10 FAM 240
ACCIDENT AND SICKNESS PROGRAM FOR EXCHANGES (ASPE)
(CT:PEC-69; 02-27-2019)
(Office of Origin: ECA)
10 FAM 241 POLICY, SCOPE AND AUTHORITY
10 FAM 241.1 Policy
(CT:PEC-007; 03-29-2002)
a. It is the policy of the Department of State to
maintain a system that will provide limited accident and sickness insurance for
participants in programs sponsored by the Bureau of Educational and Cultural
Affairs (ECA) and for participants of certain other Department-sponsored
programs enrolled for Bureau coverage.
b. The Bureaus Accident and Sickness Program for
Exchanges (ASPE) provides for the treatment of illnesses and medical
emergencies. It is not for long-term treatment or convalescence. An exchange
participant requiring extensive treatment or convalescence ordinarily will be
returned to his or her home country for treatment as soon as the attending
physician indicates the patients condition has stabilized and the patient can
be released for travel.
10 FAM 241.2 Definitions
(CT:PEC-007; 03-29-2002)
a. Injury is an accidental bodily injury sustained and
requiring medical treatment.
b. Sickness is a sickness, illness, or disease
requiring medical treatment.
c. Hospital is a legally constituted and lawfully
operated hospital which accepts registered in-patients.
d. Physician is a professionally qualified individual
duly licensed to practice medicine (including but not limited to surgery,
dentistry, and ophthalmology) in the State or country in which he or she
resides or practices. The attending physician cannot be a member of the
covered persons immediate family or anyone who lives with the covered person.
e. Infirmary is a place for the care of the infirm,
sick or injured; hospital; an institution which operates as a hospital pursuant
to law for the care and treatment of sick or injured persons as in-patients.
f. Qualified nurse is a professional, qualified
individual duly licensed to care for the sick.
10 FAM 241.3 Authority
(CT:PEC-33; 08-07-2017)
Fulbright-Hays Act; see 1 FAM 046.3.
10 FAM 242 INSURANCE BENEFITS
10 FAM 242.1 Accident and Sickness
Medical Expenses
(CT:PEC-007; 03-29-2002)
a. ASPE will pay for the expenses actually incurred by
an exchange participant over and above the first $25.00 when injury or sickness
requires the following:
(1) Treatment by a physician;
(2) Confinement within an infirmary or a hospital;
(3) Employment of a qualified nurse;
(3) X-ray examination;
(5) Use of ambulance or therapeutic services;
(6) Laboratory services, supplies or medicines deemed
necessary by the attending doctor;
(7) Dental care for the emergency alleviation of pain
and including cosmetic dentistry, false teeth and bridgework, when necessitated
by injury to the participant;
(8) The replacement of eyeglasses, contact lenses,
and/or glass eye when broken as the result of an injury; and
(9) Treatment for pregnancy, including resulting
childbirth or miscarriage or any complication of pregnancy, during the period
of the participant's coverage.
b. ASPE will pay expenses of medical treatment for
conditions other than pregnancy during the ensuing 52 weeks from the date of
the accident or the commencement of the sickness not to exceed $50,000.00 in
the aggregate, as the result of any one injury or sickness. Medical claims
payments are made only for usual, customary, and reasonable charges.
10 FAM 242.2 Death Expenses
(CT:PEC-007; 03-29-2002)
In the event of the death of an exchange participant
during coverage, ASPE will pay the actual charges for preparing and
transporting to his or her former home (in accordance with applicable
international requirements) the remains of any such participant who may die
while away from their homes, but not to exceed $7,500.00.
10 FAM 242.3 Benefits Limitations
(CT:PEC-007; 03-29-2002)
ASPE does not cover the following:
(1) Costs associated with a pre-existing condition. A
pre-existing condition is any condition which;
(a) Had its origins (determined by medical staff as
occurring prior to participants coverage whether previously diagnosed or not);
(b) A Physician was consulted prior to participants
coverage;
(c) Treatment or medication was received prior to
participants coverage; or
(d) Would have caused any prudent person to seek medical
advice or treatment prior to the covered persons effective date.
