Worldwide health insurance and services for international living
The Global Citizen health plan is designed to support the international lifestyles of those who travel to or from the United States for extended periods of business, leisure and study. If you leave home for six months or more, your health and financial security are at serious risk because of significant gaps in most available insurance coverage and services. This risk is only heightened by limited knowledge of health and safety hazards around the world, including medical treatment from unfamiliar providers.

Global Citizen is the premier international health plan because it combines comprehensive worldwide benefits with a new generation of medical assistance services, which include an impressive array of online tools used to identify, access and pay for quality healthcare all around the world.

Global Citizen gives you the freedom to access care inside and outside the U.S. If you need benefits outside the U.S. only, explore the Global Citizen EXP plan.

What good is insurance if you can’t find a doctor you can trust?
HTH Worldwide provides all the tools a Global Citizen needs to manage health and safety risks, including finding the right doctor and clearly communicating your medical condition.

Easy Access to an Elite International Provider Community
HTH’s expanding International Provider Community numbers more than 4,500 carefully selected medical providers in almost every country of the world. Because of HTH’s rigorous selection criteria, less than 2% of providers outside the U.S.qualify to participate. Covering 112 specialties and subspecialties, the Provider Community database is searchable online to review detailed profiles of each provider.

Participating doctors, dentists and behavioral health professionals are English-speaking and individually contracted to schedule outpatient visits via HTH’s online request service and to accept payment directly from HTH.

Global Citizen members are always free to choose any medical provider outside the U.S.without incurring a financial penalty.

The Freedom to Access Care in the U.S.
Global Citizen members also gain access to a contracted nationwide network of over 700,000 preferred providers, including more than 4,000 hospitals. The plan also covers care delivered by non-contracted providers.

Personal Safety Intelligence
HTH maintains unsurpassed resources designed to promote personal safety by giving Global Citizen members convenient access to vitally important news, health and safety analysis and medical translation tools.
· Global Health and Safety news alerts published daily and delivered by email.
· City Health and Security Profiles for nearly 600 destinations in over 150 countries outside the U.S.
· Brand name equivalents for 300 common over-the-counter and prescription drugs in 24 of the most frequently visited countries.
· Translation of hundreds of medical terms and phrases into the 10 most widely spoken languages.

Around-the-Clock Assistance Call Center
HTH maintains a 24/7, toll-free call center to assist Global Citizen members with everything from routine requests to medical emergencies.HTH staff has years of experience with international medical assistance and has close working relationships with its International Provider Community.

Emergency Evacuation and Centers of Excellence
HTH coordinates emergency services with a worldwide network of contracted Physician Advisors as well as air ambulance operators selected for their safety records. Members in need of life-saving medical intervention are treated in Centers of Excellence in the U.S. and around the world whenever possible.

Informed Choice^SM
When Global Citizen members experience an unanticipated medical problem, they can request a second opinion and referral through the Informed Choice service. An HTH International Physician Advisor is available to discuss the member’s diagnosis and treatment plan directly with the attending physician.

Personalized Recruitment
If Global Citizen members need a physician in an area not currently covered by the HTH International Provider Community, HTH will make every effort to recruit and contract with an appropriate, qualified doctor.

Well Prepared^SM
An important companion on international assignments, the Well Prepared profile is a personal web page used by Global Citizen members to search the HTH Health and Safety databases, store pertinent information and launch requests for doctor appointments, provider recruitment, direct pay services and second opinions.

Appointment Scheduling and Direct Pay
Using the web or the telephone, Global Citizen members can request appointments within the International Provider Community. When Direct Pay services outside the U.S. are available, the copay and deductible are waived, and HTH pays the participating physician directly.

A Recognized Leader
HTH Worldwide is a recognized leader in international health insurance and medical assistance services, serving hundreds of thousands of world travelers annually.

Highest Standards of Service
Global Citizen is administered by HTH Worldwide Insurance Services to meet the highest expectations. HTH has set new standards for international assistance services and for applying stringent criteria when contracting with doctors and hospitals outside the U.S.

Strength of a U.S. Regulated Insurer
· Global Citizen is underwritten by A-rated insurance companies licensed by state departments of insurance as admitted carriers.
· Global Citizen protects your rights by meeting the standards of state regulators and features benefits more generous than non-admitted ”surplus coverage.”

Global Citizen Advantages over Competing Plans
· No waiting periods associated with any preventive services.
· Administered using HIPAA guidelines — the pre-existing condition exclusion can be waived with proof of prior creditable insurance.
· Covers injuries or illnesses that are a result of a terrorist act.
· No precertification required except for transplants.
· Deductible is waived for office visits to HTH participating providers outside the U.S.and preferred providers inside the U.S.
· No limit on time spent in or out of the U.S.

Global Citizen and Global Citizen EXP plans offer comprehensive benefits and a range of deductible options that allow members to select the right amount of insurance coverage for their budget and lifestyle.For detailed benefit schedule and rates, please see inserts. To calculate your total out-of-pocket expense, add the deductible and coinsurance maximum.

For families, the deductible and coinsurance maximum is a multiple of 2.5.

After 12 months of continuous coverage, Global Citizen members may renew their coverage or apply for a new plan that covers maternity costs in the same way as all other medical conditions.

To be eligible for the maternity benefit, a member must not be pregnant at the time of upgrade.

Amounts paid to satisfy a deductible are credited to all other deductibles.

