Glossary

A private company contracted by the US Department of State to administer the ASPE health benefit plan. The current administrator is Seven Corners.

Means an establishment which, may or may not be part of a Hospital and which meets the following requirements:

1. is in compliance with the license or other legal requirements in the jurisdiction where it is located;
2. is primarily engaged in performing surgery on its premises;
3. has a licensed medical staff, including Physicians and Registered Nurses:
4. has permanent operating room(s), recovery room(s) and equipment for emergency care, and
5. has an agreement with a Hospital for immediate acceptance of patients who require Hospital care following treatment in the ambulatory surgical facility.

When a claim has been denied, an Exchange Participant has the right to appeal the decision. The Exchange Participant must submit detailed justification, supported by pertinent documentation to the Administrator for review.

Accident and Sickness Program for Exchanges, the self-funded health benefit plan offered to US Department of State exchange program Exchange Participants administered by Seven Corners, Inc.

A section on the ASPE claim form that, when signed and dated by the Exchange Participant, authorizes the Administrator to make payment directly to the health care provider.

The one-year period that begins on your start date in the ASPE program.

A letter providing evidence of your prior health coverage. Upon request this document is provided by Seven Corners.

A written request for payment for medical services. Claims are submitted along with receipts and any other relevant documentation to Seven Corners after treatment has been received. Claim forms are available here

A secondary condition, either Injury or Sickness, which develops or is in conjunction with an already existing Injury or Sickness.

Any medical condition that is distinct complication from a normal pregnancy, but is adversely affected by or caused by pregnancy. Complications of pregnancy includes: acute nephritis, nephrosis, cardiac decompensation, missed abortion, a medically necessary caesarean section, ectopic pregnancy which is terminated, a spontaneous termination of pregnancy occurring when a viable birth is not possible, and similar serious adverse medical conditions caused by or affected by pregnancy. Not included in Complications of pregnancy: false labor and/or occasional spotting. In addition, Physician prescribed rest during pregnancy, morning sickness, preeclampsia, and conditions involved in a difficult pregnancy not medically classified as a distinct complication of pregnancy.

A physical abnormality or condition that is present at birth, whether inherited or caused by the environment.

Copay is the specified dollar amount that a patient is expected to pay directly to the provider at the time of service.

Expenses for medical services or supplies that are:

1. allowable by the ASPE health benefit plan,
2. administered or ordered by a Physician,
3. medically necessary to the diagnosis and treatment of an Injury or Sickness,
4. related to medical conditions that are not pre-existing per the ASPE health benefit plan definition, and
5. not in excess of the negotiated rate based on services provided or the usual, customary and reasonable fee schedule.

Medical services or supplies that are allowable by the ASPE health benefit plan, related to medical conditions that are not pre-existing per the ASPE health benefit plan definition and when provided by a provider acting within the scope of their license. In order to be considered a covered service, charges must be incurred while your coverage is in force.

An Exchange Participant in an eligible USDOS sponsored exchange program who is enrolled in the ASPE health benefit plan. “Eligible Program” does not include those for which USDOS support is primarily for administrative or facilitative support rather than direct participant costs. “Participants” does not include escorts, escort / interpreters, staff of organizations receiving grant support directly or indirectly from the USDOS, independent consultants associated with these organizations, or dependents of program participants.

Durable Medical Equipment means medical equipment which:

1. is prescribed by the Physician who documents the necessity for the item, including the expected duration of its use;
2. can withstand long term repeated use without replacement;is not useful in the absence of Injury or Sickness; and
3. can be used in the home without medical supervision.

See Covered Person definition above.

A sudden, unexpected onset of a medical condition that, in the reasonable opinion of the Exchange Participant, 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 cause serious impairment to the Exchange Participant’s health.

Exchange Participants are eligible to participate in ASPE when they are registered or enrolled in the program by their commission or cooperating agency. The commission or cooperating agency issues each Exchange Participant and ASPE identification card.

