU Pharmacies Medicap Pharmacies Nash Finch Company TrueCare Pharmacy NeighborCare Pharmacies NeighborCare Pharmacies PharmaCare Specialty Pharmacy Pharmacy Express Services Schnucks Pharmacy Brookshire Brothers Pharmacy Shoppers Pharmacy Brookshire Grocery Co.
Twin Knolls Pharmacy Stewart Memorial Wegmans Food Markets Community Hospital Thrifty Drug Stores TrueCare Pharmacy Baystate Pharmacy Pharmacy Providers BJ's Wholesale Club Wayne-Oakland Pharmacy Management Costco Pharmacies Price Chopper/Hen House Allina Community Pharmacies Rinderer's Drug Stores Schnucks Pharmacy SunScript Pharmacy Hannaford Brothers Costco Pharmacies Leader Drug Stores SUPERVALU Pharmacies Louis & Clark Drug Fairview Pharmacy Services TrueCare Pharmacy NeighborCare Pharmacies Unity Retail Pharmacies PharmaCare Specialty Pharmacy Healtheast Pharmacies Univeristy Health System Pharmacies Leader Drug Stores Valu Merchandisers/ Sedell's Pharmacy Medicap Pharmacies Nash Finch Company Park Nicolett Pharmacies Brookshire Grocery Co.
PharmaCare Specialty Pharmacy Costco Pharmacies D & W Food Centers Snyder's Drug Stores SUPERVALU Pharmacies Leader Drug Stores Thrifty Drug Stores Medicap Pharmacies Felpausch Pharmacy Weber & Judd Kahler Henry Ford Health System Pharmacies SafeScript Pharmacy Schnucks Pharmacy Leader Drug Stores Costco Pharmacies TrueCare Pharmacy Martin's Super Markets Dierberg Family Markets Medicap Pharmacies Dillon's Pharmacy Winn Dixie Stores NeighborCare Pharmacies Leader Drug Stores May's Drug Stores Costco Pharmacies Medicap Pharmacies Leader Drug Stores Nash Finch Company Professional Village Pharmacy Sav-Mor Drug Stores NeighborCare Pharmacies BJ's Wholesale Club Raleys Drug Center Costco Pharmacies Smith's Food & Drug Smith's Food & Drug SunScript Pharmacy Snyder's Drug Stores TrueCare Pharmacy Thrifty Drug Stores Hannaford Brothers Leader Drug Stores P & C Food Market Buffalo Pharmacies CuraScript Pharmacy Costco Pharmacies Dillon's Pharmacy CuraScript Pharmacy Drug World Pharmacies Keystone Med-Chest Kohll's Pharmacy & Homecare BJ's Wholesale Club Leader Drug Stores Costco Pharmacies Gristedes Pharmacy Medicap Pharmacies Nash Finch Company Hannaford Brothers NeighborCare Pharmacies King Kullen Pharmacies Corp.
Pharmacy Express Services Leader Drug Stores Giant Food Stores Maxor National Pharmacy Medicap Pharmacies TrueCare Pharmacy Leader Drug Stores Memorial Sloan Kettering Medicap Pharmacies Valu Merchandisers/ NeighborCare Pharmacies NeighborCare Pharmacies P & C Food Market Quick Chek Food Stores PharmaCare Specialty Pharmacy Costco Pharmacies ShopRite Pharmacy Leader Drug Stores Wegmans Food Markets Payless Drug Stores ShopRite Pharmacy Raleys Drug Center Ralph's Pharmacies Wayne Drug Co.
Scolari's Food & Drug Co.