1. Copay waived when visiting an HTH Worldwide contracted provider.
2. Deductibles are Per Person per Policy Period.
3. The Out of Pocket Maximum is calculated by adding the deductible and coinsurance maximum together. A family is charged a maximum of 2.5 deductibles.
4. Amounts paid to satisfy a deductible are credited to all other deductibles, both inside and outside the U.S. For example, if you satisfy your Outside U.S. deductible, this amount is credited to the U.S. (In Network) and U.S. (Outside Network) deductible requirement.
5. An Insured Person only has to satisfy his/her Out of Pocket Maximum once a Year for all services received outside of the U.S. and in the U.S.
6. Emergency room visits that do not result in inpatient admissions will be subject to a $50 penalty

Does not include U.S. benefits.
1. Copay waived when visiting an HTH Worldwide contracted provider.
2. Emergency room visits that do not result in inpatient admissions will be subject to a $50 penalty.
3. Out of Pocket Maximums exclude the Deductible.

You can either apply online on this web site or may be initiated on the phone at (866) INSU-BUY. Application must be signed and mailed to:

BuyAmericanInsurance.com
3105 Broken Bow Way, Suite 100
Plano, TX 75093, USA

A personal check, money order or credit card number must accompany the application and must be sufficient to pay for one month of standard premium. HTH will hold the form of payment until an underwriting decision is made. If your application is accepted, the payment will be applied to your account. Quotes obtained online or by telephone are advisory only. Actual premium is determined by the medical underwriting process.

HTH Worldwide will review your medical history as provided on the application and may request an Attending Physician’s Statement. HTH publishes standard premium rates for non-smokers. Smokers and other applicants with certain medical histories may be offered a policy at a higher rate. Not all applicants will be accepted.Your effective date of insurance will be on the 1st or 15th day of the month following underwriting approval.

Member Welcome Kit
When your application is accepted, HTH Worldwide will mail you and any family members covered under the plan a Welcome Kit with identification cards, a certificate of insurance and instructions on how to register online to use the Global Health and Safety Resources. Procedures for filing a claim or requesting direct payment of participating providers will also be included.

Renewals
Global Citizen is annually renewable and coverage is continuous when renewed. You must continue to meet the plan’s eligibility requirements. There are no medical questions at renewal and premium rates do not change based on your individual claims history. Your renewal rate will be the same as all persons renewing in your rating class.

After 12 months of continuous coverage, Global Citizen members may apply for a new plan that covers maternity costs in the same way as all other medical conditions. Members must submit a simple Health Statement to supplement their original application.

How Coverage Ends
Your coverage ends on the earlier of:

1. The last day of the month after the date the Insured Person is no longer eligible;
2. The end of the last period for which premium has been paid;
3. The date the Policy terminates;
4. The date the Lifetime Maximum Benefit of the Plan has been exhausted;
5. The date of fraud or misrepresentation of a material fact by the Insured Person, except as indicated in the Time Limit on Certain Defenses provision.

Extension of Benefits
If an Insured Person is Totally Disabled on the date of termination of the Policy, coverage will be extended until the earlier of:

1. The date payment of the maximum benefit occurs;
2. The date the Insured person ceases to be Totally Disabled; or
3. The end of 90 days following the date of termination.

Pre-existing conditions
The Global Citizen plan does not cover services for treatment of a medical condition for which medical advice, diagnosis, care, or treatment was recommended or received during 180 days immediately preceding the member’s eligibility date.

Creditable coverage
The 180-day pre-existing conditions period can be reduced or eliminated if you have been covered by a creditable group or individual health insurance plan.

Conforms to state requirements
If any provision of a Global Citizen plan is in conflict with the statutes of the state in which the member resides, it is amended to conform to the minimum requirements of those statutes.

Global Citizen has three tiers of coinsurance: 100% outside the U.S.; 80% in-network inside the U.S.; 60% out-of-network inside the U.S. All Global Citizen plans have a $5,000,000 lifetime maximum and a $100,000 maximum benefit for emergency medical evacuation.

The Out-of-Pocket Maximum is calculated by adding the deductible and coinsurance maximum together. Please refer to chart on page 3 of Brochure.

Maternity benefits are not covered under this plan. After 12 months of continuous coverage, Global Citizen members may apply for a new plan that covers maternity costs.

Global Citizen EXP covers most services outside the U.S. at 100%. All Global Citizen EXP plans have a $5,000,000 lifetime maximum and a $100,000 maximum benefit for emergency medical evacuation.

Maternity benefits are not covered under this plan. After 12 months of continuous coverage, Global Citizen EXP members may apply for a new plan that covers maternity costs.

1. Who is eligible to buy a Global Citizen plan?

All U.S. citizens living abroad who are 74 or younger at the time of application are eligible to apply for coverage.

All legal residents of the U.S.(citizens and foreign nationals) who are age 74 or younger at the time of application are eligible if they live in a state listed below:

Insurance Benefits underwritten by HM Life Insurance Company
Alabama, Alaska, Arizona, Arkansas, California, Colorado, Delaware, District of Columbia, Florida, Georgia, Hawaii, Illinois, Iowa, Kansas, Louisiana, Maine, Michigan, Mississippi, Missouri, Nebraska, New Mexico, North Dakota, Ohio, Oklahoma, Pennsylvania, Rhode Island, South Carolina, Virginia, West Virginia, Wisconsin, Wyoming

Insurance Benefits Underwritten by Unicare Life and Health Insurance Company
Connecticut, Indiana, Kentucky, Montana, Nevada, North Carolina, Tennessee, Texas, Utah, Vermont

If you live in any other U.S. state please contact us.


