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Patriot Exchange Program

Medical Insurance for individuals and groups involved in educational or cultural exchange

1 Month to 4 Years

Hello. Hola. Hallo. Hej.

You can greet someone in a foreign country in many ways. When you travel, stay safe and secure by saying hello to Patriot Exchange ProgramSM, a one-of-a-kind international medical insurance plan that brings you Global Peace of Mind® when you're traveling abroad.

Why Consider International Travel Medical Insurance?

Traveling abroad can be an exciting experience, especially when you're involved in an educational or cultural exchange program. But what would happen if you became ill or injured while away from home? Your experience can quickly turn frightening if you're not prepared for a medical emergency.

Whether your trip takes you abroad for a few weeks or a year, your cultural exchange experience should be an enjoyable one. You have enough to worry about when you're traveling. Don't let your medical coverage be an uncertainty. Patriot Exchange ProgramSM has been developed to provide you, your group, and your dependents traveling with you Coverage Without Boundaries®. The plan offers a complete package of international benefits available 24 hours a day. Simply select the plan option that best fits your needs.

Patriot Exchange Program

The Patriot Exchange Program is designed to meet the U.S. visa insurance requirements for individuals and groups of five or more students studying abroad or participating in a cultural exchange program, including J1 and J2 visa holders. Coverage may be purchased for spouses and unmarried, dependent children traveling with the student/participant. Individuals and groups can select from different plan options - $50,000, $100,000, $250,000, and $500,000 maximum limit per illness/ Injury. The $50,000 maximum limit per Illness/Injury option does not comply with J1 and J2 visa requirements. This program also offers three different areas of coverage, and an optional Add-On rider for high school sports, personal liability and legal assistance. In addition, groups may purchase annually renewable long term plans that have the flexibility to be tailored to meet specific needs of each program.

How Does the Affordable Care Act (ACA) Affect My Coverage?

Non-US Citizens: As non-resident aliens, international students, scholars, and people involved in cultural exchange programs on F, J, M and Q visas (and certain family members) are not subject to the individual mandate for their first five years in the U.S. All other J categories (teacher, trainee, work and travel, au pair, high school, etc.) are not subject to the individual mandate for two years (out of the past six). Since international students are not subject to the mandate, they are not required to purchase a plan that meets PPACA requirements and can purchase the Patriot Exchange Program.

US Citizens: Under ACA, all U.S. citizens, nationals and resident aliens are required to purchase minimum essential coverage (ACA compliant coverage), unless they are exempt. Exempt U.S. citizens include U.S. citizens who reside outside of the U.S. for 330 of any 365-day period, or have a tax home (main place of work or employment, or if you don't have a main place of work or employment, your main residence) in a foreign country, and is a bona fide resident of a foreign country.

Please note that this insurance is not subject to, and does not provide benefits required by, ACA. On January 1, 2014, ACA requires U.S. citizens, U.S. nationals and resident-aliens to obtain ACA compliant insurance coverage unless they are exempt from ACA (international students on F, J, M and Q visas (and certain family members of students) are not subject to the individual mandate for their first 5 years in the U.S. All other J categories - teacher, trainee, work and travel, au pair, high school, etc. - are not subject to the individual mandate for 2 years out of the past six). Penalties may be imposed on persons who are required to maintain ACA compliant coverage but do not do so. Eligibility to purchase or renew this product, or its terms and conditions, may be modified or amended based upon changes to applicable law, including ACA. Please note that it is solely your responsibility to determine if ACA is applicable to you and the Company and the administrator shall have no liability whatsoever, including for any penalties that you may incur, for your failure to obtain required ACA compliant coverage. For information on whether ACA applies to you or whether you are eligible to purchase the Patriot Exchange Program, please contact your attorney or CPA.

A Unique, Full-Service Approach

We know that the reasons to travel abroad are many and varied - that's why our services are designed to provide you with the assistance you need no matter where you are. By providing global products and services to vacationers, those working or living abroad for short or extended periods, people traveling frequently between countries, and those who maintain multiple countries of residence, we are the single resource for all your international travel medical insurance needs.

