GeoBlue Study Abroad Administration Guide

Transcription

1 GeoBlue Study Abroad Administration Guide Minnesota State Colleges & Universities

2 Contents WELCOME ADMINISTRATION 4 Website Registration 4 Managing Group Enrollment 5 Renewing, Changing, Canceling, or Editing a Member 6 ID Cards 6 Plastic ID Cards 6 Electronic ID Cards 6 Replacement ID Cards 7 Premium Payment / Invoicing MEMBER SERVICES 8 International Network 8 Contracted Providers 9 Medical Assistance & Customer Service 9 Personal Solutions 9 Emergency Medical Assistance 10 Political Evacuations 11 Claims and Reimbursements 11 Methods of Claim Submission 11 Currency Conversion GLOBAL HEALTH AND SAFETY TOOLS 12 GeoBlue app and Member Hub 12 Notice of Privacy Practices REVIEWING PLAN BENEFITS APPENDIX 2

3 Welcome to GeoBlue HEALTH PLANS THAT POWER INTELLECTUALLY CURIOUS TRAVELERS IN EVERY CORNER OF THE WORLD! Embarking on a study-abroad program is an exciting venture that opens up the mind and gives students, faculty and staff a broader, more global view of the world. GeoBlue brings peace of mind to students, parents, faculty and administrators, and lets them focus on experiencing a rich, new culture. GeoBlue combines the latest mobile technology and worldwide healthcare expertise to deliver global medical assistance and health benefits that put the health, safety and convenience of world travelers first. GeoBlue s innovative approach opens the door to an elite community of thousands of carefully selected, contracted doctors and hospitals in almost every country in the world. GeoBlue also delivers exceptional service via toll-free multi-lingual customer support and proprietary web-based administrative capabilities. GeoBlue is jointly owned by Bupa, The Blue Cross Blue Shield Association and select Blue Cross and/or Blue Shield Plans, and is the international solution for all Blue Cross and/or Blue Shield Plans. We are here to help you! Each group covered by GeoBlue is assigned a dedicated account manager who will address any issues you may encounter, special circumstances, or provide additional assistance to manage your plan; this includes benefit questions, escalated claims, enrollment, invoicing and renewal inquiries, and fulfillment or website issues. Your account manager will support any training and educational initiatives you offer your international faculty and staff, or the administrators using the web tools. GeoBlue s 24/7 Customer Service and Global Health and Safety (GHS) teams are also here to support you when members are sick or injured, have questions, or need assistance throughout the world. Name Title Contact Info Tim Munnelly Dustin Miller Account Manager Account Specialist tmunnelly@geo-blue.com dlmiller@geo-blue.com 24/7 Customer Service Customer Service 24/7 Global Health and Safety Emergency Medical Assistance Toll Free Domestic Calls Collect Calls from Outside the U.S. or customerservice@geo-blue.com After contacting/visiting your local emergency room, please notify us at (International Collect Calls Accepted) or globalhealth@geo-blue.com 24/7 Global Health and Safety Routine or Non-Emergency Care (International Collect Calls Accepted) or globalhealth@geo-blue.com Thank You for Choosing GeoBlue! In an emergency situation, members should ALWAYS seek immediate medical care, THEN contact GeoBlue once the situation has stabilized. 3