(2) Such injury or such sickness for which any
benefits are provided by Worker's Compensation or occupational disease acts,
welfare programs or any other valid and collectible insurance policy.
(3) Such injuries or such sickness contracted or
sustained by the participant:
(a) While in active duty in military or naval service of
any country at war; or
(b) Which is the result of, or is caused by, any act of
war.
(4) Dental care, unless required by an accidental
injury to the insured. Any claim for dental treatment will be rejected when
not accompanied by proof of an accidental injury to the participant. However,
the emergency alleviation of pain shall be covered subject to a $500.00 maximum
limitation. For the purpose of this subchapter, Pyorrhea is a disease and
falls under sickness expense benefits.
(5) Routine physical or any other examinations where
there are no objective indications of impairment to normal health.
(6) Birth control expenses, including surgical
procedures and devices.
(7) Eye examinations, fitting, and prescriptions.
However, in the event eye glasses, contact lenses, and/or glass eye become
broken or destroyed as the result of an accidental injury to the individual,
ASPE will pay claims for replacement of such eye glasses, contact lenses and/or
glass eye as may be prescribed by an optometrist, oculist or ophthalmologist.
(8) Expenses incurred for the treatment of an injury
or sickness after 52 weeks from the time of the injury or onset of the
sickness.
10 FAM 243 INSURANCE COVERAGE PERIOD
(CT:PEC-007; 03-29-2002)
The period of insurance coverage for all participants is
the period from the date a participant departs his or her home, during direct
travel to the place of assignment and during participation in an exchange
activity, until the time he or she returns home by the most direct route. This
period includes any periods of academic recess during an academic year and any
travel performed within the country of assignment during those periods or
travel performed as an adjunct of a participant's study/research/teaching
activity. Insurance coverage is not provided during an extended stopover or
during diversionary travel while en route to or from the place of assignment or
during an interruption in the exchange activity for personal reasons.
10 FAM 244 INSURANCE COVERAGE
GUIDELINES FOR BUREAU PROGRAMS
10 FAM 244.1 International Visitor
Program
(CT:PEC-007; 03-29-2002)
a. All International Visitors are provided coverage
under ASPE. Escorts of international visitors are not covered by ASPE.
b. Voluntary visitors to the United States are not
covered by ASPE.
10 FAM 244.2 Insurance Coverage for
Academic Programs
(CT:PEC-007; 03-29-2002)
a. All U.S. and foreign Fulbright grantees whose grants
are approved by the J. William Fulbright Foreign Scholarships Board are
provided with ASPE coverage. Coverage is provided to these grantees regardless
of the source of funding.
b. Fulbright grantees who are enrolled in a self-paid
or a mandatory university or institutional health benefit plan are still
covered by ASPE. However, they can obtain benefits from the ASPE only after
their university or institutional plan benefits are exhausted. ASPE will cover
these grantees during their travel from and return to their homes, subject to
the limitations in 10
FAM 243, when this is necessary to ensure that there is no gap in coverage.
c. Academic Specialists traveling under Bureau grants
to lecture or conduct consultations or symposia abroad are provided with ASPE
coverage.
d. Hubert H. Humphrey Fellows are provided ASPE
coverage unless the program managers arrange comparable alternative coverage.
e. Teacher exchange participants are provided ASPE
coverage. In "paired exchanges," in which participants exchange
their classroom duties, the period of coverage extends from the earliest
required departure date to the latest return date necessitated by any
difference in the teaching years of the paired exchange participants.
f. Bureau-funded participants in American studies
exchange programs, such as the American Studies Institutes program, are
provided ASPE coverage.
g. English Teaching Fellows, EFL Fellows and English
language specialists under Bureau direct grants or Bureau grants administered
by a non-profit private organization are provided ASPE coverage.
h. Participants in "U.S. Based Training
Programs" for educational advisors abroad are provided ASPE coverage.
i. Participants in academic exchange activities funded
by Bureau grants to Cooperating Private Institutions (CPIs), when the specific
participants are not approved by the Board of Foreign Scholarships, are not
provided ASPE coverage.