Our service and support sets us apart. We've served millions of people around the globe - always focused on the specific needs of each individual and group. We've set the benchmark for industry service levels by integrating independent credentialing services with in-house, fully owned and operated service divisions. We're there with you, wherever you go - bringing support for all your insurance needs around the globe - providing you Global Peace of Mind®.

PEP Services

An online service located in our Client Center that allows you to manage your accounts, 24 hours a day, seven days a week, from anywhere in the world. Some features include:

  • Submission and management of claims
  • Initiate Precertification
  • Access Customer Care via email or telephone
  • Locate and recommend a provider/ facility
  • Obtain ID cards and other insurance documents

Locating a Provider

You may seek treatment with the hospital or doctor of your choice. When seeking treatment in the U.S., you have access to the Preferred Provider Organizations (PPO), which are separately organized networks of hundreds of thousands of established, highly qualified health care physicians and many well-recognized hospitals in the U.S. You can quickly search the network. Additionally, to help you locate health care providers outside the U.S., we provide online International Provider AccessSM (IPA), a database of over 17,000 providers.

Universal Rx Pharmacy Discount Savings

This discount savings program allows you to purchase prescriptions at one of over 35,000 participating pharmacies in the U.S. and receive the lower of 1) Universal Rx contract price or 2) the pharmacy regular retail price. This program is not insurance coverage; it is purely a discount program.

Akeso Care Management® (AkesoCare)

The ability to access quality health care is of paramount importance when a medical emergency arises abroad. To coordinate care and provide U.S. and internationally based medical management services, IMG formed AkesoCare, a URAC accredited, on-site specialized division devoted entirely to medical management. AkesoCare's clinical members are experts at assessing the need for services and ensuring those services are delivered in a timely, cost-effective manner.

From routine medical care to complex case management, from check-ups to emergency medical evacuations, AkesoCare is there for you. They are committed to patient protection and empowerment, quality operations and provider compliance. This translates into better care for you - around the world, around the clock.

PEP Summary of Benefits (Individual and Group)

Plan MaximumChoice of $50,000, $100,000, $250,000 or $500,000 per illness or injury
Lifetime maximum of $5,000,000
Deductible$100 per Illness or Injury
CoinsuranceNo coinsurance
Treatment Period Maximum60 days for chronic conditions
Inpatient/Outpatient Benefit
Hospital Room and BoardUp to the average semi-private room rate
Intensive Care UnitURC*
Physical TherapyURC* - 1 visit per day
Physician VisitURC* - 1 visit per day
Student Health Center$5 co-pay per visit. Not subject to deductible
Prescription DrugsURC*
Eligible Medical ExpensesURC*
Emergency Room Visit with In-patient AdmissionURC*
Emergency Room Visit without In-patient AdmissionAdditional $250 deductible
DentalInjury due to covered Accident- $500 maximum per Accident
Sudden & Unexpected Pain to natural teeth- $350 maximum
Evacuation Benefits
Emergency Medical Evacuation$50,000 lifetime maximum
Emergency Reunion$15,000 lifetime maximum
Return of Mortal Remains or Cremation/Burial$25,000 maximum for Return of Mortal Remains
or $5,000 maximum for Cremation/Burial
Political Evacuation and Repatriation$10,000 lifetime maximum
Additional Benefits
Accidental Death & Dismemberment$25,000 Principal Sum ($25,000 two limbs; $12,500 one limb)
Terrorism$50,000 lifetime maximum
Sudden & Unexpected Recurrence of a Pre-existing Condition (U.S. Citizens plan only): Eligible Medical Expenses: $5,000 lifetime maximum
Emergency Medical Evacuation: $25,000 maximum
Pre-existing Conditions For conditions existing within 36 months before effective date, charges excluded until after 12 months of coverage and then $500 maximum per period of coverage and $50,000 lifetime maximum
Incidental Trip CoverageUp to a cumulative 14 days
Optional Add-On Rider
Lost Personal Property$250 maximum
Legal Assistance$500 maximum
Personal Liability - Injury to third party
Personal Liability - Damage to third party's property
$2,000 maximum after $100 deductible
$500 maximum after $100 deductible
High School SportsURC*

Groups may also purchase a customizable long-term plan. Any coverages, benefits and premium rates offered are in U.S. Dollars.
*Usual, Reasonable and Customary (URC) charges.