4 Administration geobluestudents.com Website Registration All of the tools you will need to complete administrative functions can be found on our website, From the main landing page, click Log In or Register and then choose For Administrators. To access sign on with your user name and password. To receive your user name, please contact your account manager. Your account manager will need your name, phone number and address to create a user name for you. We ll also need to know the level of access you require. Full access is needed to submit enrollments and cancellations as well as make changes. View Only access allows enrollment and/or billing information to be viewed, but will not allow any changes or new enrollments. MANAGING GROUP ENROLLMENT Once logged onto the Roster page, you can enroll, terminate, or edit existing student information or coverage in one of two ways. Roster Method for large groups of students 1. From the Rosters tab, you will first need to download the roster template. This is an excel document that you can save to your hard drive. 2. Once you have the roster template, please enter the information as requested. All highlighted fields are mandatory. 3. After you have entered the information, save the excel sheet as a text only tab delimited file. You can do this by clicking Save as from the template menu, and changing the file type in the drop down to Text (Tab Delimited). 4. From the Rosters tab, click the Upload Roster link. If you have saved your text file using the name you would like on your roster, you can leave the first option checked. If you would like to change the name of roster without changing the name of the text file, you can choose the Create a New Roster Called option, and enter the name in the field. 5. The Billing Period and Premium Basis will automatically populate. 6. To upload the file, click on Choose File, locate the text file from the search box and open it. You are now ready to click the orange Upload Roster box. 7. If a roster is successfully uploaded with no exceptions, a confirmation and link to Review Roster Details or Submit Roster will be displayed. You may choose to submit the roster by clicking on the Submit Roster button, or review/modify roster details by clicking on Review Roster Details. To ensure your roster was submitted for internal processing, select the Rosters tab and confirm your roster is NOT showing as Open. You may also confirm your submission on the Submitted Rosters page. 8. If a roster is successfully loaded WITH exceptions, a result page will display with the number of rows that were successfully loaded, and a list of the exceptions. 9. Exceptions are categorized as a list of errors associated with an uploaded file. A list of rosters and exceptions can be accessed by clicking Upload/Download Roster Template > Upload Summary. To view the exceptions for a particular roster, click View Exceptions. The View Exceptions screen displays a summary of roster upload information and a list of errors. The Exceptions List displays the first name, last name, date of birth, error message, and an options to either update or delete the row. If the row is updated with the correct information, the exception will disappear and the record will be moved to the open current roster. If the row is removed, no information will be moved to the current open roster and the exception will be deleted. All exceptions MUST be handled before a roster can be submitted. 10. Once all exceptions have successfully been resolved, the roster may be submitted by clicking the Review Open Roster Details button on the roster upload summary page, followed by the Submit Roster button on the Open Roster Details page. If you need to add, review or modify any participant, dependent or their payment information, you may do so by selecting the desired user from the Open Roster Details page. 11. After verifying that the roster data is correct, you may return to the Open Roster Details page by selecting the Back to Current Roster button on the participant details page. Next, click the Submit Roster button on the right side of the page. Once the roster is submitted, a message will appear confirming a successful submission. 12. Electronic ID cards and individual certificate numbers will be available online within 24 hours on the Submitted Rosters Tab (to access cards for the entire group) or the Enrolled Participants Tab (for an individual card only.) 4

5 geobluestudents.com Administration Individual Method for small numbers of students 1. From the Open Rosters tab, select Create a New Roster (located on the right.) 2. Enter your roster name and then click the orange box Create a New Roster. 3. Next, click the blue Add a Participant box, in the top right. 4. Enter the participant information and then click Continue. Mandatory fields are marked with an asterisk (*) and are the same as the roster template method explained previously. 5. A summary of the participant information will appear. If all the information is accurate, you may click the orange Add to the Roster box. If you need to make changes or revise the information, you may click on the blue Edit Participant box. 6. Finally you may view and then submit your roster. RENEWING, CHANGING, CANCELING, OR EDITING A MEMBER 1. All changes should be made from the Enrolled Participants tab. There are two types of changes; premium related changes and informational changes. 2. Locate the participant you would like to change, and to the right of the name you will see options to Change, Renew, or Cancel the policy. a. To renew a policy, click Renew under the member name, in the Enrolled Participants Tab and a new open roster will need to be created;it is recommended using student name renewal or a similar name. In the middle of the page you will see a Valid Through field. Here you may enter the new valid through date. Next, scroll down to the bottom of the page and click Submit. Since this created a new open roster, please be sure to submit the roster (as is normally included in the process.) b. To cancel a policy, also follow the Enrolled Participants tab, but under the member name select the Cancel link instead. In the space labeled, Please enter the effective cancellation date add the cancellation date (to void the entire trip, enter the policy start date) and in the Reason for Change include the reason. Finally, click the Send Cancellation Request tab. c. To submit a premium related change (i.e. insured status, effective date), go to the Enrolled Participants tab, and under the member name select Change, followed by Submit a Premium Related Change. Fill out the requested information, and then click Send Change Request. d. To submit an informational change (i.e. address, name) go to the Enrolled Participants tab and under the member name click Change, followed by Submit an Informational Change. You will need to create a new roster and then click the Start Informational Changes button. After the desired changes have been made, click Continue. Since you have created a new roster, be sure to submit it from the Open Roster tab. Renewals Renewals completed via template should follow the same process as new enrollees, taking care to enter the first and last names, date of birth and student ID number exactly as they are stored in our system. Cancellation Requests and Claims Activity Upon receipt of a cancellation request, GeoBlue will query its claim system to determine if claims have been processed or are pending payment. If claims have already been paid after the requested termination date, the termination date request will not be honored. If claims are pending, the GeoBlue account manager will discuss options with the group administrator to pay or deny the pending claims, based on the requested termination date. 5