NOTE: Fulbright students,
Fulbright lecturers/research scholars, Humphrey Fellows, and Teacher Exchange
participants must provide a health clearance certificate, which must be filed
at the post or with a Bureau Program Agency prior to the grant award.
j. Spouses and dependents are not provided ASPE
coverage (10 FAM
246).
10 FAM 244.3 Insurance Coverage for
Citizen Exchange Programs
(CT:PEC-007; 03-29-2002)
a. The ECA Bureau provides ASPE coverage to foreign
participants in exchange activities conducted by non-profit private sector
organizations when the Bureau provides funding for the exchange and determines
the participants. The Bureau also provides ASPE coverage to U.S. participants
engaged in program activities conducted abroad by non-profit private
organizations that receive funding from the Bureau for these activities.
b. The ECA Bureau provides ASPE coverage to
participants in the Jazz Ambassador Program and the Cultural Specialist
Program, beginning from time of departure for an activity abroad until direct
return to point of origin, subject to the relevant limitations in 10 FAM 243.
10 FAM 244.4 Insurance Coverage for
Youth Exchange Programs
(CT:PEC-007; 03-29-2002)
a. U.S. and foreign participants in youth exchanges
conducted by cooperating private organizations can be provided ASPE coverage if
the Bureau provides the "primary funding" for the youth exchange,
i.e., the Bureau provides at least 50% of the total funding for both program
and administrative costs directly associated with the specific exchange, and
the Bureau is responsible for determining specifically who participates in the
exchange. (A grant of funds to an organization as a contribution to the direct
expenses of individuals who are also funded by other sources is not primary
funding). Otherwise, the cooperating private organizations responsible for
conducting the program are responsible for providing ASPE coverage to Youth
Exchange Program grantees.
b. Participants in youth exchange programs for which
the sponsoring organizations receive only facilitative funding (funding which
does not include travel and per diem for participants) from the Bureau are not
provided ASPE coverage.
10 FAM 244.5 Other
Department-Sponsored Programs
(CT:PEC-007; 03-29-2002)
Participants in other Department-sponsored programs not
mentioned in this subchapter may be enrolled in ASPE with the written approval
of the Executive Director for the Bureau of Educational and Cultural Affairs.
10 FAM 245 EMERGENCY BENEFITS
10 FAM 245.1 Medical Evacuation
Coverage
(CT:PEC-007; 03-29-2002)
a. In the event that emergency Medical Evacuation
(MEDEVAC) of an exchange participant is required because of a life-threatening
situation and the participant does not have insurance to cover medical
evacuation costs, the ASPE will pay the expenses of the medical evacuation.
The participant's return airline ticket will be used for a portion of this
expense.
b. Determination of what constitutes a medical
emergency is made by the Bureau on a case-by-case basis. In the Bureau's view,
each medical emergency is unique and it is impossible to establish a policy for
all situations.
c. Paramount is the protection of the health of
grantees, and the Bureau expects the post and the embassy to take whatever
steps are necessary. In general, the participant should be afforded the same
treatment as an officer at the post, with respect to evacuation. The Bureau
requires that medical evacuation be the result of specific advice from an
embassy-approved medical authority that the grantee's medical situation is
life-threatening and that the medical evacuation is required.
d. As soon as possible after a medical evacuation is
determined by the posts medical personnel to be necessary, the post should
contact the Bureau Office of the Executive Director and the appropriate program
officer in the Bureau to explain the situation. The Office of the Executive
Director needs to know the type of MEDEVAC arrangements required by the
situation and an estimate of costs. The program officer can provide assistance
with the notification of relatives, arrangements for the patient's reception in
the United States, and arrangements regarding the grantee's professional
commitments.
10 FAM 245.2 Emergency Medical
Benefits
(CT:PEC-007; 03-29-2002)
a. Program officers in contract agencies or posts
abroad/Fulbright Commissions must notify the Bureau program officer promptly
when a grantee sustains an accident or illness which may result in costly
medical treatment.
b. See 10 FAM 247 for
claims procedures.