Costco Pharmacies Wegmans Food Markets Leader Drug Stores Smith's Food & Drug Medicap Pharmacies NeighborCare Pharmacies Costco Pharmacies BJ's Wholesale Club Risch Drug Stores Costco Pharmacies Farm Fresh Pharmacy Ritzman Pharmacies CuraScript Pharmacy Food Lion Pharmacy Riverside - Div of Penn Traffic Harris Teeter Pharmacy Sav-Mor Drug Stores SUPERVALU Pharmacies Leader Drug Stores Giant Food Stores Medicap Pharmacies Greco Enterprises NeighborCare Pharmacies PharmaCare Specialty Pharmacy Klingensmith's Drug Stores Harp's Food Stores Leader Drug Stores Med-Fast Pharmacy Leader Drug Stores Medicap Pharmacies Harris Teeter Pharmacy May's Drug Stores Leader Drug Stores Medicap Pharmacies NeighborCare Pharmacies Medicap Pharmacies Med-X Corporation/Drug Mart Thrifty Drug Stores PharmaCare Specialty Pharmacy NeighborCare Pharmacies Pharmacy Providers TrueCare Pharmacy Riverside - Div of Penn Traffic Valu Merchandisers/ Anchor Pharmacies ShopRite Pharmacy Buehler Pharmacies SUPERVALU Pharmacies Costco Pharmacies Discount Drug Mart Bi-Mart Corporation Wegmans Food Markets Costco Pharmacies Fitzgerald's Pharmacy (F & F Pharmacies) Costco Pharmacies Hi-School Pharmacy Leader Drug Stores Leader Drug Stores Medicap Pharmacies Medicap Pharmacies NeighborCare Pharmacies NeighborCare Pharmacies Payless Drug Stores PharmaCare Specialty Pharmacy PharmaCare Specialty Pharmacy Quality Food Centers PharmaCare Specialty Pharmacy Costco Pharmacies Costco Pharmacies Schnucks Pharmacy Food Lion Pharmacy The Pay-Less Pharmacy Group Intermountain Health Care TrueCare Pharmacy Leader Drug Stores Harris Teeter Pharmacy Payless Drug Stores Smith's Food & Drug Leader Drug Stores Brookshire Brothers Pharmacy Medicap Pharmacies Brookshire Grocery Co.
Costco Pharmacies NeighborCare Pharmacies CuraScript Pharmacy Costco Pharmacies PharmaCare Specialty Pharmacy Piggly Wiggly/Price Wise Kelsey-Seybold Pharmacy Hannaford Brothers Leader Drug Stores Leader Drug Stores Market Basket Pharmacies Maxor National Pharmacy Leader Drug Stores Medicap Pharmacies Medicap Pharmacies Minyard & Sack ‘N Save Pharmacies Nash Finch Company NeighborCare Pharmacies Oncology Pharmacy Services Peoples Rx Pharmacy PharmaCare Specialty Pharmacy Anchor Pharmacies BJ's Wholesale Club Pharmacy Providers Costco Pharmacies Costco Pharmacies Randall's Food & Drugs Farm Fresh Pharmacy Rogers Pharmacies Food City Pharmacies Food City Pharmacies SafeScript Pharmacy Food Lion Pharmacy SunScript Pharmacy Giant Food Stores Harris Teeter Pharmacy Tom Thumb Food & Pharmacy Harris Teeter Pharmacy TrueCare Pharmacy Leader Drug Stores Leader Drug Stores United Supermarkets Medicap Pharmacies Medicap Pharmacies Moore & King Pharmacy NeighborCare Pharmacies Shoppers Pharmacy Ukrop's Supermarkets Wegmans Food Markets Mercy Health System Bartell Drug Company Morton Drug Company Bi-Mart Corporation Nash Finch Company Costco Pharmacies NeighborCare Pharmacies Northwest Health Ventures/Lehman Hi-School Pharmacy Leader Drug Stores Schnucks Pharmacy Medicap Pharmacies Snyder's Drug Stores NeighborCare Pharmacies SUPERVALU Pharmacies Pacmed Clinic Pharmacies Thrifty Drug Stores Payless Drug Stores PharmaCare Specialty Pharmacy Quality Food Centers Yoke's Washington Foods Leader Drug Stores Medicap Pharmacies Smith's Food & Drug Giant Food Stores Leader Drug Stores For the most current list of pharmacies in the Pharmacy Medicap Pharmacies Network, go to www.usdos.sevencorners.com and click on NeighborCare Pharmacies the tab pharmacy network You may obtain up to a one-month supply (30 days) of your prescription medication from a Pharmacy Network provider and up to a three-month supply (90 days) through the Direct Mail Service. Leader Drug Stores Marshfield Clinic Pharmacy Medicap Pharmacies If you are planning to leave the US, and you know you 3. Even if the medication is a covered prescription under will need a prescription drug refill of any kind while you are ASPE, it may not be allowed into the country you are overseas, you should follow these steps: traveling. Don't assume that you can get a prescription just because ASPE would pay for the medication.