6 Administration geobluestudents.com ID CARDS Member Name School Name Members: See benefit booklet for services covered by your plan. Possession of this card does not guarantee eligibility for benefits. Claims incurred Outside the U.S., Puerto Rico, and U.S. Virgin Islands File GeoBlue, all claims Attn: with Claims GeoBlue, Department, 100 Matsonford Road One P.O. Box Radnor 1748, Corporate Center, Suite 100 Radnor, Southeastern, PA 19087, PA , USA. USA. Visit for for instructions. 24/7 Member Services Outside the U.S Toll Free Within the U.S /7 Medical Assistance and Evacuation Collect Calls Accepted Coverage 01-Jan-16 to 01-Jan-17 Medical benefits are underwritten by 4 Ever Life Insurance Company, Oakbrook Terrace, IL, an independent licensee of the Blue Cross and Blue Shield Association. GeoBlue is the trade name of Worldwide Insurance Services, LLC (Worldwide Services Insurance Agency, LLC in California and New York), an independent licensee of the Blue Cross and Blue Shield Association. The GeoBlue ID card will list the names of all covered members on the plan as well as their certificate number. The coverage dates are listed on the front of the card. Important phone numbers and claims submission information is on the back of the card. Plastic ID Cards Per the school or group s discretion, plastic ID cards, a welcome carrier and a privacy notice will also be delivered to enrollees. Members and up to four (4) dependents will receive two (2) printed ID cards. If a member has over four dependents, two additional ID cards with their names listed will be sent. Electronic ID Cards Members can conveniently view, fax or their ID card through our mobile app under, Eligibility. Members can also access an electronic copy of the ID card on the Member Hub, at The printed copy of the ID card includes all the same information as the plastic copy, and is still valid at providers offices. Replacement ID Cards If you need hard copy replacements of ID cards, please contact your account manager. Please allow 7 to 10 business days for the ID cards to reach the member. 6

7 Administration geobluestudents.com PREMIUM PAYMENT / INVOICING Invoices can be customized and printed from the administrator s site; they are generated from roster submissions. The invoice will contain the total amount due, along with the participant s name, ID number, date of birth, and coverage dates. You can also create a custom invoice to include additional details, such as the home country, host country, and dependent information. Premiums can be paid by check, up to thirty days after the roster has been submitted. Sign on to your group s page, and select the Invoicing link You will be routed to a list of all the invoices for your group. You can download or print the invoices as needed. Payments are due within thirty days of the roster submission. Any credits or cancellations will create a credit invoice which can be applied to the next invoice, or returned to the group via check (USD.) NOTE: Applied credits are our standard, default procedure. If a refund check is needed instead, you must notify your account manager or the GeoBlue finance department. To submit payment via ACH or Wire, please use this information: Citizens Bank, Beneficiary Name: Worldwide Insurance Services, LLC., ABA: , Beneficiary Acct: , Swift Code: CTZIUS33 (International User Only) Federal ID#: Checks can be mailed to: Worldwide Insurance Services, LLC. WIS-S PO Box Pittsburgh PA

8 Member Services geobluestudents.com INTERNATIONAL NETWORK Contracted Providers GeoBlue has a distinctive process for evaluating medical providers that is unparalleled in the international insurance industry. GeoBlue has approximately 165 Regional Physician Advisors (RPAs) who are strategically located around the globe, to identify the best doctors and hospitals for contracting, in their local communities. Our providers must meet extensive selection criteria, and agree to adhere to the quality standards set forth by GeoBlue. Additionally, they must be nominated by one of our RPAs, practice westernstyle medicine, possess accreditations and board certifications from American, UK, Canadian and Australian authorities, as well as speak English fluently. Through this selection process, GeoBlue has developed and continues to expand upon an elite network of contracted and profiled providers and facilities around the world. We are committed to delivering Direct Pay for both inpatient and outpatient services; our contracted network receives direct payment from GeoBlue, so that our members will not have to incur out of pocket expenses and submit a claim for reimbursement. Recruiting and Requesting Doctors Our International Community of Providers is not static, therefore our Provider Relations department is constantly working to add vetted providers. We also offer Personal Recruitment, so if a member is aware of a provider while abroad that might meet GeoBlue s standard of care, they are welcome to submit the contact information for that provider. the provider relations team will review and verify if the provider is suitable for network admission. If the provider is then successfully contracted, it will enable the member to take advantage of Direct Pay for future visits. NOTE: A member s benefits never decrease or change if they go to a non-network provider while abroad. To request assistance finding a provider in our international network, please contact the Global Health and Safety Department (GHS). They can be reached 24 hours a day, 7 days a week. GHS can be reached by globalhealth@geo-blue.com or by calling (International Collect Calls Accepted). You can also view our network providers and request Direct Pay by downloading the GeoBlue mobile app. 8

