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C10.9.1. Healthcare coverage while in the United States. All International Military Students (IMS) and authorized dependents are required to have healthcare coverage while in the United States. There are five primary methods by which healthcare coverage may be provided for the IMS and/or his/her authorized dependents. The IMS are held responsible for payment of all incurred healthcare bills, including co-payments, deductibles, and services not covered by the following methods:
C10.9.1.1. Foreign government indemnification and direct payment to the service providers for healthcare costs incurred by the IMS and/or his/her authorized dependents. Bills for healthcare services are sent directly to an IMS’ government entity with a U.S. address for payment. Bills should be paid within 90 days after the bill is sent. Arrangements that require the IMS to pay for medical services and then seek reimbursement from his/her government are prohibited unless DSCA (Programs Directorate) has granted a waiver. A waiver request with specific details must be submitted by the Security Cooperation Office (SCO) through the Combatant Command (CCMD) to DSCA (Programs Directorate) 60 days prior to the IMS reporting to the first course. DSCA (Programs Directorate) will coordinate approval of the waiver request with the military departments (MILDEPs). The approved waiver will be kept on file by the SCO and annotated on the Invitational Travel Order (ITO) where indicated. The waiver will be valid unless there is a failure to pay bills within 90 days.
C10.9.1.2. Training case line item for medical coverage. A Foreign Military Sales (FMS) training case may provide for medical coverage. If a country wishes to include payment of pregnancy, childbirth costs, and/or non-emergency dental care or other elective procedures for an IMS and/or dependents with this line, the details must be included in the ITO. The IMS and/or dependents may be indemnified by the IMS’ government for pregnancy coverage, and if not, supplementary commercial insurance may be required to meet the requirements of this manual. The cost of supplemental insurance is not treated as a cost of the training or the course itself.
C10.9.1.3. Grant programs. Some U.S. Government (USG) grant programs (e.g., International Military Education and Training (IMET), Combating Terrorism Fellowship Program (CTFP), Foreign Military Financing (FMF) cases with approved medical lines) pay for the healthcare costs of the IMS only.
C10.9.1.4. Reciprocal Health Care Agreements (RHCA) and NATO/Partnership for Peace (PfP) Standardization of Forces Agreements (SOFA). The IMS and dependents from nations with either a RHCA or NATO/PfP SOFA require supplemental commercial healthcare insurance or indemnification by their government for medical services not covered under the RHCA or NATO/PfP SOFA.
C10.9.1.4.1. Charges for medical care in DoD medical facilities do not apply if the IMS is covered by a reciprocal health care agreement between the United States and the IMS’ government, and it covers the same type of expenses charged to the IMET program. When such an agreement exists, the SCO checks item 16b(3) on the ITO and adds the following statement to item 13, “Medical care in the Department of Defense (DoD) facilities is provided under [reference the agreement, date, etc]. Reimbursement for services provided is not required.” Note that agreements vary and may not cover certain categories (such as IMET students, civilian students, or dependents) and are applicable only for medical and dental care in DoD medical and dental facilities; therefore, if a training installation does not have a DoD medical facility, the terms of the agreement do not apply.
C10.9.1.5. Medical Care for IMET Students. The IMET program will pay for IMS’ medical care received from civilian healthcare facilities, and a country or medical insurance will be required to pay for medical and dental care of accompanying dependents. A factor of $35 per IMS training line is authorized for programming purposes under generic code N7E (T-MASL IIN 365003/365004) for payment of medical care.
C10.9.1.6. Commercial healthcare insurance policies procured by the IMS. The insurance provider must directly reimburse medical healthcare providers in U.S. dollars, and have a claims office with a U.S. address and U.S. phone number.
C10.9.2. Healthcare costs incurred in a DoD Military Treatment Facility (MTF). These costs are considered to be a personal debt of the IMS to the USG. The healthcare notation on the IMS ITO states who is financially responsible for paying the healthcare costs. The SCO, in coordination with the MILDEP, must work with the partner nation to collect any unpaid debt.
