DSCA Policy Memorandum 11-32

1. Purpose.

   The purpose of this memorandum is to provide additional information for the healthcare coverage requirements issued in Defense Security Cooperation Agency (DSCA) Policy Memorandum 10-39, dated June 23, 2010. This policy memorandum applies to international military students (IMS) and international civilian students (ICS) participating in education and training under security assistance and security cooperation programs managed or administered by the DSCA. This memorandum also pertains to all authorized dependents who accompany or join the IMS, or the ICS during their education and training. For clarity, this memo replaces Policy Memorandum 10-39 in its entirety.

   1. The policy in this memorandum is effective 30 days from the date of signature of the memo. IMS enrolled in training/education programs prior to the effective date of this memo may continue to adhere to the requirements stipulated in DSCA policy memo 10-39. IMS enrolled in training/education programs prior to May 26, 2010 may continue to adhere to DSCA policy message 07-27. Support for International Military Student Officer (IMSO) (reference Section 7.d. of this policy) should be implemented as soon as possible (i.e., if contractor support is provided, subject to military departments (MILDEPs) contracting process constraints).
   2. This policy should be used concurrently with DSCA Policy Memo 09-42, Medical Screening of International Military Students, Civilians and Authorized Dependents.
   3. Unless otherwise noted, all references to IMS in this memorandum refer to both IMS and ICS, and all references to dependents refer to authorized dependents of the IMS or ICS (authorization for dependents and listing of dependents are in section 12 of the invitational travel order (ITO)).

2. Acronyms.

   Term	Meaning
   COCOM	Combatant Commands
   CTFP	Combating Terrorism Fellowship Program
   DISAM	Defense Institute of Security Assistance Management
   DLIELC	Defense Language Institute English Language Center
   DoD	Department of Defense
   FMF	Foreign Military Financing
   FMS	Foreign Military Sales
   ICS	International Civilian Students
   IMS	International Military Student (term includes both international military and civilian participants)
   IMSO	International Military Student Officer
   IMET	International Military Education and Training
   ITO	Invitational Travel Order
   MILDEP	Military Department
   MTF	Military Treatment Facility
   NATO/PfP	North Atlantic Treaty Organization/Partnership for Peace
   RC	Regional Centers for Security Studies (e.g., Africa Center for Strategic Studies, Asia-Pacific Center for Security Studies, Center for Hemispheric Defense Studies, George C. Marshall European Center for Security Studies, Near East South Asia Center for Strategic Studies)
   RHCA	Reciprocal Healthcare Agreement
   SCO	Security Cooperation Officer
   SOFA	Status of Forces Agreement

3. General.

   All IMS and authorized dependents are required to have healthcare coverage while in the United States. The IMS are held responsible for payment of all incurred healthcare bills, including co-payments, deductibles, and services not covered by the following methods.

   1. There are five primary methods by which healthcare coverage may be provided for IMS, and/or authorized dependents:

      1. Foreign government indemnification and direct payment to service providers for healthcare cost incurred by IMS and/or 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.

         NOTE: Arrangements that require the IMS to pay for medical services and then seek reimbursement from their government are prohibited unless DSCA (Programs Directorate) has granted a waiver. A waiver request with specific details must be submitted by the SCO through the COCOM to DSCA (Programs Directorate) 60 days prior to reporting to the first course. DSCA (Programs Directorate) will coordinate approval of the waiver request with MILDEPs. The approved waiver will be kept on file by the SCO and annotated on the ITO where indicated. Waiver will be valid unless there is a failure to pay bills within 90 days.