9 Member Services geobluestudents.com MEDICAL ASSISTANCE & CUSTOMER SERVICE Personal Solutions GeoBlue provides members with an indispensable set of personal solutions, including concierge-level services provided by a Global Health and Safety coordinator. Appointment Scheduling To schedule an appointment, members can simply find a participating provider or hospital through the Member Hub or app, view the provider profile and contact the office directly. After the member makes an appointment, contact us to provide the doctor s office with the information required to arrange Direct Pay. For optimal service, request Direct Pay at least 48 hours prior to your appointment; this is necessary when scheduling follow-up appointments as well. In many countries, providers will request payment at the time of the visit unless Direct Pay has been arranged While it s often easier to set up your own appointments, we can help when members are unsure about where to seek care. To request help scheduling a convenient, cashless office visit with one of GeoBlue s trusted English-speaking doctors, contact us 24/7 at Customer Service Unrivaled Service for Travelers in Higher Education GeoBlue is built on a strong foundation of great customer service. From plans designed with higher education decision-makers in mind, to processes that make it easy to find care and file claims, meeting customer needs is our goal. Customer Service and Medical Assistance Members can call GeoBlue s call center 24/7/365, for assistance with arranging healthcare services, getting a letter for a visa appointment, or with questions about their insurance benefits. The GeoBlue staff has years of experience with international medical assistance and health plan administration. GeoBlue s dedication to customer service and relationships with key international medical experts enable us to overcome obstacles in many corners of the world. Customer Service can be reached at , or by calling collect or by at customerservice@geo-blue.com. In an emergency situation, members should ALWAYS seek immediate medical care, THEN contact GeoBlue once the situation has stabilized. Pre-trip Planning for Chronic Disease Management GeoBlue s insight and unique international experience allows us to provide members managing a chronic condition with pre-trip planning assistance prior to beginning their program, and access to the best local specialists available in their program location. Please contact our Global Health and Safety Department if you need help with managing a chronic condition while abroad. Emergency Medical Assistance When a member is receiving inpatient care, GeoBlue case managers and medical directors will coordinate the assessment of the medical condition with local medical personnel, using the latest medical standards to determine whether the member should be evacuated to a higher level of care. Medical Evacuations GeoBlue plays an active coordination role in all medical evacuations. When a member is in a situation that may require an evacuation, GeoBlue s medical team will work with the doctor responsible for treating the patient and a Regional Physician Advisor (RPA) to assess the appropriateness of local care. The RPA is able to provide credible information on the quality of services being provided and suggest regional options, if appropriate, for the patient. If it is necessary to transfer the patient, GeoBlue will work with a contracted air ambulance provider. These providers are carefully screened and credentialed, with specific attention paid to safety records. Selection of a specific provider is based on the location of the patient, the patient s medical condition and aircraft availability. If a patient can be transported by commercial airline and requires a medical escort, we arrange for a physician and/or nurse with specific expertise on managing patients during a flight. GeoBlue will also ensure that all transportation logistics are in place, and that re-admission arrangements (including guarantees of payment) have been made if the member needs receiving care upon arrival. Medical evacuations are only covered if arrangements are made in conjunction with GeoBlue and have been pre-approved. Please call the Global Health and Safety Department for more information. Repatriation of Mortal Remains GeoBlue will coordinate the repatriation of mortal remains to any location around the globe. GeoBlue will connect with local authorities to ensure that all required documentation is issued in a timely manner and coordinate transportation of the remains to the member s home country, based on family preferences and in conjunction with the receiving facility. Please contact the Global Health and Safety Department for more information. 9