PEP Rates

Individual Monthly Premiums

Non-U.S. Citizens - While Outside Country of Residence
AgeMaximum Limit per Illness/Injury
$50,000$100,000$250,000$500,000
31 days - 24 $48.62
$51.05 w/Add-On
$56.45
$59.25 w/Add-On
$60.36
$63.37 w/Add-On
$63.66
$66.84 w/Add-On
25 - 49$63.37
$66.53 w/Add-On
$73.50
$77.15 w/Add-On
$78.59
$82.52 w/Add-On
$82.90
$87.04 w/Add-On
50 - 64$135.70
$142.49 w/Add-On
$157.35
$165.20 w/Add-On
$168.27
$176.68 w/Add-On
$177.53
$186.41 w/Add-On
U.S. Citizens - While Outside the U.S.
AgeMaximum Limit per Illness/Injury
$50,000$100,000$250,000$500,000
31 days -24$34.46
$36.18 w/Add-On
$40.08
$42.07 w/Add-On
$42.72
$44.85 w/Add-On
$45.08
$47.33 w/Add-On
25 - 49$39.88
$41.88 w/Add-On
$46.50
$48.82 w/Add-On
$49.44
$51.91 w/Add-On
$52.16
$54.76 w/Add-On
50 - 64$103.43
$108.60 w/Add-On
$111.72
$117.29 w/Add-On
$128.27
$134.68 w/Add-On
$135.35
$142.11 w/Add-On
Non-U.S. Citizens - Europe Only
AgeMaximum Limit per Illness/Injury
$50,000$100,000$250,000$500,000
31 days -24$28.62
$30.05 w/Add-On
$33.31
$34.96 w/Add-On
$35.52
$37.29 w/Add-On
$37.47
$39.34 w/Add-On
25 - 49$33.10
$34.75 w/Add-On
$38.40
$40.32 w/Add-On
$41.06
$43.12 w/Add-On
$43.31
$45.47 w/Add-On
50 - 64$85.85
$90.14 w/Add-On
$92.84
$97.47 w/Add-On
$106.44
$111.76 w/Add-On
$112.29
$117.90 w/Add-On

Group Monthly Premiums

Non-U.S. Citizens - While Outside Country of Residence
AgeMaximum Limit per Illness/Injury
$50,000$100,000$250,000$500,000
31 days -24$43.78
$45.97 w/Add-On
$50.80
$53.35 w/Add-On
$54.34
$57.06 w/Add-
$57.29
$60.15 w/Add-On
25 - 49$57.05
$59.91 w/Add-On
$66.15
$69.45 w/Add-On
$70.74
$74.28 w/Add-On
$74.60
$78.35 w/Add-On
50 - 64$122.13
$128.24 w/Add-On
$141.60
$148.70 w/Add-On
$151.45
$159.03 w/Add-On
$159.77
$167.76 w/Add-On
U.S. Citizens - While Outside the U.S.
AgeMaximum Limit per Illness/Injury
$50,000$100,000$250,000$500,000
31 days -24 $31.03
$32.59 w/Add-On
$36.07
$37.88 w/Add-On
$38.47
$40.39 w/Add-On
$40.59
$42.62 w/Add-On
25 - 49$35.87
$37.67 w/Add-On
$41.85
$43.95 w/Add-On
$44.49
$46.71 w/Add-
$46.96
$49.31 w/Add-On
50 - 64$92.98
$97.63 w/Add-On
$100.54
$105.58 w/Add-On
$115.46
$121.24 w/Add-On
$121.84
$127.93 w/Add-On
Non-U.S. Citizens - Europe Only
AgeMaximum Limit per Illness/Injury
$50,000$100,000$250,000$500,000
31 days -24$25.78
$27.07 w/Add-On
$29.97
$31.48 w/Add-On
$31.98
$33.58 w/Add-On
$33.75
$35.44 w/Add-On
25 - 49$29.80
$31.28 w/Add-On
$34.56
$36.29 w/Add-On
$36.93
$38.78 w/Add-On
$39.00
$40.95 w/Add-On
50 - 64$77.29
$81.15 w/Add-On
$83.54
$87.73 w/Add-On
$95.82
$100.61 w/Add-On
$101.06
$106.11 w/Add-On