      2. Training case line item for medical coverage. An FMS or FMF 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 IMS and/or dependents within this line, the details must be included in the ITO. IMS and/or dependents may be indemnified by IMS' government for pregnancy coverage, and if not, supplementary commercial insurance may be required to meet the requirements of paragraphs 4e and 5 of this policy. The cost of supplemental insurance is not treated as a cost of the training or the course itself.
      3. Grant programs. Some U.S. Government grant programs (e.g., IMET, CTFP, FMF cases with approved medical lines, etc.) pay for the healthcare costs of the IMS only.
      4. RHCA and NATO/PfP SOFA nations. 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.
      5. 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.
   2. When healthcare costs are incurred in a DoD Military Treatment Facility (MTF) they are considered to be a personal debt of the IMS to the U.S. Government.
   3. In most cases, civilian healthcare providers/treatment facilities will require the patient to show how costs for healthcare will be paid. Properly prepared ITOs fulfill this requirement. When the ITO indicates commercial healthcare insurance is required, the IMS will need to provide the servicing medical treatment facility with their insurance card.
   4. When a specific medical or dental treatment is not available at a DoD treatment facility, IMS and 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.)
4. Healthcare Coverage.
   1. Non-NATO/PfP SOFA IMS healthcare coverage will be provided by the appropriate program as designated on the ITO (e.g., IMET, CTFP, country direct, FMS case, FMF case, or a personally procured medical insurance policy that meets DSCA requirements).
   2. 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 that do not provide complete coverage require either a separate FMS case for medical expenses or commercial insurance that meets DSCA requirements.
   3. For an IMS with NATO/PfP under a SOFA status, the following healthcare provisions pertain:
      1. Healthcare at a DoD MTF is as follows:
         1. Outpatient care (medical and emergency dental) in DoD MTF is at no charge for IMS and authorized dependents (some treatments are available for only IMS and not for authorized dependents).
         2. Inpatient care for both IMS and dependents (if available) is on a reimbursable basis. Healthcare insurance is required for IMS and/or authorized dependents if not covered by the program or case or if payment is not guaranteed in writing by the foreign government.
      2. Healthcare at a civilian treatment facility is as follows:
         1. 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. 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.
         2. Inpatient care for both IMS and dependents is on a reimbursable basis. IMS and/or dependents are required to have supplemental medical insurance coverage.
   4. IMS covered under a RHCA.
      1. RHCAs differ by country in coverage and may not provide full healthcare coverage. It is critical that the RCHA 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 full service MTF, or the nearest MTF is located a considerable distance from the schoolhouse/training activity. In addition, IMS and authorized dependents may require care while traveling away from their assigned military installation. Section 4.e. of this policy memo specifies the total amount of insurance required. All IMS and their authorized dependents that are relying 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 U.S. under DoD sponsorship.
      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.
   5. Minimum Required Healthcare Insurance Policy Coverage.
      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 U.S. The initial insurance policy should be in effect for one year or the duration of the IMS stay in the United States under DoD security cooperation sponsorship.
      2. Medical benefits of at least $400,000 per year (payable in U.S. dollars; no conversion from foreign currency).
      3. Deductible not to exceed $1000 annually per family.

      4. Repatriation of remains in the amount of $50,000 (per individual), should a death occur in the U.S.

         NOTE: This provides for the preparation and transportation of remains to home country.

      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 IMS, international civilian students, and/or authorized dependents to return to their home country.

      6. Healthcare insurance policy coverage must meet the following requirements:

          

         1. NOTE: 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.
         2. No exclusion for payment of benefits directly to a DoD MTF if applicable.
         3. Provide nationwide coverage/service; non-U.S. based policies must provide benefits in the U.S.
         4. Provide single source administration/management for the policy.
         5. Have a point of contact in the U.S. In all cases, the insurance company is to pay promptly in U.S. currency directly to healthcare provider.
         6. Have a copy of the policy written in English.
            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 the policy.
            2. Some MILDEP schools may require the IMSO to review health insurance policies for compliance 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.

         7. If U.S. education and training is taking place in a third country, medical coverage must meet the requirements of the host country.

             

            NOTE: Contact SCO, DoD training facility, or Regional Centers in host country to determine specific requirements.