10 Member Services geobluestudents.com POLITICAL EVACUATIONS GeoBlue offers Political Security and Natural Disaster (PEND) evacuation services through our vendor, DRUM Cussac. If this coverage is elected by the group, the plan will pay for specified costs of emergency evacuations under certain conditions for covered members. In the event of a covered emergency situation, on a best-effort basis, DRUM arranges and pays for an emergency evacuation by any appropriate means consistent with the member s health and safety. Services during the evacuation may include transportation to the home country, as well as the arrangement of food, lodging, and other reasonable expenses if required. A covered emergency is determined by DRUM in ALL cases, but the types of triggers may include: 1. Appropriate Authority (such as the U.S. State Department) issues travel advice recommending that members should leave that country or region. 2. The recognized government in the Host Country declares a state of emergency necessitating immediate evacuation 3. A natural disaster makes the Host Country uninhabitable 4. The political or military events in the Host country represent an imminent threat of bodily harm. Please contact your account manager or our Global Health and Safety Department should you need assistance with an evacuation. If you are interested in adding PEND to your policy, please contact your account manager as additional fees will apply. The Political, Military and Natural Disaster Evacuation Services (PEND) are provided through Drum Cussac Group Ltd. (Drum), an independent third party, non-affiliated service provider based in the UK. Drum does not supply Blue Cross or Blue Shield products or other benefits, and is therefore solely responsible for and accepts all liability for PEND and other collateral services it provides. GeoBlue makes no warranty, express or implied, and accepts no responsibility resulting from the provision or use of Drum PEND or other Drum services. 10

11 Member Services geobluestudents.com CLAIMS AND REIMBURSEMENTS Methods Of Claim Submission If a physician, ambulance company or other provider sends their bill directly to a member or a member has paid a medical provider at the time the services were rendered, a claim form will need to be submitted for reimbursement. The claim form was specifically developed so that members can notify GeoBlue of any covered health services, for which we have not already been billed. Claims can be submitted directly online via eclaims, or through the mobile app, or by , fax or regular mail. Claims do NOT need to be translated into English prior to being submitted to GeoBlue. We accept claims in all languages. You may also check the status of a claim submission and view the Explanations of Benefits (EOBs) on the GeoBlue Member Hub, online. eclaims Submit claims directly through the Member Hub, on Filing online enables the member to attach itemized billing statements, scans of checks or payments, or other necessary electronic documents. Claims filed online are saved in the Claims section of the Member Hub. Paper Claims Claim forms can be downloaded from the Member Hub on Completed forms can be submitted via , fax or postal mail. claims@geo-blue.com Fax: Postal Mail: GeoBlue, Attn: Claims Department, P.O. Box 1748, Southeastern, PA , USA. Methods Of Reimbursement Claims payments can be made to members by paper check, in U.S. Dollars. Please allow 7 to 10 business days for checks to reach the member. If a member has questions about that status of their check, please contact Customer Service at customerservice@geo-blue.com, call (Domestic Calls) or (Collect Calls Outside the U.S.) Currency Conversion GeoBlue utilizes OANDA, an outside vendor specializing in currency conversions and exchanges. GeoBlue accepts claims billed in ALL currencies, and will reimburse a claim in any currency currently authorized for payment by the United States Government. The authorized currencies are subject to change; should the currency originally requested by the member no longer be available for use in reimbursements, they will be notified by GeoBlue. If an invoice does not indicate which currency it should be paid in, the payment will default to the currency of the country in which the services were rendered. 11

12 Global Health and Safety Tools geobluestudents.com WEB TOOLS GeoBlue s online tools and mobile app provide a worldwide, all-access pass to an exclusive level of care. Members can quickly and conveniently connect to quality care across the globe from emergency needs, to filling a simple prescription, to translating symptoms, or even finding the right doctor at home or abroad. With the mobile app, a copy of your identification card is always available to share with providers. All tools are supported through our 24/7/365 customer Sservice. These self-service tools are available at and enable members to navigate risks and find the best care options: Find a doctor and schedule an appointment Review detailed profiles of contracted doctors outside of the U.S. to find the best match and locate the office. Translate medical terms Translate symptoms, diagnoses and treatment plans into the most common languages. Translate medications Find country-specific prescription and over-the-counter names and preparations for over 400 medications. Global Security Intelligence GeoBlue s unsurpassed online and mobile resources promote personal safety, by giving members convenient access to vitally important tools and news: Daily alerts detailing the latest security and health issues in a specific destination. Country or city profiles on crime, terrorism and natural disasters. Mobile App The GeoBlue app provides members with the most convenient access to the best doctors, hospitals and resources anywhere in the world. The app is available for Apple, Android and Kindle Fire devices, and puts the following functions in the hands of the member: Search providers for medical or mental health care and map them using GPS technology. Request an appointment with a trusted GeoBlue provider. Arrange direct payment for future appointments to secure cashless access to care. File a claim through the app or by sending a photo of a completed form. Determine a medication s availability, generic name, and local brand name. Translate medical terms and phrases for various different symptoms and situations; use the audio feature to play the translation. NOTICE OF PRIVACY PRACTICES Display an ID Card on a mobile device and /fax a copy directly to provider s office. Please see Appendix 12