10 FAM 246 INSURANCE COVERAGE FOR
DEPENDENTS OF EXCHANGE PARTICIPANTS
(CT:PEC-007; 03-29-2002)
The ECA Bureaus ASPE coverage and the MEDEVAC procedure
(see 10 FAM
245.1) do not apply to the spouse or dependent children of exchange program
participants. Participants should be advised by post or sponsoring
organization to purchase at their own expense health and MEDEVAC insurance for
a spouse and dependent children.
10 FAM 247 PROCESSING CLAIMS
10 FAM 247.1 Claims Processor
(CT:PEC-007; 03-29-2002)
a. ECA contracts with a claims processor to provide a
review of medical claims for consistency with Bureau policy and standard
medical practices. ECA officials do not have the authority to guarantee
verbally or in writing the payment of any medical expenses. All claims must be
submitted on the ASPE claim form to the claims processor for review.
b. Bureau program officers should not deal with
participants on the handling of medical claims when a Bureau Program Agency or
Cooperating Private Institution is involved in the administration of the
participants program. It is the responsibility of the Program Agency or
Cooperating Private Institution to assist participants with claims preparation
and communication with the claims processor.
c. All communications with posts, Program Agencies,
Cooperating Private Institutions, or binational commissions on the status of
hospitalized grantees must be coordinated with the Bureaus Office of the
Executive Director (ECA/EX).
10 FAM 247.2 Coordinating Benefits
(CT:PEC-007; 03-29-2002)
Each participant must report on the claim form submitted
to the claims processor any other health and accident insurance coverage which
the participant may have, including any mandatory university or institutional
plan. If the participant has health and accident insurance from another
source, the Bureau pays medical expenses, subject to applicable ASPE limits,
only after the other insurer pays its benefits in full.
10 FAM 247.3 Emergency Medical
Claims
(CT:PEC-007; 03-29-2002)
a. A Bureau grantee may request emergency medical
benefits not covered by ASPE, if during the period of a Bureau grant a grantee
incurs medical expenses which exceed $50,000 or are otherwise not covered by
ASPE, and if these expenses cannot be paid by other insurance or the grantees
personal funds. The Bureau will consider such requests if judged to be in the
overall interest of the program, if the grantee cannot pay the expenses, and
subject to the availability of appropriated funds.
b. The Bureau program officer is primarily responsible
for ensuring that payment by the Bureau for such expenses is justified because the
grantee cannot pay such expenses and must obtain concurrence of the Program
Office Director and the Bureau Executive Director when it is recommended that
the Bureau pay emergency medical benefits.
c. Program officers in contract agencies or posts
abroad/Fulbright commissions must ensure that immediately after medical
services are rendered to the grantee, the grantee files a claim with the
Departments claims processor and with any other insurance carrier for benefits
purchased by or for the grantee.
d. The Bureau program officer reviews the case and
determines whether to recommend payment of a grantee's medical expenses as an
emergency medical benefit. To recommend payment of such benefits, the program
officer submits a memorandum requesting emergency medical benefits through the
Division Chief and Program Office Director to the Bureau Executive Director.
The memorandum must be accompanied by the following:
(1) Term of claimant's Bureau grant;
(2) Physician's description of case;
(3) Tabulation of payments made by insurance
companies, if any, and/or the grantee;
(4) All medical bills related to the claim;
(5) A memorandum from the program agency/Fulbright
Commission which justifies the payment of emergency medical benefits. The
justification should indicate that the Emergency Medical Benefit claim has been
discussed with the grantee and the grantee cannot cover these costs personally;
(6) Statement that there is no university or other
insurance coverage and participant has no personal insurance or personal
resources to pay the remaining medical bills; and
(7) A copy of each claim payment check from the claims
processor.
e. The Bureau Office of the Executive Director reviews
each request and considers the justification and availability of appropriated funds
for the grantee's medical expense. If the request for emergency medical
benefits is approved, ECA/EX will initiate payment of the claim and advise the
program officer that the claim is being processed. If the request is denied,
the program officer is notified, through the Office Director and Division
Chief, with the reason(s) for denial.
10 FAM 248 AND 249 UNASSIGNED