DEFENSE SECURITY COOPERATION AGENCY  2800 DEFENSE PENTAGON  WASHINGTON, D.C. 20301-2800

6/23/2010

COMMANDER, U.S. AFRICA COMMAND, 
DIRECTOR OF STRATEGY PLANS AND PROGRAMS 

COMMANDER, U.S. CENTRAL COMMAND, 
CHIEF, SECURITY COOPERATION DIVISION 

COMMANDER, U.S. EUROPEAN COMMAND, 
POLICY, STRATEGY, PARTNERING, AND RESOURCES 

COMMANDER, U.S. NORTHERN COMMAND, 
DIRECTOR OF PLANS, POLICY AND STRATEGY 

COMMANDER U.S. SOUTHERN COMMAND, 
DIRECTOR OF TRAINING, EXERCISE AND ENGAGEMENT 

COMMANDER, U.S. PACIFIC COMMAND, 
DIRECTOR FOR LOGISTICS, ENGINEERING AND SECURITY ASSISTANCE 

DEPUTY UNDER SECRETARY OF THE AIR FORCE 
FOR INTERNATIONAL AFFAIRS 

DEPUTY ASSISTANT SECRETARY OF THE ARMY 
FOR DEFENSE EXPORTS AND COOPERATION 

DEPUTY ASSISTANT SECRETARY OF THE NAVY 
FOR INTERNATIONAL PROGRAMS

SUBJECT:

International Military Students, Civilians and Authorized Dependants Healthcare Coverage, DSCA Policy; Defense Security Cooperation Agency (DSCA) Policy Memorandum 10-39

REFERENCE:

1. Defense Security Cooperation Agency, Security Assistance Management Manual (DoD 5105.38-M), Chapter 10

1. Purpose: The purpose of this memorandum is to provide additional information on expanded healthcare coverage requirements issued by DSCA on March 26, 2010. This policy applies to International Military Students (IMS) and international civilian students (hereafter referred to as IMS) participating in education and training under security assistance and security cooperation programs managed or administered by the Defense Security Cooperation Agency (DSCA). This memorandum also pertains to all authorized dependents who accompany or join the IMS during their education and training.

   1. All IMS enrolled in training/education programs prior to March 26, 2010, may continue to adhere to the requirements stipulated in DSCA Policy Memorandum 07-27. If contractor support is provided for International Military Student Officer (IMSO) responsibilities (reference Section 7 .f.( I) of this policy), implementation is subject to Military Service (MILSRV) contracting process constraints.
   2. This policy should be used concurrently with DSCA Policy Memorandum 09-42, Medical Screening of International Military Students, Civilians and Authorized Dependents.

    

2. Acronyms/Definitions: The following acronyms/definitions apply:

   Term	Description
   Authorized Dependent	Authorization for dependents provided in section 12 of ITO; authorized dependents listed in section 15 of ITO.
   COCOMs	Combatant Commands
   CTFP	Combating Terrorism Fellowship Program
   DLIELC	Defense Language Institute English Language enter
   DoD	Department of Defense
   FMF	Foreign Military Financing
   FMS	Foreign Military Sales
   IMET	International Military Education and Training
   IMS	International Military Student (term includes both military and civilian participants)
   IMSO	International Military Student Officer
   ITO	Invitational Travel Order
   MILSRV	Military Service
   MTF	Military Treatment Facility
   NATO/PfP	North Atlantic Treaty Organizational Partnership for Peace
   RC	Regional Centers (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
   SOFA	Status of Forces Agreement
   SCO	Security Cooperation Officer
   TRICARE	DoD provided Healthcare Insurance Coverage

3. General: All IMS and authorized dependents are required to have healthcare coverage while in the United States.

   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. 
         NOTE: Arrangements that require the IMS to pay for medical services and then seek reimbursement from their government are not acceptable. Such arrangements are cost prohibitive for even routine medical services due to the high cost of healthcare in the United States.
      2. Medical line in training case: Some FMS and FMF training cases may provide for medical coverage. However, this medical line may not cover all medical cost (e.g. exempts pregnancy); therefore, IMS and/or authorized dependents may require their government's indemnification of cost for medical services not covered by the training case or they may require a supplemental commercial insurance policy to fully meet the requirements of Section 4.e. and 5 of this policy. The cost of supplemental insurance is not treated as a cost of the training or 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 cost of the IMS. These programs do not cover health care cost for authorized dependents.
      4. RHCA and NATO/PfP nations. IMS and authorized 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 in the United States.