C10.9.2.1. When a specific medical or dental treatment is not available at a DoD treatment facility, the IMS and/or authorized dependents must obtain a referral from the appropriate DoD treatment facility for the medical or dental treatment to be received in a civilian medical or dental facility (with the exception of an emergency or unavailability of the DoD treatment facility, such as weekend closure.)
C10.9.2.2. Civilian healthcare providers/treatment facilities typically will require the patient to show how costs for healthcare will be paid prior to treatment. Properly prepared ITOs fulfill this requirement. When the ITO indicates commercial healthcare insurance is required, the IMS will need to show to the servicing medical treatment facility his/her insurance card.
C10.9.3. The IMET and CTFP programs provide healthcare coverage for the IMS only. Authorized dependents will require healthcare insurance, if payment is not guaranteed in writing by the foreign government. Other U.S. grant programs with a medical line on the case or that self-insure also provide healthcare coverage for IMS. Those programs that do not provide complete healthcare coverage require either a separate FMS case for medical expenses or commercial insurance that meets DSCA requirements.
C10.9.4. NATO/PfP IMS under a SOFA status. The following healthcare provisions pertain:
C10.9.4.1. Healthcare at a DoD Medical Treatment Facility (MTF).
C10.9.4.1.1. Outpatient care (medical and emergency dental) provided by a DoD MTF is at no charge to the IMS and authorized dependents (some treatments are available for only the IMS and not for authorized dependents).
C10.9.4.1.2. Inpatient care for both the IMS and dependents (if available) is on a reimbursable basis. Healthcare insurance is required for the IMS and authorized dependents if not covered by the program or case, or if payment is not guaranteed in writing by the foreign government.
C10.9.4.2. Healthcare at a civilian treatment facility.
C10.9.4.2.1. Inpatient care for both the IMS and dependents is on a reimbursable basis. The IMS and/or dependents are required to have supplemental medical insurance coverage.
C10.9.4.2.2. If referred by a DoD MTF, IMS outpatient care (medical and emergency dental) at a civilian treatment facility is at no charge, and the referring DoD MTF is responsible for payment.
C10.9.4.2.3. If referred by a DoD MTF, outpatient care for authorized dependents is covered by TRICARE which is a healthcare program of the U.S. DoD Military Health System; standard/extra for outpatient care, and a co-pay are required, as well as a deductible if not yet met.
C10.9.5. Healthcare provisions for IMS covered under RHCA.
C10.9.5.1. RHCAs differ by country in coverage and may not provide full healthcare coverage. It is critical that the RHCA be carefully reviewed by the SCO to determine if it is current or will expire during the IMS’ expected stay. RHCAs usually provide care in a U.S. DoD MTF at no cost, and do not cover civilian provided healthcare. Many military installations do not have a full service MTF, or the nearest MTF is located a considerable distance from the schoolhouse/training activity. In addition, the IMS and authorized dependents may require care while traveling away from their assigned military installation.
C10.9.5.2. For verification and information on RHCA, please access the DISAM International Training Management web page at http://www.disam.dsca.mil/itm/ and go to RHCA under Functional Areas, Health Affairs.
C10.9.5.3. All IMS and their authorized dependents that rely on an RHCA as their primary source of insurance coverage must secure the supplemental healthcare insurance needed to meet the requirements specified. This healthcare coverage must remain in effect for the duration of the IMS and dependent’s stay in the United States under DoD sponsorship.
C10.9.6. Minimum Required Healthcare Insurance Policy Coverage.
C10.9.6.1. Healthcare insurance policy coverage should include coverage for all non-elective medical conditions, and must remain in effect for the duration of the IMS and authorized dependents DoD sponsored stay in the United States. The initial insurance policy must be in effect for one year or the duration of the IMS’ stay in the United States under DoD SC sponsorship (including leave period indicated in the ITO).