Is an acronym for Explanation of Benefits. Although EOBs often look like a medical bill, the EOB tells you what portion of a claim was paid to the Health Care Provider and what portion of the payment, if any, is your responsibility.

Any services or supplies related to non-covered plan benefits.

Any treatment, procedure, facility, equipment, drug, device or supply which:

1. is not accepted as standard medical treatment for the condition being treated; or
2. requires but has not received federal or other governmental agency approval at the time of service.

A licensed physician, hospital or clinic that provides medical services.

An institution which:

1. operates as a Hospital pursuant to law for the care and treatment of sick or injured persons as inpatients;
2. provides 24-hour nursing service by registered nurses on duty or on call;
3. has a staff of one or more Physicians available at all times;
4. provides organized facilities for diagnosis, treatment and surgery either on its premises, or in facilities available to it on a pre-arranged basis: and
5. is not primarily a nursing, rest, convalescent home or similar establishment, or any separate ward, wing or section of a Hospital used as such.

A card issued by the ASPE health benefit plan that bears the member’s name, identifies the membership by number and may contain information about his or her coverage.

An accidental bodily injury sustained by an Exchange Participant while covered under the ASPE health benefit plan and which occurs independent of all other causes.

A person who is a resident patient, using and paying for the room and board facilities of a Hospital.

An intensive care unit, cardiac care unit, or other unit or area of a Hospital:

1. reserved for the critically ill requiring close observation; and
2. equipped to provide specialized care by trained and qualified personnel and special equipment and supplies on a standby basis.

The financial loss associated with an accident or illness for a claim submitted to the Administrator.

The program of health care for the aged and disabled established by Title XVIII of the Social Security Act of 1965, as amended.

A licensed physician, licensed clinical psychologist or a master of social work (MSW), acting within the scope of his or her license who is not the Exchange Participant or a member of the Exchange Participant’s immediate family, who may provide services that are medically necessary for mental and nervous disorders only.

Neurosis, psychoneurosis, psychosis, or mental or nervous disease or disorder of any kind.

A person who receives medical services and treatment on an Outpatient basis in a Hospital, Physician’s office, Ambulatory Surgical Center, or similar centers, and who is not charged room and board for such services.

The retail and mail service pharmacy network.

1. Flying, except:
   • as a passenger on a regularly scheduled airline;
   • as a passenger on a chartered carrier for purposes of an approved grant program activity;
   • as a passenger in the Military Airlift Command of the U.S. or similar air transport services of other countries.
2. Playing, practicing, or participating in professional sports, or during travel for such purposes. Professional sports also include skateboarding, snowboarding, BMX racing, X-games (extreme sports), and boxing.
   If your participation in a professional sports event is part of your grant the perilous activity clause does not apply.
3. Operation of a vehicle while not properly licensed to do so or riding in a non-commercial vehicle operated by a person not licensed to do so in the jurisdiction in which the accident takes place.
4. Operation of a vehicle while under the influence of drugs or alcohol.
5. Dangerous activity not directly related to the fulfillment of grant objectives, e.g., boxing, bungee jumping, scuba diving, skydiving, rock climbing (indoor/outdoor), hang gliding, operation of an all-terrain vehicle (ATV) or motocross bike, downhill skiing, horseback riding, parachuting, zip lining, parasailing, bungee jumping, water skiing, wakeboard riding, jet skiing, windsurfing, snowmobiling, spelunking, and motorcycle/motor scooter riding.
   If your grant requires that you travel to areas requiring an ATV, motorcycle/motor scooter or snowmobile then item 5 does not apply.

A qualified, licensed health care practitioner, acting pursuant to a license, who is not the Exchange Participant or a member of the Exchange Participant’s immediate family.

A physical or mechanical therapy, diathermy, ultrasonic, heat treatment in any form, manipulation or massage.

Seven Corners must be contacted to confirm coverage and benefits:

1. as soon as non-Emergency hospitalization is recommended;
2. within forty-eight (48) hours of the first working day following an Emergency hospitalization;
3. when your Physician recommends any surgery, including Outpatient; or
4. for medical evacuation, repatriation and assistance services.