1. Gather information about the availability of the medication in the host country to which you are travel- 4. The following countries will not accept prescriptions ing. Due to regulations regarding controlled sub- shipped from the US.
stances and/or prescription medications, drugs available in the US are not necessarily available over- seas and vice versa. If the medication you are taking is not available in your host country, there are many restrictions on shipping prescription medication that can affect your ability to get your medication. In addition, if the medication you take is available in your 5. Take all of your findings into consideration relating to host country, the Ministry of Health or customs may your health before you make your travel arrange- not allow your medication to be shipped from the US.
ments. Important medications may not be available, (i.e. Birth control medication including the Nuvaring).
and you need to make every personal effort to deter- Whether or not a medication can be sent to you mine what your options are if you cannot obtain a drug outside the US can vary by types of medication your doctor has prescribed for you that you need to (i.e., special packaging), by mail carrier type, and continue to take while out of the US. sometimes it is just simply not allowed. If you find out your prescription is allowed and you 2. Call your doctor and see how much of a day work everything out with your provider, the following process supply of your medication he/she can prescribe you describes the method of obtaining the prescription through so you can have it filled before you leave, and discuss with him/her the information you found out about your specific prescription and its dispensing regulations in 1. Please review the list of medication excluded from the the country you are going. Find out what s/he suggests ASPE pharmacy benefits. If the drug you are taking is and if there are any alternatives if you are NOT able to not a covered ASPE approved medication, the pay- get the drug you are currently being prescribed once ment will be YOUR responsibility. you leave the US.
2. If it is a covered ASPE medication and it is a mainte- nance medication that is allowed to be shipped to your It is your responsibility to determine and insure that host country, the minimum for ordering through mail you will be able to purchase maintenance medication service is a 90-day supply. It is your responsibility to in your host country. To ensure you do not encounter purchase at least a 60-day supply of required medica- issues, get all the facts! tion to take with you to your host county—this is not reimbursable by ASPE. Prescriptions must be written by a licensed US physician.
Prescriptions ordered through the mail order When you pay for prescription drugs out of pocket and pharmacy will be filled using generics unless it is a covered ASPE medication you can complete a Outside specified by your Doctor. the US–Reimbursement Form for Prescription Drugs. The Mail order prescriptions cannot be filled until you form is provided in the back of this guide and additional are active on your grant—the start date on your forms are available through one of the following ways: ASPE ID card. ASPE does not pay for prescription Go to www.usdos.sevencorners.com, select forms, medications before or after your grant. (see dates and download the Outside the US–Reimbursement on your ASPE ID card) Form for Prescription Drugs Please use the Outside the US–Mail Order Call Customer Service 1.800.461 .0430 or collect Presription Form to order your prescriptions. The at +01.317.818.2867 form must be completely filled out and include a street mailing address plus phone number for a To obtain reimbursement, the form must be submitted FedEx or DHL shipment. A copy is provided in the with the medication receipt which must include: back of the guide and additional copies can be the name and address of the pharmacy or hospital obtained in one of the following ways: where the medication was purchased, the physician's name, the date of service, Go to www.usdos.sevencorners.com to download a description of the prescription drug, and the charge a Outside the US–Mail Order Prescription Form. Call customer service at 1 .800.461 .0430 or collect at +01.317.818.2867 Carmel, IN 46082-3724 Remember that if you have less than 90 days left on your grant, your refill will not be a full 90 day refill. It will be filled with an amount necessary to cover you during your eligibility period. Any over-the-counter drug or medical supplies that Drugs not approved by the FDA can be bought without a prescription Drugs labeled "Caution-Limited by Federal Law to Any quantity of drugs dispensed which exceeds the Investigational Use," drugs which are in connection supply and refill limits with experimental or investigative services or supplies, Any prescription or refill dispensed more than one including drugs requiring federal or other governmental year after the original prescription agency approval or granted at the time they are prescribed.
Prescriptions filled prior to the effective date or Multiple Sclerosis agents such as Betaseron, Avonex, after the termination date of the Exchange Copaxone, Tysabri Participant's coverage AIDS related drugs (HIV) Nutritional Supplements Anorexiants, anti-obesity drugs Drugs used to deter smoking Therapeutic devices or appliances or other non- Anti-narcolepsy drugs medical substances, regardless of their intended use Related services or supplies including, but not Nonprescription contraceptives and supplies related to limited to, administration of high dose chemotherapy, birth control, injectable and implantable contraception, radiation therapy, or any other form of therapy, or with the exception of birth control pills, diaphragms, Immunosuppressive drugs are not covered when patch and ring which are covered associated with any tissue or solid organ transplant Unreceipted blood, blood plasma or blood expanders Any drug for cosmetic purposes, including, but not Vitamins, or vitamin derivatives limited to, Rogaine All drugs related to Erectile Dysfunction (ED) Fluoride preparations Human growth hormones Immunization agents If you receive covered medical services from a medical Claims are automatically submitted to Seven Corners by provider that is not in the Medical Provider Network and you the provider or hospital when you use a medical provider that paid for medical bills out of your pocket, you must complete is in the Medical Provider Network. You are responsible for an Accident/Illness Medical Claim Form and submit it along paying your co-pay at the time of service. Payment for services, with your itemized medical bills to receive reimbursement for other than the co-pay, will not be expected in advance. Addi- your payment.