Eligible Family
Family members included in the plan must be Eligible Dependents. An Eligible Dependent means a person who is the Eligible Participant's spouse age 74 or less and/or:

• unmarried natural child, stepchild or legally adopted child who has not yet reached age 19;
• own or spouse's own unmarried child, of any age, enrolled prior to age 26, who is incapable of self support due to continuing mental retardation or physical disability and who is chiefly dependent on the Eligible Participant. The Insurer requires written proof from a Physician of such disability and dependency within 31 days of the child's 26th birthday and annually thereafter.
• unmarried child, from their 19th to their 22nd birthday who is a full-time student attending an accredited college, university, vocational or technical school, and who is fully dependent upon the Eligible Participant for support. The Insurer may require proof of student status, but not more than once a Year;
• grandchild, niece or nephew who otherwise qualifies as a dependent child, if: (i) the child is under the primary care of the Insured Participant; and (ii) the legal guardian of the child, if other than the Insured Participant, is not covered by an accident or sickness policy.
  
  The term "primary care" means that the Insured Participant provides food, clothing and shelter on a regular and continuous basis during the time that public schools are in regular session.

A person may not be an Insured Dependent for more than one Insured Participant.

Eligible Dependents must be residents (either U.S. citizens or foreign nationals) of the U.S.


2. How do I qualify for maternity benefits?

After 12 months of continuous coverage, Global Citizen members may apply for a new plan that covers maternity costs in the same way as all other medical conditions. Members must submit a simple Health Statement to supplement their original application, indicating that they are not pregnant at the time of upgrade.

3. Do all eligible family members have to apply for Global Citizen?

Yes. The Global Citizen plan is available to individuals and their dependents. All eligible family members must apply for coverage.


4. Will my policy automatically renew? At what rate?

Global Citizen is renewable up to age 84. Policies are renewed at prevailing rates based on age and sex. Your personal health history will not prevent you from renewing and will not determine the renewal rate.

5. When does my coverage end?

HTH may terminate your policy if:

1. You no longer meet the eligibility requirements
2. You fail to pay your premium
3. You exhaust the Lifetime Maximum Benefit of the plan
4. HTH discovers that you committed fraud or misrepresented a material fact to HTH
5. HTH terminates the plan in your state or geographic service area

6. Who is the insurer?
Strength in ratings, top industry support
HTH's international health insurance plans are backed by a U.S. Insurer, no matter how much time you spend in or out of the U.S.:
· HM Life Insurance Company of Pittsburgh, PA rated A- (Excellent) by A.M. Best
· HM Life Insurance Company of New York, NY rated A- (Excellent) by A.M. Best
· UNICARE Life & Health, a WellPoint company rated A- (Excellent) by A.M. Best

7. Will my pre-existing condition be covered under a Global Citizen plan?

Global Citizen is administered using HIPAA guidelines. If you were previously covered by a group or annually renewable individual U.S. health plan that issues you a Certificate of Creditable Coverage, HTH Worldwide will credit you for this prior coverage to the pre-existing conditions waiting period, provided you meet HTH's medical underwriting criteria. The number of months of coverage shown on the Certificate will reduce or eliminate the six-month pre-existing condition waiting period. If you have six or more months of creditable coverage, your waiting period will be eliminated. If you have less than six months creditable coverage, your waiting period will be reduced by the number of months you had creditable coverage. For example, if you have two months of creditable coverage, your waiting period will be reudced from six months to four months.

8. Am I guaranteed to be issued a Global Citizen policy if I apply?

No, Global Citizen is not a guaranteed issue plan. Each application is medically underwritten. Your application may be 1) accepted, 2) accepted with a rate increase due to your health status, or 3) denied.

9. Is the quote I receive binding?

No. The quote you receive may not apply if 1) you provided us with an inaccurate zip code, 2) you misstated a material fact on your application, or 3) we increase the rate due to your health status.

10. When determining a rate while overseas, what zip code should I use?

Policies for U.S. citizens residing overseas are issued through the Global Citizens Association office in Washington D.C. The zip code that applies is 20036. Please enter "20036" or "0" in the quoting tool if applying online while living overseas.

11. What is the Global Citizens Association?

GCA is a not-for-profit association serving those who travel the world for business, study and leisure. GCA promotes health and safety around the world through online knowledge tools and email news alerts. GCA members also benefit from the Association's group purchasing programs for travel, insurance, entertainment and telecommunication services. GCA benefits are available through its Rewards Worldwide Program.

12. What about accessing participating medical providers outside the U.S. and avoid claim forms?

HTH’s Global Health and Safety services help members identify access and pay for quality healthcare all over the world, including a contracted community of elite providers in 180 countries. Members can access these carefully selected providers and arrange for the bills to be sent directly to HTH Worldwide for payment as follows: On our web site, click on “Member Login” then click on “Register Here”. After registering, create a Well Prepared profile and use the related web tool to request an appointment with the participating provider. HTH will automatically arrange for direct settlement of the bill for this visit. Direct billing can also be requested by telephone using the collect call assistance number listed on the member ID card. Please note that in the U.S a member can simply show their ID card at time of service and participating providers will only bill the member for any applicable deductible or copayment. Members have access to a U.S. PPO Network and can locate providers online.