       

   2. The IMS is held responsible for payment of all incurred healthcare bills, including co-payments, deductibles, and services not covered by insurance.
   3. The IMS is held responsible for payment of all incurred healthcare bills, including co-payments, deductibles, and services not covered by insurance.
   4. 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.
   5. IMS and their non-U.S. citizen dependents, while under sponsorship of DoD security assistance or security cooperation education and training programs, are not authorized to participate in U.S. Federal, State or other U.S. taxpayer subsidized medical/dental programs. 
      Note: in cases of a medical emergency, no IMS or their dependents will be denied medical treatment.

    

4. Healthcare Coverage:

   1. Non-NATO/PfP SOFA IMS healthcare coverage 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 the DSCA requirements).
   2. The IMET and CTFP programs provide health care coverage for the IMS only; authorized dependents will require healthcare insurance if payment is not guaranteed by the foreign government..

   3. For an IMS from a country under a NATO/PfP SOFA, the following healthcare provisions pertain:

      1. Healthcare at a DoD MTF is as follows:

         1. IMS outpatient care (medical and emergency dental) in DoD MTF is at no charge. Authorized dependent outpatient care (medical and emergency dental) in DoD MTF is at no charge if available.
         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/ case or if payment is not authorized 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 000 MTF, outpatient care for authorized dependents is covered by TRICARE standard/extra. 
            NOTE: A co-pay is 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. For IMS covered under a Reciprocal Healthcare Agreement (RHCA):

      1. RHCAs differ by country in coverage and may not provide full healthcare coverage. RCHAs usually provide care in a U.S. DoD MTF at no cost, and with few exceptions 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 specifies the total amount of insurance required. All IMS and their authorized dependents relying on an RHCA as their primary source of insurance coverage must secure the supplemental healthcare insurance needed to meet the full requirements specified. This healthcare coverage must remain in effect for the full duration of the IMS and authorized dependent's stay in the United States under DoD sponsorship. 
         NOTE: Information on RHCA, is available on the DISAM International Training Management web page at http://www.disam.dsca.miUitml 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 United States. 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, whichever is less, and must be renewable.
      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 United States. 
         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 and/or authorized dependent to return to home country.

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

         1. No exclusion for payment of benefits directly to a DoD MTF if applicable.
         2. Provide nationwide coverage/service; non-U.S. based policies must provide benefits in the United States.
         3. Provide single source administration/management for the policy.
         4. Have a point of contact in the United States. In all cases, the insurance company is to pay promptly in U.S. currency directly to healthcare provider.
         5. Have a copy of the policy written in English; a copy of this policy will be provided to the SCO, the servicing MTF and the IMSO at all schoolhouses within the IMS' training tracks (e.g. to include DLIELC).
         6. If U.S. education and training is taking place in a third country, benefits must meet the requirements of the host country.

          

      7. The minimum dollar standards and coverage requirements will be reviewed annually by DSCA to ensure that minimum requirements reflect current cost and coverage of the U.S. healthcare.

       

    

5. Pregnancy Coverage:

   1. All female IMS and authorized female dependents between the ages of 18 to 44 require either country indemnification or healthcare insurance of at least $250,000 for prenatal, childbirth, and postnatal care in addition to the insurance requirements specified in Section 4.e. 
      NOTE: MILSRVs may be granted a waiver to this requirement by DSCA for selected schools or selected courses. 
      NOTE: An IMS may voluntarily choose to provide a statement by their physician that they and/or their dependents are physically incapable of producing children; in this situation pregnancy insurance is not required .
   2. Pregnant dependents will not be authorized to accompany or join an IMS unless the costs of prenatal, childbirth and postnatal care are indemnified by their country, covered by an FMS (national funds) case, or by an already existing pregnancy insurance policy for at least $250,000. 
      NOTE: Pregnancy insurance is in addition to insurance requirements specified in Section 4.e. of this policy.
   3. An IMS or authorized dependent without pregnancy coverage who is found to be pregnant after arrival in the United States will be returned to 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.
   4. Pregnancy and childbirth coverage is not usually included in insurance policies purchased less than 12 months in advance, and is generally very expensive.
   5. Pregnancy is considered a pre-existing condition and pregnancy insurance coverage is not available for purchase after an IMS or dependent is determined to be pregnant.