tionally, when you use the Medical Provider Network, you will not be responsible for charges over the usual, customary and An Accident/Illness Medical Claim is provided in the reasonable charges. All covered services are paid according back of this guide, and additional forms are available through to the negotiated fee schedule. one of the following ways: Go to www.usdos.sevencorners.com, to download the Accident/Illness Medical Claim ASPE requires all of its members (exchange participants) Call Customer Service 1.800.461 .0430 or collect to pay a $15.00 co-pay for all office visits, ER, urgent care and at +01.317.818.2867 outside the US and one will be hospitalizations. The provider will require the co-pay at the time of visit. As a reminder the co-pay amount will be pre-printed on your ASPE ID card.
You must submit information NO LATER than one year from the date of the medical service to receive reimburse- ment. Original bills will not be returned. Keep a photocopy of If your claim is denied for payment, you may appeal the all bills and receipts for your personal records. The bills you denial decision by submitting an appeal in writing to: submit MUST INCLUDE the following information: Name, address and professional status of the person or organization providing the service Provider Tax ID number (for providers in the US) ASPE Health Benefits Name of patient receiving service Description of each service Carmel, IN 46082-3724 Charge for each service For eligible psychotherapy expenses, Payment of medical benefits is subject to the availability include the length of each session and session of appropriated funds at the time the claim is filed. type (ex. group or individual) Sign the completed claim form and mail it to the address No legal action may be brought against the ASPE prior to on the back of your identification card. the expiration of 120–days after written claim form and other proof of loss have been submitted. Additionally, no legal action may be brought against the ASPE after the expiration of three years from the time of submission of written claim form and required proof of loss.
The ASPE program contains a Coordination of Benefits If you receive an injury due to the actions of another provision. This provision is used when you are eligible for pay- person, and benefits are paid under your ASPE plan due ment of claims under more than one health care benefit plan. to that injury, USDoS will be entitled to a refund from such When you have health care coverage other than ASPE recovery of all benefits paid if money is recovered from the (except Medicare or Medicaid), your other coverage is the third party, its insurer, or uninsured motorist insurance. primary payer and must pay claims first up to the limit of its Upon request, you must complete the required Accident policy. ASPE is then designated as the secondary payer and forms and return them to USDoS and cooperate fully with must pay any remaining amount covered by your ASPE plan. USDoS asserting its right to recover.
The ASPE is secondary to all other insurance polices, When payments for a given medical treatment have except Medicare/Medicaid been made in excess of the amount necessary, USDoS has the right to recover such overpayments. The USDoS will notify you of the overpayment and request reimbursement If you have health care coverage other than this USDoS from the health care provider plan, use the following guidelines to determine when claims should be submitted to USDoS as the primary payer: 1st: Submit claims to private insurance carrier and obtain payment and EOBs 2nd: Submit your original medical bills and EOBs from your primary carrier, and ASPE will pay your remaining charges covered under your ASPE benefit plan. If you become disabled prior to age 65 or are otherwise entitled to Medicare benefits (i.e. for renal dialysis), the bene- fits you are entitled to receive from Medicare will be reduced by the amount the ASPE health benefit plan would pay. You must first use ASPE health plan benefits to which you are entitled before submitting charges to Medicare or Medicaid for reimbursement. Administrator—A private company contracted by the USDoS to Covered Services—Medical services or supplies covered by the ASPE administer the ASPE health benefit plan. The current ASPE health benefit plan are those related to medical conditions which are administrator is Seven Corners, Inc. not pre-existing, and provided by a provider acting within the scope of their license. In order to be considered a covered service, charges Ambulatory Surgical Facility—An establishment which may or may must be incurred while your coverage is in force.
not be part of a Hospital and which meets the following requirements: 1. is in compliance with the license or other legal requirements Covered Expense—Expenses for medical services or supplies that are: in the jurisdiction where it is located; 1. allowable by the ASPE health benefit plan, 2. is primarily engaged in performing surgery on its premises; 2. administered or ordered by a Physician, 3. has a licensed medical staff, including Physicians and 3. medically necessary to the diagnosis and treatment of an Registered Nurses; Injury or Sickness, 4. has permanent operating room(s), recovery room(s) and 4. related to medical conditions that are not pre-existing per equipment for emergency care, and the ASPE health benefit plan definition, and 5. has an agreement with a Hospital for immediate acceptance 5. not in excess of the negotiated rate based on services provided of patients who require Hospital care following treatment in or the usual, customary and reasonable fee schedule.
the ambulatory surgical facility.