13. Where can I read the fine print?

To see plan definitions, limitations, review a sample certificate.

14. Can you tell me what an HSA is? How would I benefit from choosing an HSA account with HTH?

HSA stands for Health Savings Account and is used to pay health-related expenses with tax-sheltered contributions if you are covered by a qualifying high-deductible health plan (HDHP). Global Citizen 1050 for individuals or 2100 for families are qualified HDHPs. HSAs also allow you to build up savings to pay for future medical expenses. Please consult your tax advisor for further details. You can open an HSA with HTH WorldWide Bank. Note: HTH Members can choose to set up an HSA with any bank of their choice.

The optional RX plan is not available on the HSA plans due to IRS regulations. Please contact us for more information regarding HSA plan.

15. How long will the medical underwriting process take?

The underwriting time frame depends on the medical history listed on the application. Turnaround can be as quick as one day or as long as one month. HTH's commitment is to respond to a submission in writing within 3 business days. This may mean that HTH sends a request for additional information to the applicant, such as a specific medical questionnaire, or notify the applicant that they erroneously missed a question on the application form. Occasionally HTH has to obtain medical records from hospitals or providers. HTH's turnaround time in these situations will depend on how quickly the provider responds to HTH's request.

If HTH receives the application before the requested effective date, HTH can honor the effective date even if the approval comes through thereafter.

16. I am based in the U.S. Can you help me find participating doctors in my hometown?

Inside the U.S., HTH has a network of over 700,000 providers available to its members. You can find a doctor in the network by searching Aetna (search Aetna Standard Plans/Open Choice PPO) network. Always speak directly with the provider you have chosen to confirm that they are currently participating with the Aetna Open Choice PPO network.

17. How do I find doctors and hospitals outside the U.S.?

When you are outside of the U.S., you can call HTH collect to locate a provider or hospital near where you are located. After you purchase the insurance, you will also get the access to the web site to find doctors and hospitals and review detailed profiles. In a case of an emergency, HTH always suggests you go to the nearest local emergency facility.

18. I am trying to find a doctor in the U.S. in your network, but there is no one listed within 25 miles of where I am searching. What should I do?

In the U.S., if a member does not have a participating physician in an appropriate specialty available to them within 25 miles, HTH will apply in-network benefits (80%) to the provider they see.

Outside the U.S., 100% coverage always applies after any applicable deductible or co-payment.

19. I am a Canadian citizen planning to move to the U.S. Am I eligible for your Global Citizen plan?

In order to be eligible for the Global Citizen plan, you must be a citizen or a resident of the United States. If you are in the U.S., you must reside in an approved state. As a Canadian, once you arrive in the U.S. you can apply for coverage if you reside in an approved state (see above for a list of approved states). To ensure that you meet HTH's medical underwriting standards prior to arrival in the U.S., you may wish to complete an HTH pre-screening form.

20. I live in New York and therefore am not eligible to buy a Global Citizen plan. When will New York be an approved state?

It is very difficult to predict state approvals. HTH is working with state insurance regulators to accelerate the process if possible.

If you are going abroad, you may wish to complete a pre-screening form prior to leaving. You can then apply for coverage using an abbreviated application when you are no longer a resident of New York.

21. I purchased an annual plan, but would like to cancel my insurance prior to its expiration. Will I have to pay any cancellation fees?

Any cancellation requests must be received by HTH in writing via email, fax or regular mail. There are no cancellation fees or penalties. However, HTH does not refund premium for a partial month. Retroactive cancellations are also not permitted.

22. Are acts of terrorism covered under this plan?

Yes. The Global Citizen plan does not exclude illnesses or injuries related to terrorism or a terrorist act. In order to be covered in countries where there are open hostilities, such as Iraq and Afghanistan, a member must not be engaged in hostile or combative activities.

23. How does the optional pharmacy benefit work?

The optional pharmacy benefit provides coverage inside the U.S. and a higher benefit limit outside the U.S.

HTH offers members the convenience of a direct billing service inside the U.S. so that the member is only responsible for co-payment at participating pharmacies. Most major pharmacies participate in this program. Outside the U.S., members pay the pharmacy directly and then submit a claim to HTH for reimbursement. The optional pharmacy benefit is not subject to the deductible or to the co-insurance on the plan.

24. How are medical evacuation decisions made?

The evacuation benefit pays for a medical evacuation to the nearest Hospital, appropriate medical facility or back to the U.S. Transportation must be by the most direct and economical route. All evacuations require written certification by the attending physician that the evacuation is medically necessary.

25. Can I add my partner to my Global Citizen policy? Will my partner have to be medically underwritten?

Yes, you can add a spouse or dependent to your policy. A dependent must prove evidence of insurability by submitting an underwriting application. They may be accepted, accepted with a rate up, or declined for coverage based on their medical history. Adding a partner or dependent should follow a life event, such a marriage or birth.

26. Is birth control covered?

Use of birth control is not automatically excluded on the policy. HTH reviews the medical condition for which birth control is being used. If it is being used solely as a contraceptive, it is excluded. If it is being used to treat an approved condition, it will be covered. In this instance, the member will have to pay for the prescription up front and submit a claim to HTH, along with a letter from the prescribing doctor indicating the medical necessity of the contraceptive.