13 Appendix geobluestudents.com

14 SCHEDULE OF BENEFITS TABLE 1 MEDICAL EXPENSES Limits Individual Insured Limits Spouse Limits Dependent Child(ren) Coverage Year Limit $100,000 $100,000 $100,000 Coverage Year Deductible $0 per Coverage Year $0 per Coverage Year $0 per Coverage Year EMERGENCY MEDICAL EVACUATION EMERGENCY FAMILY TRAVEL ARRANGEMENTS REPATRIATION OF MORTAL REMAINS ACCIDENTAL DEATH & DISMEMBERMENT Maximum Benefit up to $250,000 per Coverage Year Maximum Benefit up to $1,500 per Coverage Year Maximum Benefit up to $25,000 per Coverage Year Maximum Benefit: Principal Sum up to $10,000 Maximum Benefit up to $250,000 per Coverage Year Maximum Benefit up to $1,500 per Coverage Year Maximum Benefit up to $25,000 per Coverage Year Maximum Benefit: Principal Sum up to $5,000 Maximum Benefit up to $250,000 per Coverage Year Maximum Benefit up to $1,500 per Coverage Year Maximum Benefit up to $25,000 per Coverage Year Maximum Benefit: Principal Sum up to $1,000 SCHEDULE OF BENEFITS TABLE 2 MEDICAL EXPENSE BENEFITS COVERAGE A MEDICAL EXPENSES Physician Office Visits Inpatient Hospital Services Hospital and Physician Outpatient Services Emergency Hospital Services Certificate Limits

15 SCHEDULE OF BENEFITS TABLE 3 MEDICAL EXPENSE BENEFITS The benefits listed below are subject to coverage maximums, Deductible, Coinsurance, and Copayments listed in Tables 1 & 2 above. MEDICAL EXPENSES Maternity Care for a Covered Pregnancy Inpatient treatment of mental and nervous disorders including substance abuse Outpatient treatment of mental and nervous disorders including substance abuse Treatment of specified therapies, including acupuncture and Physiotherapy Annual cervical cytology screening for women 18 and older Low dose mammography screening, one baseline mammogram and one mammogram per year Colorectal cancer screenings Diabetic Supplies/Education Prostate screening tests Child Preventive and Primary Care Services Breast Reconstruction due to Mastectomy Repairs to sound, natural teeth required due to an Injury Outpatient prescription drugs including oral contraceptives and devices Covered Person Reasonable Expenses Reasonable Expenses up to $2,500 Maximum per Coverage Year for a maximum period of 30 days per Coverage Year Reasonable Expenses up to $500 Maximum per Coverage Year Reasonable Expenses up to 20 visits per Coverage Year on an Outpatient basis up to $500 per Coverage Year maximum 100% of actual charge up to a maximum of $10,000 per Coverage Year, limited to a 31 day supply for initial fill or refill GENERAL CERTIFICATE EXCLUSIONS Unless specifically provided for elsewhere under the Certificate, the Certificate does not cover loss caused by or resulting from, nor is any amount charged for, any of the following: 1. Expenses incurred in excess of Reasonable Expenses.