             

      7. The minimum dollar standards and coverage requirements will be reviewed annually by DSCA (Programs Directorate) to ensure that minimum requirements reflect current cost and coverage of the U.S. healthcare.
5. Pregnancy Coverage.

   1. 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 for any incurred cost, in writing, prior to their arrival.

      NOTE: Pregnancy insurance is in addition to insurance requirements specified in paragraph 4.e. of this policy.

   2. An IMS or authorized dependent without pregnancy coverage who is found to be pregnant after arrival in the U.S. will be returned to their 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.
   3. Pregnancy and childbirth coverage is not usually included in insurance policies purchased less than 12 months in advance, and is generally very expensive.
   4. 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.
6. Invitational Travel Order.
   1. Required health screening and healthcare financial responsibility entries for 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.
   2. For 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 the 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 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 is included in this coverage.
   3. Dependents are encouraged to accompany or join the IMS attending the following institutions or courses:
      • National Defense University (except Joint Forces Staff College which does not authorize dependents)
      • Army War College
      • Inter-American Defense College
      • Intermediate Level Education and School of Advanced Military Studies at the Army Command and General Staff College
      • ILE at the Western Hemisphere Institute for Security Cooperation
      • Army Sergeants Major Course
      • Navy Command College
      • Navy Staff College
      • United States Marine Corps Command and Staff College
      • USMC Expeditionary Warfare School
      • USMC School of Advanced Warfighting, Marine Corps War College
      • Air War College
      • Air Command and Staff College
      • Naval Postgraduate School
      • Graduate programs at Air Force Institute of Technology
   4. A pregnant IMS or a pregnant authorized dependent will require a health policy waiver before being placed on an ITO. Policy and procedures for a health policy waiver are provided in DSCA Policy Memo 09-42.
7. Responsibilities.
   1. Country Responsibilities. When applicable, provide to the SCO copies of signed, legal country-to-country agreements or other statements that stipulate payments and reimbursements of healthcare costs for IMS or dependents (e.g., RHCA, SOFAs, etc.).
   2. DSCA Responsibilities. DSCA is the DoD designated authority for international security cooperation training and education programs. DSCA develops, promulgates policy and guidance, and provides oversight for the implementation and execution of healthcare coverage policy to the MILDEPs, IMSO, COCOMs, and SCOs. DSCA reviews, coordinates with MILDEPs, and approves requests for exception to the healthcare coverage policy.
   3. SCO Responsibilities.
      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.
      2. When IMS is covered by 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 RHCA or NATO/PfP SOFA.
      3. A waiver granted by DSCA (Programs Directorate) is required for modified medical coverage arrangement; e.g., country insurance requires student to pay outpatient costs and seek reimbursement; or country wishes to guarantee payment for medevac or repatriation expenses rather than including in insurance. DSCA (Programs Directorate) will coordinate approval of the waiver request with the MILDEPs. SCO will include specific details, U.S. point of contacts, and U.S. billing address for the approved request with date of DSCA approval in the ITO.
      4. If applicable, ensure IMS has a copy of healthcare insurance policy (in English) for delivery to IMSO upon arrival at first education and training site.

      5. If applicable, include in block 15 of the ITO a notation of any existing special medical conditions/preconditions for both IMS and/or dependents.

         NOTE: Per DSCA Policy Memo 09-42, do not provide any details that may compromise the rights to privacy of the IMS or authorized dependents.