27. Once I'm approved for coverage do I have to go through medical underwriting again?

You do not need to go through medical underwriting when you renew your existing policy without changes. You may be medically underwritten again if you decide to select different benefits (see below). Plan changes can only be requested at time of renewal.

If a member would like to increase benefits (by lowering a deductible or adding pharmacy coverage) they must complete a new application. If a member would like to reduce their benefits, they do not need to complete a new application.

28. Is there a waiting period for pregnancy?

Maternity Benefits

Effective May 2, 2007, new applicants will no longer be eligible for maternity benefits in the first 12 months of coverage.

• After 12 months of continuous coverage a female member can choose to upgrade to a plan with maternity benefits.
• In order to qualify for the maternity benefit upgrade, an application must complete a health statement indicating that they are not pregnant at time of upgrade.
• After upgrading, members will be entitled to a lifetime maximum of $5,000,000 of maternity benefits. Newborn children will be covered automatically in the first 31 days. Well baby visits will be covered up to the policy maximum without a waiting period.

Underwriting and Rates

• HTH can accept pregnant applications with an acceptable health history as long as they apply within their first trimester of pregnancy. Please note: an approved applicant, that is pregnant, will not be covered for maternity benefits under the plan. They will be eligible for the maternity benefits upgrade after they deliver the child and have been covered for 12 continuous months.

29. Are we able to add the optional prescription benefits to a Global Citizen HSA plan?

No, HTH cannot add the optional prescription benefits to their HSA plans.

30. How can I add an adopted child to my Global Citizen policy?

An adopted child must be medically underwritten in order to be added to a policy.

31. How do I calculate out of pocket expenses and the annual limit?
Out-of-pocket expenses are defined as the expenses a member incurs when satisfying the plan’s deductible and coinsurance requirements. The deductible and coinsurance level varies based on where treatment is delivered as shown in the table below. The total annual out-of-pocket expense limit is calculated by adding the deductible and coinsurance maximum together. In this example, it is $3,500. Deductibles must be satisfied before any benefit is paid. Coinsurance is applied as a percentage of the payable medical charges. This percentage is only applied to care delivered inside the U.S. and varies depending on whether the care is delivered in-network or out-of-network.

Table illustration

Global Citizen Plan	Deductible			Coinsurance Maximum
	Outside U.S.	U.S.in Network	U.S.out of Network
500	$250	$500	$1,000	$3,000

Out of Pocket Expense Example
Member is covered under the Global Citizen 500 plan and receives services from an in-network hospital in the U.S.

Payable medical expenses are $20,000, the $500 deductible must be satisfied, and 20% coinsurance applies.

Member is responsible for $3,500 in out-of-pocket expenses (hits the limit) because the deductible and coinsurance amount to $4,500 ($500 + 20% of $20,000)

32. How are the deductible and coinsurance calculated for families?
Deductibles reflected in the Global Citizen plan grid are per person deductibles. For a family, the maximum deductible and coinsurance are increased by a factor of 2.5., regardless of the size of the family. For example, a family covered under the 500 plan pays a maximum deductible of $1,250, calculated by multiplying $500 (per person) by 2.5. The coinsurance maximum is $7,500, calculated by multiplying the coinsurance maximum of $3,000 (per person) by 2.5. The family’s annual out-of-pocket expenses limit is $8,750 ($1,250 + $7,500).