New premium rates per Insured Person effective June 1, 2016 for eligible individuals whose applications are approved by the administrator. The adminstrator reserves the right to assess the most current rates at the time of the effective date in the event these rates expire, are modified, or are replaced. Rates include premium tax where applicable.

Groups may also purchase a customizable long-term plan, for rates please contact us.
U.S. J Visa participants must select $100,000 maximum limit or higher to satisfy the J Visa insurance requirements.

PEP Plan Information

Conditions of Coverage

1) Coverage and benefits are subject to the deductible, limits and coinsurance, and all terms of the Certificate of Insurance and Master Policy. 2) Coverage under a Patriot Exchange Program plan is secondary to any other coverage. 3) Coverage and benefits are for eligible medical expenses which are medically necessary and usual, reasonable and customary. 4) Charges must be administered or ordered by a licensed physician. 5) Charges must be incurred during the Period of Coverage. 6) Claims must be presented to the adminstrator for payment within ninety (90) days from the date the claim was incurred.

Eligibility:

To be eligible to apply to the Patriot Exchange Program plan, you must

  • Be an active participant in a study or exchange program (i.e. student visa, exchange visa, visitor visa), the spouse of the participant, or a dependent traveling with the participant
  • Reside outside the country of residence for the purpose of pursuing international educational activities for a temporary period of time
  • Be physically and legally residing in host country with the intent to reside there for at least 30 days on the effective date and at renewal
  • Not be hospitalized, disabled, or HIV+ on the initial effective date.

Renewal of Coverage

Eligible insureds can request coverage under the plan be renewed monthly for up to 12 month periods, for a maximum of 48 continuous months, as long as the premium is paid when due and the insured continues to meet the eligibility requirements of the plan.

Enrollment Process

Before you begin your travel, simply apply online or fill out the Application and calculate the estimated premium for the time period you, your group, and/or your dependents will be traveling. Once you have completed the Application, return it to us.

You can apply over the phone as well by calling us.

Eligible individuals listed on the Application and for whom premiums have been paid will be covered from the latest of the following dates:

  1. The date the administrator approves your completed Application and receives the appropriate premium
  2. The date you depart from your home country
  3. The date requested on your Application

Fulfillment Kits

We process applications in a quick, timely manner. Once processing is complete, we will mail and/or email the fulfillment kit(s) to the address/email listed in the Application. The fulfillment kit(s) will include Identification Card(s), and the insurance certificate providing a complete description of the rights and benefits under the contract. For your convenience, you will get emailed this information and may also access it from the Client Center.

If you do not choose Online Fulfillment, we will mail your fulfillment materials. This may cause delays. We recommend online fulfillment for immediate access to your coverage information.

PEP Optional Riders

Adventure Sports Rider:

The Adventure Sports Rider is available on the Patriot Exchange Program for individuals and groups, and their dependents, up to the age of 65. Certain activities designated as adventure sports can be covered up to the maximums listed below. Certain activities are never covered, regardless of whether or not you purchase the Adventure Sports Rider. For a list of all the activities which can be considered to be adventure sports, a sample rider can be provided upon request.