C10.9.6.2. Medical benefits of at least $400,000 per year (payable in U.S. dollars; no conversion from foreign currency).
C10.9.6.3. Deductible not to exceed $1000 annually per family.
C10.9.6.4. Repatriation of remains in the amount of $50,000 (per individual), should a death occur in the United States, to provide for the preparation and transportation of remains to home country.
C10.9.6.5. Medical evacuation in the amount of at least $250,000 (per individual) for immediate transportation to the nearest adequate medical facility, and subsequently in the event it is determined to be medically necessary for the IMS, international civilian students, and/or authorized dependents to return to their home country.
C10.9.6.6. Healthcare insurance policy coverage must meet the following requirements. Information concerning some healthcare insurance policies that meet the requirements of this policy can be found on the web at http://www.disam.dsca.mil/itm/ under Functional Areas.
C10.9.6.6.1. No exclusion for payment of benefits directly to a DoD MTF if applicable.
C10.9.6.6.2. Provide nationwide coverage/service; non-U.S. based policies must provide benefits in the United States.
C10.9.6.6.3. Provide single source administration/management for the policy.
C10.9.6.6.4. Have a point of contact in the United States. In all cases, the insurance company is to pay promptly in U.S. currency directly to healthcare provider.
C10.9.6.6.5. Have a copy of the policy written in English.
C10.9.6.6.5.1. An English copy of the policy will be provided to the SCO, the servicing MTF, and the IMSO at all schoolhouses within the IMS’ training track (e.g., DLIELC). The IMS will also retain a copy of the policy.
C10.9.6.6.5.2. Some MILDEP schools require the IMSO to review health insurance policies for compliance with the policy in this Chapter prior to the issuance of the ITO to the IMS. The SCO will scan and send a copy (in English) of the proposed policy as directed by IMSO and/or MILDEPs.
C10.9.6.6.6. If U.S. education and training is taking place in a third country, medical coverage must meet the requirements of the host nation. Contact the SCO, the DoD training facility, or the RC in the host nation to determine specific requirements.
C10.9.6.6.7. The minimum dollar standards and coverage requirements will be reviewed annually by DSCA (Programs Directorate) to ensure that they reflect the current cost and coverage of U.S. healthcare.
C10.9.7. Pregnancy Coverage.
C10.9.7.1. Pregnancy insurance is in addition to insurance requirements specified in C10.9.6. Pregnancy and childbirth coverage is not usually included in insurance policies purchased less than 12 months in advance, and is generally very expensive. Pregnancy insurance coverage is not available for purchase after an IMS or dependent is determined to be pregnant as it is considered a pre-existing condition.
C10.9.7.2. Pregnant dependents will not be authorized to accompany or join the student unless the costs of prenatal, childbirth, and postnatal care are covered by an FMS (national funds) case, or an already existing pregnancy insurance policy for at least $250,000 prior to their arrival, or if the country agrees to pay, in writing, for any incurred cost prior to the dependent’s arrival.
C10.9.7.3. An IMS or authorized dependent without pregnancy coverage, who is found to be pregnant after arrival in the United States will be returned to her home country immediately unless the IMS’ government guarantees within ten working days after notification to pay all costs associated for prenatal, childbirth and postnatal care. Failure to provide payment of associated bills by the country within 90 days after the bill is sent could affect the authorization for dependents to accompany students from that country in the future and may result in the student’s removal from training.
C10.9.8. Invitational Travel Order Healthcare Notations.
C10.9.8.1. Required health screening and healthcare financial responsibility entries for the IMS and authorized dependents must be annotated appropriately and accurately on the ITO according to the status of the IMS. Authorized dependents will not be added to the ITO until all medical screening and healthcare coverage requirements have been verified by the SCO.