The services for which NO benefits are paid under the insurance plan

· Amounts in excess of maximum amounts of Covered Expenses stated in this Plan.
· Services not specifically listed in this Plan as Covered Services.
· Services or supplies that are not Medically Necessary as defined by the Insurer.
· Services or supplies that the Insurer considers to be Experimental or Investigative.
· Services received before the Effective Date of coverage or during an inpatient stay that began before the Effective Date of Coverage.
· Services received after coverage ends unless an extension of benefits applies under the Plan.
· Services for which the Insured Person has no legal obligation to pay or for which no charge would be made if he/she did not have a health policy or insurance coverage.
· Services for any condition for which benefits are recovered or can be recovered, either by adjudication, settlement or otherwise, under any workers’ compensation, employer’s liability law or occupational disease law, even if the Insured Person does not claim those benefits.
· Conditions caused by or contributed by: (a) An act of war; (b) The inadvertent release of nuclear energy when government funds are available for treatment of Illness or Injury arising from such release of nuclear energy; (c) An Insured Person participating in the military service of any country; (d) An Insured Person participating in an insurrection, rebellion, or riot; (e) Services received for any condition caused by an Insured Person’s commission of, or attempt to commit a felony or to which a contributing cause was the Insured Person being engaged in an illegal occupation; (f) An Insured Person, age 19 or older, being under the influence of illegal narcotics or non-prescribed controlled substances unless administered on the advice of a Physician.
· Any services provided by a local, state or federal government agency except when payment under this Plan is expressly required by federal or state law.
· Professional services received or supplies purchased from the Insured Person, a person who lives in the Insured Person's home or who is related to the Insured Person by blood, marriage or adoption, or the Insured Person’s employer.
· Inpatient or outpatient services of a private duty nurse.
· Inpatient room and board charges in connection with a Hospital stay primarily for environmental change, physical therapy or treatment of chronic pain; Custodial Care or rest cures; services provided by a rest home, a home for the aged, a nursing home or any similar facility service.
· 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.
· Treatment of Mental, Emotional of Functional Nervous Disorders (including nicotine use) or psychological testing except as specifically stated in this Plan. However, medical conditions that are caused by behavior of the Insured Person and that may be associated with these mental conditions are not subject to these limitations.
· Treatment of Drug, alcohol, or other substance addiction or abuse, except as specifically stated in this Plan.
· Dental services, dentures, bridges, crowns, caps or other dental prostheses, extraction of teeth or treatment to the teeth or gums, except as specifically stated in this Plan.
· Dental and orthodontic services for Temporomandibular Joint Dysfunction.
· Orthodontic Services, braces and other orthodontic appliances.
· Dental Implants: Dental materials implanted into or on bone or soft tissue or any associated procedure as part of the implantation or removal of dental implants.
· Hearing aids.
· Routine hearing tests except as provided under Preventive and Primary Care.
· Optometric services, eye exercises including orthoptics, eyeglasses, contact lenses, routine eye exams, and routine eye refractions, except as specifically stated in this Plan.
· An eye surgery solely for the purpose of correcting refractive defects of the eye, such as near-sightedness (myopia), astigmatism and/or farsightedness (presbyopia).
· Outpatient speech therapy.
· Any Drugs, medications, or other substances dispensed or administered in any outpatient setting except as specifically stated in this Plan. This includes, but is not limited to, items dispensed by a Physician.
· Any intentionally self-inflicted Injury or Illness. This exclusion does not apply to the Medical Evacuation, Repatriation of Remains and Bedside Visit Benefits.
· Cosmetic surgery or other services for beautification, including any medical complications that are generally predictable and associated with such services by the organized medical community. This exclusion does not apply to Reconstructive Surgery to restore a bodily function or to correct a deformity caused by Injury or congenital defect of a newborn child, or to Medically Necessary reconstructive surgery performed to restore symmetry incident to a mastectomy.
· Procedures or treatments to change characteristics of the body to those of the opposite sex. This includes any medical, surgical or psychiatric treatment or study related to sex change.
· Treatment of sexual dysfunction or inadequacy.
· All services related to the evaluation or treatment of fertility and/or Infertility, including, but not limited to, all tests, consultations, examinations, medications, invasive, medical, laboratory or surgical procedures including sterilization reversals and In vitro fertilization, except as specifically stated under this Plan.
· All contraceptive services and supplies, including but not limited to, all consultations, examinations, evaluations, medications, medical, laboratory, devices, or surgical procedures unless stated otherwise.
· Cryopreservation of sperm or eggs.
· Orthopedic shoes (except when joined to braces) or shoe inserts, including orthotics.
· Services primarily for weight reduction or treatment of obesity including morbid obesity, or any care which involves weight reduction as a main method of treatment.
· Routine physical exams or tests that do not directly treat an actual Illness, Injury or condition, including those required by employment or government authority except as specifically stated in this Plan.
· Charges by a provider for telephone consultations.
· Items which are furnished primarily for the Eligible Participant’s personal comfort or convenience (air purifiers, air conditioners, humidifiers, exercise equipment, treadmills, spas, elevators and supplies for hygiene or beautification, etc.).
· Educational services except as specifically provided or arranged by the Insurer.
· Nutritional counseling or food supplements.
· Durable medical equipment not specifically listed as Covered Services in this Plan. Excluded durable medical equipment includes, but is not limited to: orthopedic shoes or shoe inserts; air purifiers, air conditioners, humidifiers; exercise equipment, treadmills; spas; elevators; supplies for comfort, hygiene or beautification; disposable sheaths and supplies; correction appliances or support appliances and supplies such as stockings.
· Any services received on or within 6 months after the Effective Date of coverage if they are related to a Pre-existing Condition.
· Physical and/or Occupational Therapy/Medicine, except when provided during an inpatient Hospital confinement or as specifically provided under the benefits for Physical and/or Occupational Therapy/Medicine.
· All Infusion Therapy together with any associated supplies, Drugs or professional services are excluded except as specifically provided under this Plan.
· Growth Hormone Treatment.
· Routine foot care including the cutting or removal of corns or calluses; the trimming of nails, routine hygienic care and any service rendered in the absence of localized Illness, Injury or symptoms involving the feet.
· Charges for which the Insurer is unable to determine the Insurer’s liability because the Eligible Participant or an Insured Person failed, within 60 days, or as soon as reasonably possible to (a) authorize the Insurer to receive all the medical records and information the Insurer requested or, (b) provide the Insurer with information the Insurer requested regarding the circumstances of the claim or other insurance coverage.
· Charges for the services of a standby Physician.
· Charges for animal to human organ transplants.

Pre-existing Conditions
Benefits are not available for any services received: (1) on or within 6 months after the Eligibility Date of an Insured Person who is not a Late Enrollee; or (2) on or within 6 months after the Effective Date of Coverage for a Late Enrollee, if those services are related to a Pre-existing Condition. This exclusion does not apply to a Newborn who is enrolled within 31 days of birth or a newly adopted child who is enrolled within 31 days from either the date of placement of the child in the home, or the date of the final decree of adoption. In addition, the Insurer will credit time an Insured Person was covered by Creditable Coverage that was in effect up to a date not more than 63 days before the Effective Date of Coverage under this Plan, excluding the Waiting Period.

This limitation does not apply to the Medical Evacuation, Repatriation of Remains and Bedside Visit Benefits.

To review a sample certificate visit: certificate wording

If any provision of a Global Citizen plan is in conflict with the statutes of the state in which the member resides it is amended to conform to the minimum requirements of those statutes.