Chaperone / Faculty Leader Trip Interruption Rider

Groups may request the Chaperone/Faculty Leader Trip Interruption Rider rider which offers up to $3,000 in benefits. In the event of the original chaperone/leader's hospitalization, a relative's unexpected death, or travel plans must be cancelled as a result of a break-in or destruction due to forces of nature at his/ her residence, the subsequent chaperone/faculty leader can be reimbursed for the certain transportation costs to join the group.

AgeLifetime Maximum
31 days - 49$50,000
50 - 59$30,000
60 - 64$15,000

PEP Claims Procedure

Precertification

Certain treatment and supplies including hospital admission, inpatient or out-patient surgery, and other procedures as noted in the Certificate Wording must be Precertified for medical necessity, which means the insured person or their attending physician must communicate with a representative at the number listed on the Identification Card prior to admittance to a hospital before receiving certain treatments and supplies, or performance of a surgery. In case of an Emergency Admission, the Precertification must be made within 48 hours of the admission, or as soon as reasonably possible. If a hospital admission or a surgery is not Precertified, eligible claims and expenses will be reduced by 50%. It is important to note that Precertification is only a determination of medical necessity, not an assurance of coverage, verification of benefits or a guarantee of payment. All medical expenses eligible for reimbursement must be medically necessary and will be paid or reimbursed at usual, reasonable, customary rates. Please refer to the Certificate Wording for full details of the Precertification requirements.

For Precertification, emergency evacuation and repatriation, please call: In the U.S.: 1.800.628.4664 (toll free). Outside the U.S.: +44(0) 1444.46.5577 (collect if necessary). This information will also be provided on your ID card.

Note: You may begin the Precertification process through Client Center. Simply look for the Precertification option. You will be asked to provide the required information, which can then be submitted electronically. Once we have received all required information and medical records, our utilization management and review team will review the information provided and normally responds to the insured person or the provider within 2 business days. Please note that this online service will only initiate the process for treatment and supplies outlined in the contract, and it should not be used to request pre-certification for emergency admissions, procedures, or evacuations.

Claims Payment

All benefits payable under Patriot Exchange Program are subject to the terms and conditions in the Certificate of Insurance. To make claim processing efficient, claims for eligible medical expenses may be paid in two ways:

  1. Eligible expenses that have been paid by or on behalf of the insured person may reimbursed by check directly to the insured person.
  2. Eligible expenses that have not yet been paid by the insured person may, at the option of the administrator, be paid either to the insured person or directly to the provider.

Claim forms can be accessed here and mailed to the address shown on the claim form. All contact numbers, claim forms and Certificate of Insurance are included in the fulfillment kit.

Administrator

IMGTM
P.O. Box 88509
2960 North Meridian Street
Indianapolis, IN 46208-0509 USA

Underwriter

Coverage is underwritten and issued by Sirius International Insurance Corporation, rated A (excellent) by A.M. Best and A- by Standard & Poor's (at the time of printing).

FOR ADDITIONAL INFORMATION

Insubuy®, Inc.
4200 Mapleshade Ln, Suite 200
Plano, TX 75093

Toll Free: (866) INSUBUY
Phone: (972) 985-4400
Fax: (972) 767-4470
Website: www.insubuy.com

This invitation to inquire allows eligible applicants an opportunity to seek information about the insurance offered and is limited to a brief description of any loss for which benefits may be payable. Benefits are offered as described in the insurance contract. Benefits are subject to all deductibles, coinsurance, provisions, terms, conditions, limitations, and exclusions in the insurance contract. The contract does contain a pre-existing condition exclusion and does not cover losses or expenses related to a pre-existing condition.

This brochure contains many of the valuable trademarks, names, titles, logos, images, designs, copyrights and other proprietary materials owned and registered and used by of International Medical Group, Inc. and its representatives throughout the world. © 2007-2016 International Medical Group, Inc. All rights reserved.

Version: 1017

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