Covered Person—Exchange Participants in an eligible ECA/USDoS Benefit Year—The one-year period that begins on your start date in sponsored exchange program enrolled in the ASPE benefit plan. the ASPE program. "Eligible Program" does not include those for which USDoS support is primarily for administrative or facilitative support rather than direct Certificate of Coverage—Is a "Proof of Coverage" letter providing Participant costs. "Participants" does not include escorts, escort/ evidence of your prior health coverage. Upon request this document interpreters, staff of organizations receiving grant support directly or is provided by Seven Corners. indirectly from USDoS, independent consultants associated with these organizations, or dependents of program participants.
Co-Pay—Co-pay is the specified dollar amount that a patient is expected to pay directly to the provider at the time of service.
Durable Medical Equipment (DME)—DME means medical Covered Charges—Charges for medical services or supplies that are: 1. is prescribed by the Physician who documents the 1. allowable by the ASPE health benefit plan; necessity for the item, including the expected duration 2. administered or ordered by an eligible health care provider; 3. medically necessary to the diagnosis and treatment of an 2. can withstand long term repeated use without replacement; Injury or Sickness; 3. is not useful in the absence of Injury or Sickness; and 4. related to medical conditions that are not pre-existing per the 4. can be used in the home without medical supervision. ASPE health benefit plan definition, and 5. not in excess of the negotiated rate based on services pro- Emergency—A sudden, unexpected onset of a medical condition vided or the usual, customary and reasonable fee schedule.
that is of such a nature that failure to render immediate care by a licensed medical provider would place the Exchange Participant's life in danger, resulting in the loss of life or limb, or would cause serious impairment to the Exchange Participant's health.
Enrollment—Exchange Participants are eligible to participate in Injury—An accidental bodily injury sustained by an Exchange the ASPE Health Benefit Plan when they are enrolled in the program Participant while covered under the ASPE health benefit plan and by their program agency, commission or cooperating agency. The which occurs independent of all other causes.
program agency, commission or cooperating agency issues each Exchange Participant an ASPE identification card.
Inpatient—A person who is a resident patient, using and paying for the room and board facilities of a Hospital.
Exclusions—Any services or supplies related to pre-existing conditions or any other non-covered plan benefits. Intensive Care Facility—An intensive care unit, cardiac care unit, or other unit or area of a Hospital: EOB—Is an acronym for Explanation of Benefits. Although EOBs often 1. reserved for the critically ill requiring close observation; and look like a medical bill, the EBO tells you what portion of a claim was 2. equipped to provide specialized care by trained and qualified paid to the health care provider and what portion of the payment, if personnel and special equipment and supplies on a any, you are responsible for.
standby basis.
Experimental—Any treatment, procedure, facility, equipment, drug, Loss—The financial loss associated with an accident or illness for a device or supply which: claim submitted to the Administrator.
1. is not accepted as standard medical treatment for the condition being treated; or Medical Network Provider—Providers of service who have been 2. requires but has not received federal or other governmental selected or have decided to become part of a preferred network to agency approval at the time of service.
work with an insurer to help control costs to patients.
Health Care Provider—A licensed physician, hospital or clinic that Medicare—The program of health care for the aged and disabled provides medical services.
established by Title XVIII of the Social Security Act of 1965, as amended.
Hospital—An institution which: Mental Health Care Provider—A licensed physician, licensed clinical 1. operates as a Hospital pursuant to law for the care and psychologist, licensed clinical social worker or a master of social treatment of sick or injured persons as inpatients; work (MSW), acting within the scope of your license who is not the 2. provides 24-hour nursing service by registered nurses on duty Exchange Participant or a member of the Exchange Participant's immediate family, who may provide services that are medically 3. has a staff of one or more Physicians available at all times; necessary for mental and nervous disorders only.