C10.9.8.2. For the IMS and authorized dependents, the SCO will check the appropriate block of the ITO to indicate how healthcare charges will be paid and ensure the ITO includes a U.S. billing address and telephone number. When commercial insurance is the means of healthcare coverage, the SCO will include the insurance company name, policy number, inclusive dates of the policy, and its U.S. point of contact in block 12 of the ITO. If the foreign government or an FMS case is designated as the source of funding for the IMS and authorized dependant healthcare coverage, a statement will be included in the Remarks Section of the ITO that indicates whether or not all costs associated with pregnancy coverage are included in this coverage.
C10.9.8.3. A pregnant IMS or a pregnant authorized dependent will require a health policy waiver before being authorized on an ITO.
C10.9.9. Healthcare Coverage Responsibilities.
C10.9.9.1. DSCA Responsibilities. DSCA is the DoD designated authority for international SC training and education programs. DSCA develops and promulgates policy and guidance, and provides oversight for the implementation and execution of healthcare coverage policy to the MILDEPs, IMSOs CCMDs, and SCOs. DSCA reviews, coordinates with the MILDEPs, and approves requests for exceptions to the healthcare coverage policy.
C10.9.9.2. Combatant Commands Responsibilities. Ensure that the SCO understands and adheres to the policies contained in this chapter.
C10.9.9.3. MILDEP Responsibilities. When commercial healthcare coverage is required, establish procedures for the review of student healthcare policies to ensure compliance with the SAMM and any applicable MILDEP directives. If a MILDEP uses a contractor to review student healthcare coverage policies, the cost of the contract for medical review may be computed as part of the tuition rate. See the DoD Financial Management Regulation, Volume 15, Chapter 7, paragraph 071002.D. The cost developed will be the same per student regardless of the training rate, as the cost is an incremental cost. If the cost to review the medical healthcare coverage is not included in the IMSO duties, then a separate line will be included on the case and the country charged for the service.
C10.9.9.3.1. In coordination with the CCMD, enforce the following directives when notified by the IMSO of IMS non-compliance with this policy:
C10.9.9.3.1.1. When notified by the IMSO of an irresolvable lapse or lack of required commercial healthcare insurance for the IMS, coordinate with the IMS’ government to determine the payment mechanism for outstanding medical bills. If the IMS’ government does not agree to pay for required healthcare insurance or outstanding medical bills MILDEPs need to take action to withdraw the IMS from education and training and return the IMS to his/her home country.
C10.9.9.3.1.2. When notified by the IMSO of an irresolvable lapse of required commercial healthcare insurance for authorized dependents, the MILDEP will take the following action:
C10.9.9.4. Country Responsibilities. When applicable, provide to the SCO copies of signed, legal country-to-country agreements or other statements that stipulate payments and reimbursement methods of healthcare costs for the IMS and/or authorized dependents (e.g., RHCA, SOFAs).
C10.9.9.5. SCO Responsibilities.
C10.9.9.5.1. Determine healthcare coverage requirements and payment method(s) applicable to IMS and authorized dependents (if any). If commercial healthcare coverage is required, scan and send an English language copy of the insurance policy along with the proposed ITO to the IMSO and any others specified by the MILDEP at least 30 days prior to report date for unaccompanied IMS and at least 60 days prior for accompanied students. Obtain concurrence from the IMSO that coverage meets the requirements of this policy prior to signing the ITO.
C10.9.9.5.2. When the IMS is covered by a RHCA or NATO/PfP SOFA, ensure ITO block 12 specifies either a supplemental commercial healthcare insurance policy or indemnification by their government for healthcare services not covered under the RHCA or NATO/PfP SOFA.
C10.9.9.5.3. Submit a waiver request through the CCMD to DSCA (Programs Directorate) for a modified medical coverage arrangement (e.g., country-provided healthcare coverage requires student to pay outpatient costs and seek reimbursement); or a country wishes to guarantee payment for medevac or repatriation expenses rather than including in the insurance. DSCA (Programs Directorate) will coordinate approval of the waiver request with the MILDEPs. The SCO will include specific details, the U.S. points of contact, and the U.S. billing address for the approved request with the date of DSCA approval, in the ITO.