    

6. Invitational Travel Order (ITO):

   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 sea 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 health care coverage, the sea 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 dependent healthcare coverage, a statement will be included in the Remarks Section of the ITO that indicates whether or not an 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
      • Army War College
      • Inter-American Defense College
      • Intermediate Level Education (ILE) and School of Advanced Military Studies (SAMS) 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 (USMC) 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

      NOTE: Dependents are not encouraged to accompany or join the IMS at other courses.

       

   4. A pregnant IMS and/or a pregnant authorized dependent will require a health policy waiver before being placed on an ITO. 
      NOTE: Procedures for a health policy waiver are provided in DSCA Policy Memorandum 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 health care costs for IMS and/or dependents (e.g., RHCA, SOFAs, etc.).

   2. SCO Responsibilities:

      1. Determine healthcare coverage method(s) applicable to IMS and/or authorized dependents. When commercial healthcare coverage is required, obtain approval from the appropriate IMSO that coverage meets the requirements of this policy. 
         NOTE: If the authorizing MILSRV has established the requirement for review of health insurance policies for compliance prior to issuing the ITO, the SCO will scan and send a copy (in English) of the proposed commercial healthcare policy to the appropriate IMSO. The lMSO will follow the MILSRV instructions for review and approval procedures.
      2. Properly annotate healthcare coverage and include a U.S. billing address and telephone number in block 12 of the ITO.
      3. 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.
      4. If applicable, send a copy of the healthcare insurance policy (in English) to the IMSO for review and approval prior to issuance of the ITO to the IMS.
      5. If applicable, ensure IMS has a copy of health care insurance policy (in English) for delivery to IMSO upon arrival at first education and training site.
      6. If applicable, include in block IS of the ITO a notation of any existing special medical conditions/preconditions for both IMS and/or dependents. 
         NOTE: Per DSCA Policy Memorandum 09-42, do not provide any details that may compromise the rights to privacy of the IMS or authorized dependents.
      7. If applicable, when training will occur in a third country, ensure IMS has met healthcare requirements of host country.

      8. 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 financial and ethical responsibilities with regard to all aspects of this healthcare policy and have IMS acknowledge, in writing, their understanding that failure to comply could result in disenrollment.

          

       

   3. 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. taxpayer provided medical/dental assistance while under DoD sponsorship.
      2. If applicable, present healthcare insurance policy (in English) to the TMSO and to medical treatment facilities.
      3. Notify IMSO immediately of any and all known medical conditions that arise while residing in the United States (to include cases of pregnancy). This applies to IMS and all dependents.

       

   4. 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 MILSRV, review the healthcare insurance policy for compliance with requirements specified in Section 4.e. of this policy memo. Provide sea with instructions on where to send the English version for review. Report any deficiencies in healthcare policy immediately to the MILSRV country program manager and sea. 
         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 MTF and any physicians they see during their stay in the United States.
      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. In cases when an unauthorized dependent arrives at the training activity location, contact MILSRV training policy manager immediately.
      6. Periodically forward information concerning healthcare policies that meet the requirements of this policy memorandum to DISAM for posting on the DISAM web site http://www.disam.dsca.mil.

       

   5. COCOM Responsibilities:

      1. Ensure that 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.

       

   6. MILSRV Responsibilities:

      1. When commercial health care coverage is required, establish policy and procedures for the review of healthcare policies for compliance with this policy memorandum. 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.
      2. If MILSRV 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 0711 02.B. The cost developed will be the same per student regardless of the training rate, (Le. in other words, this cost is also considered to be an incremental cost).

      3. 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 lapse or lack of required commercial healthcare insurance for the IMS, coordinate with IMS' government to determine payment mechanism for outstanding medical bills. If lMS' government does not agree to pay for required health care 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 health care insurance for authorized dependents. The MILSRV will take the following action:

            1. Direct 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, direct IMSO to withdraw IMS from training and return IMS to home country.

             

          

       

    

8. Regional Centers (RC):

   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 United States, the RC will determine health care coverage requirements on a case by case basis.

    

9. The DSCA points of contact for this memorandum are JP Hoefling and Kay Judkins, at (703) 601-365513719, e-mail: john.hoefling@dsca.mil and kay.judkins@dsca.mil.

Jeanne L. Farmer 
Acting Deputy Director

CC :

STATE/PM-RSAT 
JFCOM 
SOCOM 
TRANSCOM 
USASAC 
SATFA TRADOC 
NAVICP 
NETSAFA 
AFSAC 
AFSAT 
DISAM