16 2. Services or supplies that the Insurer considers to be Experimental or Investigative. 3. Expenses incurred prior to the beginning of the current Period of Coverage or after the end of the current Period of Coverage except as described in Covered General Medical Expenses and Limitations and Extension of Benefits. 4. Preventative medicines, routine physical examinations, or any other examination where there are no objective indications of impairment in normal health, including routine care of a newborn infant, unless otherwise noted. 5. Services and supplies not Medically Necessary for the diagnosis or treatment of a Sickness or Injury, unless otherwise noted. 6. Surgery for the correction of refractive error and services and prescriptions for eye examinations, eye glasses or contact lenses or hearing aids, except when Medically Necessary for the Treatment of an Injury. 7. Cosmetic surgery and therapies. Cosmetic surgery or therapy is defined as surgery or therapy performed to improve or alter appearance or self-esteem or to treat psychological symptomatology or psychosocial complaints related to one s appearance. 8. Surgical breast reduction, breast augmentation, breast implants or breast prosthetic devices, except as specifically provided for in the Certificate. 9. Expenses incurred for elective treatment or elective surgery except as specifically provided elsewhere in the Certificate and performed while the Certificate is in effect. 10. Elective termination of pregnancy. 11. For diagnostic investigation or medical treatment for reproductive services, infertility, fertility, or for male or female voluntary sterilization procedures, or the reversal male or female voluntary sterilization procedures. 12. Expenses incurred for, or related to gender reassignment surgery. 13. Organ or tissue transplant. 14. Participating in an illegal occupation or committing or attempting to commit a felony. 15. While traveling against the advice of a Physician, while on a waiting list for a specific treatment, or when traveling for the purpose of obtaining medical treatment. 16. Expenses incurred within the Covered Person s Home Country. 17. The diagnosis or treatment of Congenital Conditions, except for a newborn child insured under the Certificate. 18. Treatment to the teeth, gums, jaw or structures directly supporting the teeth, including surgical extraction s of teeth, TMJ dysfunction or skeletal irregularities of one or both jaws including orthognathia and mandibular retrognathia, unless otherwise noted. 19. Expenses incurred in connection with weak, strained or flat feet, corns or calluses. 20. Diagnosis and treatment of acne. 21. Diagnosis and treatment of sleep disorders. 22. Expenses incurred for, or related to, services, treatment, education testing, or training related to learning disabilities or developmental delays. 23. Expenses incurred for the repair or replacement of existing artificial limbs, orthopedic braces, or orthotic devices. 24. Deviated nasal septum, including submucous resection and/or surgical correction, unless treatment is due to or arises from an Injury. 25. Expenses incurred for any services rendered by a family member or a Covered Person s immediate family or a person who lives in the Covered Person s home. 26. Loss due to an act of war; service in the armed forces of any country or international authority and Participation in a Riot or Civil Commotion. 27. Riding in any aircraft, except as a passenger on a regularly scheduled airline or charter flight. 28. Loss arising from a. participating in any professional sport, contest or competition; b. while participating in any practice or condition program for such sport, contest or competition;

17 c. SCUBA diving, sky diving, mountaineering (where ropes and climbing equipment are customarily used), ultra-light aircraft, parasailing, sailplaning/gliders, hang gliding, parachuting, or bungee jumping. 29. Medical Treatment Benefits provision for loss due to or arising from a motor vehicle Accident if the Covered Person operated the vehicle without a proper license in the jurisdiction where the Accident occurred. 30. Under the Accidental Death and Dismemberment provision, for loss of life or dismemberment for or arising from an Accident in the Covered Person s Home Country. 31. Inpatient room and board charges in connection with a Hospital stay primarily for diagnostic tests which could have been performed safely on an outpatient basis. 32. Telephone, , and Internet consultations unless specifically approved by the Administrator due to limited resources while located in a country outside of the United States. 33. Orthopedic shoes (except when joined to braces) or shoe inserts, including orthotics. 34. To the extent that such payments would be prohibited by law.

