Common use of Foreign Travel - Not Covered by Medicare Clause in Contracts

Foreign Travel - Not Covered by Medicare. This plan covers Medicare eligible expenses for medically necessary emergency services rendered in in a foreign country if Medicare would have covered the services as Medicare eligible expenses had the emergency happened in the United States. In addition, the following conditions must be met: • health services are not eligible for payment under any Medicare program; • emergency care is received during the first sixty (60) days of a trip outside the United States; and • emergency care is received on or after the effective date of your plan. Benefits for emergency medical care in foreign countries are payable to you only in United States currency. The amount paid to you is based on the bank transfer exchange rate in effect the date the services were rendered. You may be required to pay up front for the emergency services at the time of service. You are then responsible to complete a foreign claim research form and a claim form and submit both to us for processing. To obtain forms, please call the Medicare Concierge Team. See Section 9 for contact information. To file a claim, please send us the itemized bill for the healthcare service, a completed foreign claim research form, and a claim form with the following information: • your name; • your Plan 65 subscriber ID number; • name, address, and telephone number of the provider who performed the service; • date and description of the service; and • the charge for the service. Please send to the address listed in Section 9: Contact Information. Claims must be filed within twelve (12) months of the date you receive a healthcare service.

Foreign Travel - Not Covered by Medicare. This plan covers Medicare eligible expenses for medically necessary emergency services rendered in in a foreign country if Medicare would have covered the services as Medicare eligible expenses had the emergency happened in the United States. In addition, the following conditions must be met: • health services are not eligible for payment under any Medicare program; • emergency care is received during the first sixty (60) days of a trip outside the United States; and • emergency care is received on or after the effective date of your plan. Benefits for emergency medical care in foreign countries are payable to you only in United States currency. The amount paid to you is based on the bank transfer exchange rate in effect the date the services were rendered. You may be required to pay up front for the emergency services at the time of service. You are then responsible to complete a foreign claim research form and a claim form and submit both to us for processing. To obtain forms, please call the Medicare Concierge Team. See Section 9 for contact information. To file a claim, please send us the itemized bill xxxx for the healthcare service, a completed foreign claim research form, and a claim form with the following information: • your name; • your Plan 65 subscriber ID number; • name, address, and telephone number of the provider who performed the service; • date and description of the service; and • the charge for the service. Please send to the address listed in Section 9: Contact Information. Claims must be filed within twelve (12) months of the date you receive a healthcare service.

Foreign Travel - Not Covered by Medicare. This plan covers Medicare eligible expenses for medically necessary emergency services rendered in in a foreign country if Medicare would have covered the services as Medicare eligible expenses had the emergency happened in the United States. In addition, the following conditions must be met: •  health services are not eligible for payment under any Medicare program; •  emergency care is received during the first sixty (60) days of a trip outside the United States; and •  emergency care is received on or after the effective date of your plan. Benefits for emergency medical care in foreign countries are payable to you only in United States currency. The amount paid to you is based on the bank transfer exchange rate in effect the date the services were rendered. You may be required to pay up front for the emergency services at the time of service. You are then responsible to complete a foreign claim research form and a claim form and submit both to us for processing. To obtain forms, please call the Medicare Concierge Team. See Section 9 for contact information. To file a claim, please send us the itemized bill for the healthcare service, a completed foreign claim research form, and a claim form with the following information: •  your name; •  your Plan 65 subscriber ID number; •  name, address, and telephone number of the provider who performed the service; •  date and description of the service; and •  the charge for the service. Please send to the address listed in Section 9: Contact Information. Claims must be filed within twelve (12) months of the date you receive a healthcare service.

Foreign Travel - Not Covered by Medicare. This plan covers Medicare eligible expenses for medically necessary emergency services rendered in in a foreign country if Medicare would have covered the services as Medicare eligible expenses had the emergency happened in the United States. In addition, the following conditions must be met: •  health services are not eligible for payment under any Medicare program; •  emergency care is received during the first sixty (60) days of a trip outside the United States; and •  emergency care is received on or after the effective date of your plan. Benefits for emergency medical care in foreign countries are payable to you only in United States currency. The amount paid to you is based on the bank transfer exchange rate in effect the date the services were rendered. You may be required to pay up front for the emergency services at the time of service. You are then responsible to complete a foreign claim research form and a claim form and submit both to us for processing. To obtain forms, please call the Medicare Concierge Team. See Section 9 for contact information. To file a claim, please send us the itemized bill xxxx for the healthcare service, a completed foreign claim research form, and a claim form with the following information: •  your name; •  your Plan 65 subscriber ID number; •  name, address, and telephone number of the provider who performed the service; •  date and description of the service; and •  the charge for the service. Please send to the address listed in Section 9: Contact Information. Claims must be filed within twelve (12) months of the date you receive a healthcare service.

Foreign Travel - Not Covered by Medicare. ‌ This plan covers Medicare eligible expenses for medically necessary emergency services rendered in in a foreign country if Medicare would have covered the services as Medicare eligible expenses had the emergency happened in the United States. In addition, the following conditions must be met: • health services are not eligible for payment under any Medicare program; • emergency care is received during the first sixty (60) days of a trip outside the United States; and • emergency care is received on or after the effective date of your plan. Benefits for emergency medical care in foreign countries are payable to you only in United States currency. The amount paid to you is based on the bank transfer exchange rate in effect the date the services were rendered. You may be required to pay up front for the emergency services at the time of service. You are then responsible to complete a foreign claim research form and a claim form and submit both to us for processing. To obtain forms, please call the Medicare Concierge Team. See Section 9 for contact information. To file a claim, please send us the itemized bill xxxx for the healthcare service, a completed foreign claim research form, and a claim form with the following information: • your name; • your Plan 65 subscriber ID number; • name, address, and telephone number of the provider who performed the service; • date and description of the service; and • the charge for the service. Please send to the address listed in Section 9: Contact Information. Claims must be filed within twelve (12) months of the date you receive a healthcare service.