4. provides organized facilities for diagnosis, treatment and surgery either on its premises, or in facilities available to it Outpatient—A person who receives medical services and treatment on a pre-arranged basis, and on an Outpatient basis in a Hospital, Physician's office, Ambulatory 5. is not primarily a nursing, rest, convalescent home or similar Surgical Center, or similar centers, and who is not charged room and establishment, or any separate ward, wing or section of a board for such services.
Hospital used as such.
Pharmacy Network—The retail and mail service pharmacy network.
Identification Card—A card issued by the ASPE health benefit plan that bears the member's name, identifies the membership by Physician—A qualified, licensed health care practitioner, acting number and may contain information about your coverage.
pursuant to a license, who is not the Exchange Participant or a member of the Exchange Participant's immediate family.
Pre-Existing Condition—Any condition which: Other Providers—Nurse anesthetist, nurse practitioner, a. had its origins prior to the Exchange Participant's effective psychiatric social worker, respiratory therapist, speech date of coverage; therapist, occupational therapist, optician, optometrist, b. a Physician was consulted prior to the Exchange Participant‘s physicians'assistant, private duty nurse, technical surgical effective date of coverage; assistant, registered physical therapist or physiotherapist. c. treatment or medication was received prior to the Exchange All of the above mentioned providers must be licensed or Participant's effective date of coverage, or certified in the jurisdiction where the services were provided.
d. would have caused any prudent person to seek medical Registered Nurse—A graduate nurse who has been registered advice or treatment, prior to the Exchange Participant's or licensed to practice by a State Board of Nurse Examiners or effective date of coverage.
other state authority, and who is legally entitled to place the Note: For purposes of the ASPE, pregnancy is not defined as a letters RN after your name. Right of Recovery—When payments for a given medical treatment Pre-Notification—Seven Corners must be contacted: have been made in excess of the amount necessary, the USDoS to confirm coverage and benefits; has the right to recover such overpayments. The USDoS will notify as soon as non-emergency hospitalization the Exchange Participant of overpayment and request reimburse- ment from the health care provider. within 48 hours of the first working day following an emergency admission; Sickness—An illness, disease, or physical condition of an Exchange when your physician recommends any surgery Participant commencing while coverage is in force.
including outpatient; for emergency evacuation, repatriation and Usual, Customary and Reasonable (UCR)—The payment amount as determined by a nationally recognized MDR fee schedule based upon geographic location. The Administrator purchases the MDR fee Providers of Service—When you are ill or injured, your coverage helps schedule from Ingenix, and the Administrator reserves the right of pay the hospital and your physician as well as appropriate charges for final determination of the amount payable for any service or supply. other approved health care professionals. These providers include but are not limited to: The following is the basis for determination of UCR: Hospital—Any hospital accredited by the Joint Commission Usual—an amount a professional provider routinely on the Accreditation for Health Organizations, including charges for a given service.
Veterans Administration Hospitals and Department of Customary—an amount which falls within the range of Defense Hospitals. charges for a given service billed by most professional Physicians—Any provider licensed in the state or country where providers in the same locality who have similar training the services were provided. These include: Doctor of Medicine (MD), Doctor of Osteopathy (DO), Doctor of Dental Surgeries Reasonable—an amount that is Usual and Customary or (DDS or DMD), Podiatrist (POD) and Psychologist (Ph.D.). an amount not considered excessive in a particular case Certified Nurse Midwife—Must be a licensed registered nurse because of unusual circumstances.
and certified as a nurse midwife by the American College of If the charge is in excess of the UCR, no payment with respect to the excess is made, and the excess will not qualify as a Covered Expense under the ASPE health benefit plan. The Accident and Sickness Program for Exchanges (ASPE) complies with the J-1 Visa regulations which govern incoming Exchange Par ticipants. The ASPE Health Benefit Guide, when shown with a valid Identification Card is evidence of health benefit coverage under the ASPE and of the associated benefits and limitations.
No changes to the ASPE Health Benefit Plan shall be made, except by the Executive Director, Bureau of Educational and Cultural Af fairs (ECA), United States Depar tment of State (USDoS) who will make such changes that might be required to address budget, policy, regulator y, or legislative mandates.
This ASPE Health Benefit Guide replaces all Cer tificates, if any, previously issued to Eligible Par ticipants and Covered Persons ef fective 1 June 2009.
The ASPE Health Benefit Plan is funded by the USDoS through the Fulbright- Hays authorizing legislation. The payment of medical benefits is subject to the availability of appropriated funds at the time when the claim is filed.
ASPE Health Benefit Plan Carmel, IN 46082-3724

Source: http://www.fulbright.sk/data/ASPE_Insurance.pdf