18 Privacy Policy THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION 4 Ever Life Insurance Company PLEASE REVIEW IT CAREFULLY This notice describes 4 Ever Life Insurance Company s privacy practices in compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the regulations that implement HIPAA. Our Legal Duty HIPAA requires us to maintain the privacy of information we use and maintain about you (your medical information). We are required to give you this notice about our privacy practices, our legal duties, and your rights concerning your medical information. We also must inform you of a breach involving your unsecured medical information. We must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect July 1, 2013, and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this notice at any time. Any new terms will be effective for all medical information that we maintain, including medical information we create or receive before we make the changes. Before we make a significant change in our privacy practices, we will change this notice and post our new notice on our website. We will provide information about changes to the notice and how to obtain the notice in our next annual mailing to our health plan subscribers at the time of the change. You may request a copy of our notice at any time. For more information about our privacy practices, or for additional copies of this notice, please contact us using the information listed at the end of this notice. Uses and Disclosures of Medical Information We use and disclose medical information about you for the following purposes: Treatment: We may use and disclose your medical information for treatment. For example, we may disclose your medical information to a physician or other health care provider who is providing treatment to you. Payment: We may use and disclose your medical information to pay for benefits or to obtain premiums. For example, we pay claims to physicians, hospitals and other providers for services delivered to you that are covered by your health plan. We also use and disclose your medical information to establish your eligibility for benefits, to determine medical necessity, and to issue explanations of benefits. We may disclose your medical information to a health care provider or entity subject to HIPAA so they can engage in these type of payment activities. Health Care Operations: We may use and disclose your medical information in connection with our everyday work activities (health care operations). These operations include, for example, customer service, resolution of grievances, quality assessment and improvement activities, and fraud and abuse detection and compliance. They also include underwriting, enrollment, and other activities related to creating, renewing, or replacing a benefits plan. We may not, however, use or disclose genetic information for underwriting purposes. In limited circumstances, we may disclose your medical information to another entity subject to HIPAA so they can engage in their own health care operations. Required or Permitted by Law: We may use or disclose your medical information when required by law, such as in response to a court order or for government health oversight activities (i.e., inquiries from a State Department of Insurance). In limited circumstances, we may also give out medical information as permitted by law, such as for public health purposes (i.e., reporting disease outbreaks), law enforcement purposes, research studies, to avoid a serious and imminent threat to health or safety, to create de-identified information, and for emergencies. Form H 7/1/13

19 To You or Others Involved In Your Care: We may use or disclose your medical information to provide information to you or to a family member, friend or other person to help with your health care or with payment for your health care. Before we disclose your medical information to a family member, friend or other person, we will provide you with an opportunity to object to the use or disclosure. If you are not present, or in the event of your incapacity or an emergency, we will disclose your medical information based on our professional judgment of whether the disclosure is in your best interest. Plan Sponsors: If you are a participant in a group health plan, we may disclose summary information about the enrollees in your plan to the employer (or other organization that sponsors your plan) to use to obtain premium bids for the health insurance coverage offered through your plan or to decide whether to modify, amend or terminate your plan. Summary information is partially de-identified information about claims history, claims expenses, or types of claims experienced by plan enrollees. If the employer (or other plan sponsor) takes appropriate steps to comply with HIPAA, we may disclose medical information of individuals enrolled in your plan to the plan sponsor to permit the plan sponsor to perform plan administration functions. If this is the case, your group health plan will publish its own notice describing how it uses and disclosures your medical information. Situations Other Than Those Above: Except as described in this notice, we may not use or disclose your medical information without your written authorization. You may give us written authorization to use your medical information or to disclose it to anyone for any purpose. If you give us written authorization, you may revoke it at any time by notifying us of your revocation in writing. Your revocation will not affect any use or disclosure permitted by the authorization while it was in effect. We need your written authorization to use or disclose psychotherapy notes, except in limited circumstances such as when the disclosure is required by law. We also must obtain your written authorization to sell information about you to a third party or, in most circumstances, to use or disclose your medical information to send you communications about products and services. We do not need your written authorization, however, to send you communications about health related products or services, as long as the products or services are associated with your coverage or are offered by us. Individual Rights In most cases, you have the right to look at or get a copy of the medical information that we use to make decisions about you. If you request copies, we may charge you a reasonable, cost-based fee for the copies. You also have the right to receive a list of instances in which we have disclosed health information about you for reasons other than treatment, payment, health care operations, and certain other purposes. If you believe the records we maintain about you are incorrect or are missing important information, you have the right to request that we correct our records. If you believe that you would be in danger if we send your medical information to the address we have for you in our records, you have the right to request that we communicate with you using alternative means or an alternative location. We will accommodate your request if the request (a) states that our communications could put you in danger, (b) is reasonable, (c) specifies the alternative means or location for communicating with you, and (d) permits us to continue collecting premiums and paying claims under your health plan. Finally, you may request that we place additional restrictions on how we use or disclose your medical information. We will consider your request but are not legally required to agree to it. All requests to exercise these rights must be made in writing by you and directed to the contact person named below. Questions and Complaints If you want more information about our privacy practices or have questions or concerns, please contact us using the information listed at the end of this notice. If you are concerned that we may have violated your privacy rights, you may complain to us using the contact information listed at the end of this notice. You may also submit a complaint to the U.S. Department of Health and Human Services. We will provide you with their address upon request. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services. Privacy Officer 4 Ever Life Insurance Company 2 Mid America Plaza, Suite 200 Oakbrook Terrace, IL Phone: Fax: privacyofficer@bcsigroup.com Form H 7/1/13