      6. If applicable, when training will occur in a third country, ensure IMS has met healthcare requirements of host country.
      7. Brief IMS on the following:
         1. Eligibility for healthcare in a DoD MTF.
         2. When applicable, advise that failure to maintain required healthcare insurance policy coverage, to include pregnancy coverage, for the duration of stay, could result in removal from education and training and return home.
         3. Inform IMS that while under sponsorship of DoD security assistance or security cooperation education and training programs, non-emergency participation on behalf of IMS or non-U.S. citizen dependents, in a U.S. Federal, State, or other U.S. taxpayer-subsidized medical/dental programs is not authorized.
         4. Inform the IMS of the financial and ethical responsibilities regarding all aspects of this healthcare policy and have IMS acknowledge, in writing, an understanding of the policy concerning healthcare insurance coverage, including consequences of a lack of pregnancy coverage and prohibition against using non-emergency U.S. taxpayer provided medical/dental assistance under DoD sponsorship. Retain the statement until IMS has returned to home country.
   4. IMS Responsibilities.
      1. Acknowledge, in writing, an understanding of policy concerning healthcare insurance coverage, including consequences of the lack of pregnancy coverage and prohibition against using non-emergency U.S. tax-payer provided medical/dental assistance while under DoD sponsorship.
      2. If applicable, present healthcare insurance policy (in English) to the IMSO and to medical treatment facilities.
      3. Notify IMSO immediately of any and all medical care required or received by 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.
   5. IMSO Responsibilities.
      1. Review 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.

      2. If commercial healthcare insurance is required for IMS and/or authorized dependents, as directed by the MILDEP, review the healthcare insurance policy for compliance with requirements specified in Section 4.e. of this policy memo. Provide 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.

         NOTE: Review for insurance policy compliance should be completed prior to issuance of the ITO.

      3. Advise IMS of the requirement to take ITO and healthcare insurance policy documentation to local medical treatment facilities and any physicians they see during their stay in the U.S.
      4. Brief IMS on all procedures and requirements as outlined in this policy memorandum, including requirements in cases of pregnancy. Obtain a signed memorandum of acknowledgement and understanding from IMS.
      5. Unauthorized dependents are not covered within this policy. In cases when an unauthorized dependant arrives at the training activity location, contact MILDEP training policy manager immediately.
   6. COCOM Responsibilities.
      1. Ensure that the SCO understands and adheres to the policies contained in this message.
      2. Include adherence to this policy as an area of interest in Inspector General inspections and performance evaluations of SCO.
   7. MILDEP Responsibilities.

      1. When commercial healthcare coverage is required, establish policy and procedures for the review of healthcare policies for compliance with this policy memo. If this task is assigned to the IMSO, ensure the IMSO has received the necessary training and/or support to meet the requirement to review IMS commercially procured healthcare policies.

         NOTE: If MILDEPs' contracts for needed support to IMSO to review proposed healthcare coverage policies the cost of the medical reviewer is additive to tuition rates and shall be computed similarly to the instructions found in the DoD Financial Management Regulation, Volume 15, Chapter 7, paragraph 071102.B. The cost developed will be the same per student regardless of the training rate, (i.e. cost is considered to be an incremental cost).

      2. In coordination with COCOM, enforce the following directives when notified by IMSO of IMS non-compliance with this policy memorandum.
         1. When notified by the IMSO of an irresolvable lapse or lack of required commercial healthcare insurance for the IMS, coordinate with IMS' government to determine payment mechanism for outstanding medical bills. If IMS' government does not agree to pay for required healthcare insurance or outstanding medical bills take action to withdraw IMS from education and training and return IMS to home country.
         2. When notified by IMSO of an irresolvable lapse of required commercial healthcare insurance for authorized dependents, the MILDEP will take the following action:
            1. Direct the SCO to remove all non-compliant authorized dependents from ITO.
            2. Direct the IMSO to collect DoD issued ID cards and request IMS to return authorized dependents to home country.
            3. If IMS fails to send authorized dependents home within 10 working days, direct IMSO to withdraw IMS from training and return IMS to home country.
            4. As applicable periodically forward information concerning healthcare policies that meet the requirements of this policy memo to DISAM for posting on the DISAM web site (http://www.disam.dsca.mil).
8. Regional Centers.
   1. Participants traveling to a RC program or event (e.g., course, seminar, conference, workshop, etc.) are responsible for meeting any and all healthcare coverage requirements imposed by the country where the RC event is being held. The host RC will advise of any corresponding requirements.
   2. If the RC program or event requires travel to the U.S., the RC will determine healthcare coverage requirements on a case by case basis.