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Accidental Injury means an accidental bodily Injury sustained by an Insured Person which is the direct cause of a loss independent of disease, bodily infirmity, or any other cause.

Age means the Insured Person’s attained age.

Alcoholism means a disorder characterized by a pathological pattern of alcohol use that causes a serious impairment in social or occupational functioning, also termed alcohol abuse or, if tolerance or withdrawal is present, alcohol dependence.

Ambulatory Surgical Center is a freestanding outpatient surgical facility. It must be licensed as an outpatient clinic according to state and local laws and must meet all requirements of an outpatient clinic providing surgical services. It also must meet accreditation standards of the Joint Commission on Accreditation of Health Care Organizations or the Accreditation Association of Ambulatory Health Care.

Certificate of Coverage is the document issued to each Eligible Participant outlining the benefits under the group Policy.

Coinsurance is the percentage of Covered Expenses the Insured Person is responsible for paying (after the applicable Deductible is satisfied and/or Copayment is paid). Coinsurance does not include charges for services that are not Covered Services or charges in excess of Covered Expenses.

Copay or Copayment is the dollar amount of Covered Expenses the Insured Person is responsible for paying. Copayment does not include charges for services that are not Covered Services or charges in excess of Covered Expenses.

Covered Expenses are the expenses incurred for Covered Services. Covered Expenses for Covered Services received from Participating Providers will not exceed the Negotiated Rate. Covered Expenses for Covered Services received from Non-Participating Providers will not exceed Reasonable Charges. In addition, Covered Expenses may be limited by other specific maximums described in this Plan under Section IV, How the Plan Works and Section V, Benefits - What the Plan Pays. Covered Expenses are subject to applicable Deductibles, penalties and other benefit limits.

Covered Services are Medically Necessary services or supplies that are listed in the benefit sections of this Plan, and for which the Insured Person is entitled to receive benefits.

Creditable Coverage means coverage provided under:

1. a self-funded or self-insured employee welfare benefit plan that provides health benefits and that is established in accordance with the Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 101 et seq.);
2. a group health benefit plan provided by a health insurance carrier or health maintenance organization;
3. an individual health insurance policy or evidence of coverage;
4. Part A or Part B of Title XVIII of the Social Security Act (42 U.S.C. Section 1395c et seq.);
5. Title XIX of the Social Security Act (42 U.S.C. 1396 et seq.), other than coverage consisting solely of benefits under Section 1928 of that Act (42 U.S.C. Section 1396s);
6. Chapter 55, Title 10, United States Code (10 U.S.C. Section 1071 et seq.);
7. A medical program of the Indian Health Service or of a tribal organization;
8. A state or political subdivision health benefits risk pool;
9. A health plan offered under Chapter 89, Title 5, United States Code (5 U.S.C. Section 8901 et seq.)
10. A public health plan as defined by federal regulations;
11. A health benefit plan under Section 5 (e), Peace Corps Act (22 U.S.C. Section 2504 (e)).

Deductible means the amount of Covered Expenses the Insured Person must pay for Covered Services before benefits are available to him/her under this Plan. The Annual Deductible is the amount of Covered Expenses the Eligible Participant must pay for each Insured Person before any benefits are available regardless of provider type.

Drug Abuse means any pattern of pathological use of a drug that causes impairment in social or occupational functioning, or that produces physiological dependency evidenced by physical tolerance or by physical symptoms when it is withdrawn.

Effective Date of the Policy is the date that the Group’s or Trust’s Policy became active with the Insurer.

Effective Date of Coverage is the date on which coverage under this Plan begins for the Eligible Participant and any other Insured Person.

Experimental / Investigational Procedures. Any medical, surgical, and/or other procedures, services, products, drugs or devices, (including implants) are considered experimental or investigational if;

1. Its use is mainly limited to laboratory and/or research; or
2. it has not been given approval for marketing by the United States Food & Drug Administration at the time it is furnished and such approval is required by law; or
3. reliable evidence shows it is the subject of ongoing phase I, II or III clinical trials or under study to determine if maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with the state or means of treatment or diagnosis; or
4. reliable evidence shows that the consensus of the opinion among experts is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with the stated means of treatment of diagnosis; or
5. reliable evidence shows that it is not generally approved or used by Physicians in the medical community; or
6. it does not have final approval from the appropriate governmental regulatory body.

Reliable evidence means only: the published reports and articles in authoritative medical and scientific literature; written protocol or protocols by the treating facility or other facilities studying substantially the same drug, device or medical treatment or procedure; or the medical informed consent used by the treating facility or other facilities studying substantially the same drug, device or medical treatment or procedure.

Full-time Student is a student enrolled at an accredited college, university, or trade school participating in the Federally Guaranteed Student Loan Program. The student must be currently attending classes, carrying at least 12 units per term.

Group refers to the business entity to which the Insurer has issued the Policy.

Hospital is a facility which provides diagnosis, treatment and care of persons who need acute inpatient hospital care under the supervision of Physicians. It must:

1. be licensed as a hospital and operated pursuant to law; and
2. be primarily engaged in providing or operating (either on its premises or in facilities available to the hospital on a contractual prearranged basis and under the supervision of a staff of one or more duly licensed physicians) medical, diagnostic, and major surgery facilities for the medical care and treatment of sick or injured persons on an inpatient basis for which a charge is made; and
3. provide 24 hour nursing service by or under the supervision of a registered graduate professional nurse (R.N.); and
4. be an institution which maintains and operates a minimum of five beds; and
5. have X-ray and laboratory facilities either on the premises or available on a contractual prearranged basis; and
6. maintain permanent medical history records.