Pre-certification is not a guarantee of coverage.

Any condition which:

1. had its origins prior to the Exchange Participant ‘s effective date of coverage;
2. a Physician was consulted prior to the Exchange Participant ‘s effective date of coverage;
3. treatment or medication was received prior to the Exchange Participant ‘s effective date of coverage; or
4. would have caused any prudent person to seek medical advice or treatment, prior to the Exchange Participant’s effective date of coverage.

Note: For purposes of the ASPE, pregnancy is not defined as a pre-existing condition.

Providers of service who have been selected or have decided to become part of a preferred network to work with an insurer to help control costs to patients.

When you are ill or injured, your coverage helps pay the hospital and your physician as well as appropriate charges for other approved health care professionals. These providers include but are not limited to:

1. Hospital – any hospital accredited by the Joint Commission on the Accreditation for Health Organizations, including Veterans Administration Hospitals and Department of Defense Hospitals.
2. Physicians – any provider licensed in the state or country where the services were provided. These include: Doctor of Medicine (MD), Doctor of Osteopathy (DO), Doctor of Dental Surgeries (DDS or DMD), Podiatrist (POD) and Psychologist (Ph.D.).
3. Certified Nurse Midwife – Must be a licensed registered nurse and certified as a nurse midwife by the American College of Nurse Midwives.
4. Other Providers – Nurse anesthetist, nurse practitioner, psychiatric social worker, respiratory therapist, speech therapist, occupational therapist, optician, optometrist, physicians’ assistant, private duty nurse, technical surgical assistant, registered physical therapist or physiotherapist. All of the above mentioned providers must be licensed or certified in the jurisdiction where the services were provided.
5. Registered Nurse - a graduate nurse who has been registered or licensed to practice by a State Board of Nurse Examiners or other state authority, and who is legally entitled to place the letters R. N. after his or her name.

When payments for a given medical treatment have been made in excess of the amount necessary, the USDOS has the right to recover such overpayments. The USDOS will notify the Exchange Participant of the overpayment and request reimbursement from the health care provider / Exchange Participant. If the health care provider does not reimburse USDOS for the overpayment, USDOS reserves the right to set the overpayment against any other benefits payable to the Exchange Participant.

An illness, disease, or physical condition of an Exchange Participant commencing while coverage is in force.

The use of telecommunications technologies to provide long-distance or remote clinical health care.

The payment amount as determined by a nationally recognized MDR fee schedule based upon geographic location. The Administrator purchases the MDR fee schedule from Ingenix, and the Administrator reserves the right of final determination of the amount payable for any service or supply.
The following is the basis for determination of UCR:

1. Usual - an amount a professional provider routinely charges for a given service.
2. Customary - an amount which falls within the range of charges for a given service billed by most professional providers in the same locality who have similar training and experience.
3. Reasonable - an amount that is Usual and Customary or an amount not considered excessive in a particular case because of unusual circumstances.
4. 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 identification card filled out by the program organization in accordance with the rules outlined below.

1. An Identification Card is valid, when filled out in its entirety, including the full and complete name of the Exchange Participant, program organization name and telephone number, and the exact dates of coverage.
2. The program organization shall not enroll anyone in the ASPE health benefit plan who is not an “Eligible Exchange Participant” as defined in this statement. Enrollment of a person who does not meet Individual Eligibility Requirements will nullify the coverage and release the program organization from any liability associated with loss or claim.
3. The program organization shall not enroll an Eligible Person in the ASPE health benefit plan for a period outside the Enrollment Period. Enrollment of an Eligible Exchange Participant for a period outside the Enrollment Period as defined will nullify the coverage and release the program organization from liability associated with losses and claims occurring outside the enrollment period.
4. An identification card is not valid if the program organization has not submitted an enrollment form to the program organization as required.
5. An identification card is not valid for anyone other than the Exchange Participant as defined above.