Summary of Changes to DSCA Policy Memorandum 10-39

1. Paragraph 1.c.: add the following sentence: "Unless otherwise noted, all references to IMS in this memorandum refer to both international military students (IMS) and international civilian students (ICS), and all references to dependents refer to authorized dependents of the IMS or ICS (authorization for dependents and listing of dependents are in section 12 of the Invitational Travel Order)."
2. Paragraph 2: delete: "Authorized Dependents-Authorization for dependents and listing of dependents are in section 12 of the ITO." Delete the last line on TRICARE.
3. Paragraph 3.: replace with the following: "General. All IMS and authorized dependents are required to have healthcare coverage while in the United States. The IMS are held responsible for payment of all incurred healthcare bills, including co-payments, deductibles, and services not covered by the following methods."
4. Paragraph 3.a.(1): add the following sentence: "Bills should be paid within 90 days after the bill is sent."
5. Paragraph 3.a.(1) Note: change to read: "NOTE: Arrangements that require the IMS to pay for medical services and then seek reimbursement from their government are prohibited unless DSCA (Programs Directorate) has granted a waiver. A waiver request with specific details must be submitted by the SCO through the COCOM to DSCA (Programs Directorate) 60 days prior to reporting to the first course. DSCA (Programs Directorate) will coordinate approval of the waiver request with MILDEPs. The approved waiver will be kept on file by the SCO and annotated on the ITO where indicated. Waiver will be valid unless there is a failure to pay bills within 90 days."
6. Paragraph 3.a.(2): change to read: "Training case line item for medical coverage. An FMS or FMF 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 IMS and/or dependents within this line, the details must be included in the ITO. IMS and/or dependents may be indemnified by IMS' government for pregnancy coverage, and if not, supplementary commercial insurance may be required to meet the requirements of paragraphs 4e and 5 of this policy. The cost of supplemental insurance is not treated as a cost of the training or the course itself."
7. Paragraph 3.a.(3): change to: "Grant programs. Some U.S. Government grant programs (e.g., IMET, CTFP, FMF cases with approved medical lines, etc.) pay for the healthcare costs of the IMS only." (delete "These programs do not cover any healthcare costs for authorized dependents.")
8. Paragraph 3.a.(5): change the sentence to read: "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."
9. Delete paragraph 3.b. in its entirety (remove: "The IMS is held responsible for payment of all incurred healthcare bills, including copayments, deductibles, and services not covered by insurance.")
10. Paragraph 3: add paragraph 3.e: "When a specific medical or dental treatment is not available at a DoD treatment facility, IMS and 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)."
11. Paragraph 4.b: change the sentence to read: "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 that do not provide complete coverage require either a separate FMS case for medical expenses or commercial insurance that meets DSCA requirements."
12. Paragraph 4.c.(1).(a): replace to read: "Outpatient care (medical and emergency dental) in DoD MTF is at no charge for IMS and authorized dependents (some treatments are available for only IMS and not for authorized dependents).
13. Paragraph 4.c.(1).(b): in the last line, change "authorized" to "guaranteed in writing".
14. Paragraph 4.c.(2)(a): replace the last sentence with the following and delete the NOTE: "If referred by a DoD MTF, outpatient care for authorized dependents is covered by TRICARE (healthcare program of the U.S. DoD Military Health System) standard/extra for outpatient care. A co-pay is required, as well as a deductible if not yet met."
15. Paragraph 4.d.: delete "with few exceptions" and "full" to read as follows: "RHCAs differ by country in coverage and may not provide full healthcare coverage. It is critical that the RCHA 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 full service MTF, or the nearest MTF is located a considerable distance from the schoolhouse/training activity. In addition, IMS and authorized dependents may require care while traveling away from their assigned military installation. Section 4.e. of this policy memo specifies the total amount of insurance required. All IMS and their authorized dependents that are relying 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 dependant's stay in the U.S. under DoD sponsorship."Paragraph 4.e.(1): delete "whichever is less, and must be renewable."
16. Paragraph 4.e.(5): replace with the following: "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 IMS, international civilian students, and/or authorized dependents to return to their home country.
17. Paragraph 4.e.(6).(f): replace "benefits must meet the requirements of the host country." with "medical coverage must meet the requirements of the host country."