This definition excludes convalescent homes, convalescent facilities, rest facilities, nursing facilities, or homes or facilities primarily for the aged, those primarily affording custodial care or educational care.

Illness is a sickness, disease, or condition of an Insured Person which first manifests itself after the Insured Person’s Effective Date.

Insured Person means both the Insured Participant and all other Insured Dependents who are covered under this Plan.

Lifetime Maximum Benefit is the maximum amount of benefits available to each Insured Person during the person’s lifetime. All benefits furnished are subject to this maximum amount.

Medically Necessary services or supplies are those that the Insurer determines to be all of the following:

1. Appropriate and necessary for the symptoms, diagnosis or treatment of the medical condition.
2. Provided for the diagnosis or direct care and treatment of the medical condition.
3. Within standards of good medical practice within the organized community.
4. Not primarily for the patient’s, the Physician’s, or another provider’s convenience.
5. The most appropriate supply or level of service that can safely be provided. For Hospital stays, this means acute care as an inpatient is necessary due to the kind of services the Insured Person is receiving or the severity of the Insured Person’s condition and that safe and adequate care cannot be received as an outpatient or in a less intensified medical setting.

The fact that a Physician may prescribe, authorize, or direct a service does not of itself make it Medically Necessary or covered by the Policy. Negotiated Rate is the rate of payment that the Insurer has negotiated with a Participating Provider for Covered Services. Newborn is a recently born infant within 31 days of birth.

Non-Participating Hospital (out of network) is a Hospital that has not entered into a Participating Hospital agreement with the Insurer at the time services are rendered.

Non-Participating Physician (out of network) is a Physician who does not have a Participating Provider agreement in effect with the Insurer at the time services are rendered.

Non-Participating Provider (out of network) is a provider who does not have a Participating Provider agreement in effect with the Insurer at the time services are rendered.

Office Visit means a visit by the Insured Person, who is the patient, to the office of a Physician during which one or more of only the following three specific services are provided:

1. History (gathering of information on an Illness or Injury).
2. Examination.
3. Medical Decision Making (the Physician’s diagnosis and plan of treatment).

This does not include other services (e.g. X-rays or lab services) even if performed on the same day.

Out-of-Pocket Maximum is the amount of Coinsurance each Insured Person incurs for Covered Expenses in a Year. The Out-of-Pocket Maximum does not include any amounts in excess of Covered Expenses, the Deductible and/or any Copayments, Prescription Drug Deductible and Copayments, any penalties, or any amounts in excess of other benefit limits of this Plan.

Participating Hospital (in network) is a Hospital that has a Participating Hospital agreement in effect with the Insurer at the time services are rendered. Participating Hospitals agree to accept the Negotiated Rate as payment in full for Covered Expenses.

Participating Physician (in network) is a Physician who has a Participating Physician agreement in effect with the Insurer at the time services are rendered. Participating Physicians agree to accept the Negotiated Rate as payment in full for Covered Services.

Participating Provider (in network) is a Participating Physician, hospital, or other health care provider that has a Participating Provider agreement in effect with the Insurer at the time services are rendered. Participating Providers agree to accept the Negotiated Rate as payment in full for Covered Expenses.

Physician means a physician licensed to practice medicine or any other practitioner who is licensed and recognized as a provider of health care services in the state and/or country the Insured Person resides or is treated; and provides services covered by the Plan that are within the scope of his/her licensure.

Plan is the set of benefits described in the Certificate of Coverage booklet and in the amendments to this booklet (if any). This Plan is subject to the terms and conditions of the Policy the Insurer has issued to the Group. If changes are made to the Policy or Plan, an amendment or revised booklet will be issued to the Group for distribution to each Insured Participant affected by the change.

Policy is the Group Policy the Insurer has issued to the Group.

Pre-existing Condition means a medical condition for which medical advice, diagnosis, care, or treatment was recommended or received during the 6 months immediately preceding the Eligibility Date

Primary Plan is a Group Health Benefit Plan, an individual health benefit plan, or a governmental health plan designed to be the first payer of claims for an Insured Person prior to the responsibility of this Plan.

Reasonable Charge, as determined by the Insurer, is the amount it will consider a Covered Expense with respect to charges made by a Physician, facility or other supplier for Covered Services. In determining whether a charge is Reasonable, the Insurer will consider all of the following factors:

1. The actual charge.
2. Specialty training, work value factors, practice costs, regional geographic factors and inflation factors.
3. The amount charged for the same or comparable services or supplies in the same region or in other parts of the country.
4. Consideration of new procedures, services or supplies in comparison to commonly used procedures, services or supplies.
5. The Average Wholesale Price for Pharmaceuticals.

Totally Disabled or Total Disability means:

1. As applied to Insured Participant, any period of time during the Insured Participant’s lifetime in which he/she is unable to perform substantially all the duties required by his/her usual occupation, provided the disability commences within twelve (12) months from the date the disabling condition occurred;
2. As applied to a Dependent, not being able to perform the normal activities of a like person of the same age and sex. The patient must be under the care of a Physician.

U.S. means the United States of America.

Year is a 12-month period beginning each January 1 at 12:01 a.m. Eastern Time.