C10.9.9.5.4. If applicable, ensure the IMS has a copy of his/her healthcare insurance policy (in English) for delivery to the IMSO upon arrival at his/her first education and training site.
C10.9.9.5.5. If applicable, include in block 15 of the ITO a notation of any existing special medical conditions/preconditions for both the IMS and/or dependents. Do not provide any details that may compromise the rights to privacy of the IMS or authorized dependents.
C10.9.9.5.6. If training will occur in a third country, ensure the IMS has met healthcare requirements of the host nation.
C10.9.9.5.6.1. Brief the IMS on the following:
C10.9.9.6. IMS Responsibilities.
C10.9.9.6.1. Acknowledge, in writing, an understanding of the policy concerning healthcare insurance coverage, including consequences of the lack of pregnancy coverage and policy against using non-emergency U.S. tax-payer provided medical/dental assistance while under DoD sponsorship.
C10.9.9.6.2. If applicable, present healthcare insurance policy (in English) to the IMSO and to medical treatment facilities.
C10.9.9.6.3. Notify the IMSO immediately of any and all medical care required or received by the IMS and/or dependents, including cases of pregnancy. It is not necessary to divulge private medical information if it does not affect successful completion of training, but it is necessary to let the IMSO know that a medical bill may be expected.
C10.9.9.7. IMSO Responsibilities.
C10.9.9.7.1. Review the ITO for accuracy. When commercial healthcare insurance policy is marked or stated in the remarks, a copy of the insurance policy, along with any updates to the policy, will be placed in the IMS file.
C10.9.9.7.2. If commercial healthcare insurance is required for the IMS and/or authorized dependents, as directed by the MILDEP, review the healthcare insurance policy for compliance with requirements in Section C10.9. prior to IMS authorization for travel. Provide the SCO with instructions on where to send the English version for review. Report any deficiencies in healthcare coverage immediately to the MILDEP Country Program Manager and SCO. If it is found that minimum coverage requirements have not been met, ID cards will not be issued to dependents.
C10.9.9.7.3. Advise the IMS of the requirement to take the ITO and healthcare insurance policy documentation to local medical treatment facilities and any physicians they see during their stay in the United States.
C10.9.9.7.4. Brief the IMS on all procedures and requirements as outlined in this chapter, including requirements in cases of pregnancy. Obtain a signed memorandum of acknowledgement and understanding from the IMS.
C10.9.9.7.5. If unauthorized dependents arrive at the training activity location, contact the MILDEP training policy manager immediately for advice on healthcare coverage.
C10.9.9.8. Regional Centers (RC) Responsibilities.
C10.9.9.8.1. Ensure that participants traveling to a RC program or event (e.g., course, seminar, conference, workshop) meet any and all healthcare coverage requirements imposed by the country where the RC event is being held.
C10.9.9.8.2. For each RC program or event that requires travel to the U.S., specific health coverage requirements will be identified.
C10.9.9.8.3. Provide healthcare requirements to the SCO to provide to the RC program participants.
C10.9.9.9. Medical Care for FMS Case Students. An FMS case may include funds to cover medical care at DoD and commercial health care facilities for FMS students training under the case. Medical care for authorized accompanying dependents may also be included in the FMS case if specifically requested by the purchaser. An FMS case should not be used for the sole purpose of obtaining medical care for international students or their dependents unless approved in writing by the DSCA (Operations, Programs, and Strategy Directorates) prior to LOA development.
C10.9.9.9.1. Cases funded by FMF may not be used to cover authorized dependent medical care.
C10.9.9.9.2. Each FMS student attending CONUS training (to include accompanying dependents authorized on the student’s ITO) must have health care coverage explicitly stated on the ITO. See Section C10.8.5. and Section C10.9. for requirements for medical screening and healthcare coverage.
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