18. Section 5, Pregnancy Coverage: change the entire section to read as follows:

    Pregnancy Coverage.

    1. 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 for any incurred cost, in writing, prior to their arrival.

       NOTE: Pregnancy insurance is in addition to insurance requirements specified in paragraph 4.e. of this policy.

    2. An IMS or authorized dependent without pregnancy coverage who is found to be pregnant after arrival in the U.S. will be returned to their 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.
    3. Pregnancy and childbirth coverage is not usually included in insurance policies purchased less than 12 months in advance, and is generally very expensive.
    4. 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.
19. Paragraph 6.c.: add "(except Joint Forces Staff College which does not authorize dependents)" right after "National Defense University", and add "Graduate programs at" to "Air Force Institute of Technology". Delete "Dependents are not encouraged to accompany or join the IMS at the other courses."
20. Paragraph 7.: add new paragraph 7.b., as follows, and renumber subsequent paragraphs:"b. DSCA Responsibilities. DSCA is the DoD designated authority for international security cooperation training and education programs. DSCA develops, promulgates policy and guidance, and provides oversight for the implementation and execution of healthcare coverage policy to the MILDEPs, IMSO, COCOMs, and SCOs. DSCA reviews, coordinates with MILDEPs, and approves requests for exception to the healthcare coverage policy."
21. Paragraph 7.c.(1): change to read: "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."
22. Paragraph 7.c.(3): change to read: "A DSCA waiver is required for modified medical coverage arrangement; e.g., country insurance requires student to pay outpatient costs and seek reimbursement, or country wishes to guarantee payment for medevac or repatriation expenses rather than including in insurance. DSCA (Programs Directorate) will coordinate approval of the waiver requests with the MILDEPs. SCO will include specific details, U.S. point of contacts, and U.S. billing address for the approved request with date of DSCA approval in the ITO."
23. Paragraph 7.c.(7).(d): change to read: "Inform the IMS of the financial and ethical responsibilities regarding all aspects of this healthcare policy and have IMS acknowledge, in writing, an understanding of the policy concerning healthcare insurance coverage, including consequences of a lack of pregnancy coverage and prohibition against using non-emergency U.S. taxpayer provided medical/dental assistance under DoD sponsorship. Retain the statement until IMS has returned to home country."
24. Paragraph 7.c.(3): change to read: "Notify IMSO immediately of any and all medical care required or received by IMS 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."

25. Paragraph 7.d.(2): replace with the following: "If commercial healthcare insurance is required for IMS and/or authorized dependents, as directed by the MILDEP, review the healthcare insurance policy for compliance with requirements specified in Section 4.e. of this policy memo. Provide 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.

    NOTE: Review for insurance policy compliance should be completed prior to issuance of the ITO."

26. Paragraph 7.d.(5): add the following before the sentence: "Unauthorized dependents are not covered within this policy."
27. Paragraph 7.d. (6): move to paragraph 7.f to become 7.f. (3) to read: "As applicable periodically forward information concerning healthcare policies that meet the requirements of this policy memo to DISAM for posting on the DISAM web site (http://www.disam.dsca.mil)."
28. Paragraph 7.f.(2).(b).(3): change to read: "If IMS fails to send dependents home within 10 working days, direct IMSO to withdraw IMS from training and return IMS to home country."