A Fee-For-Service Plan (FEP Blue Standard and FEP Blue Basic Options) with a Preferred Provider Guidance/Guidance/Manuals/downloads/ge101c03.pdf.
172 pages
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Blue Cross® and Blue Shield® Service Benefit Plan www.fepblue.org 2021 A Fee-For-Service Plan (FEP Blue Standard and FEP Blue Basic Options) with a Preferred Provider Organization IMPORTANT Ł Rates: Back Cover Ł Changes for 2021: Page 15 Ł Summary of Benefits: Page 163 This Plan™s health coverage qualifies as minimum essential coverage and meets the minimum value standard for the benefits it provides. See page 9 for details. This Plan is accredited. See page 13. Sponsored and administered by : The Blue Cross and Blue Shield Association and participating Blue Cross and Blue Shield Plans Who may enroll in this Plan : All Federal employees, Tribal employees, and annuitants who are eligible to enroll in the Federal Employees Health Benefits Program Enrollment codes for this Plan: 104 Standard Option – Self Only 106 Standard Option – Self Plus One 105 Standard Option – Self and Family 111 Basic Option – Self Only 113 Basic Option – Self Plus One 112 Basic Option – Self and Family RI 71-005
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Important Notice from the Blue Cross and Blue Shield Service Benefit Plan About Our Prescription Drug Coverage and Medicare The Office of Personnel Management (OPM) has determined that the Blue Cross and Blue Shield Service Benefit Plan™s prescription drug coverage is, on average, expected to pay out as much as the standard Medicare prescription drug coverage will pay for all plan participants and is considered Creditable Coverage. This means you do not need to enroll in Medicare Part D and pay extra for prescription drug coverage. If you decide to enroll in Medicare Part D later, you will not have to pay a penalty for late enrollment as long as you keep your FEHB coverage. However, if you choose to enroll in Medicare Part D, you can keep your FEHB coverage and your FEHB plan will coordinate benefits with Medicare. Remember: If you are an annuitant and you cancel your FEHB coverage, you may not re-enroll in the FEHB Program. Please be advisedIf you lose or drop your FEHB coverage and go 63 days or longer without prescription drug coverage that is at least as good as Medicare™s prescription drug coverage, your monthly Medicare Part D premium will go up at least 1 percent per month for every month that you did not have that coverage. For example, if you go 19 months without Medicare Part D prescription drug coverage, your premium will always be at least 19 percent higher than what many other people pay. You will have to pay this higher premium as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the next Annual Coordinated Election Period (October 15 through December 7) to enroll in Medicare Part D. Medicare™s Low Income Benefits For people with limited income and resources, extra help paying for a Medicare prescription drug plan is available. Information regarding this program is available through the Social Security Administration (SSA) online at www.socialsecurity.gov, or call the SSA at 800-772-1213, TTY 800-325-0778. You can get more information about Medicare prescription drug plans and the coverage offered in your area from these places: ŁVisit www.medicare.gov for personalized help. ŁCall 800-MEDICARE 800-633-4227, TTY 877-486-2048. RI 71-005
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Table of Contents Introduction ..4 Plain Language 4 Stop Health Care Fraud! 4 Discrimination is Against the Law 5 Preventing Medical Mistakes ..6 FEHB Facts ..9 Coverage information 9 Ł No pre-existing condition limitation .9 Ł Minimum essential coverage (MEC) 9 Ł Minimum value standard 9 Ł Where you can get information about enrolling in the FEHB Program .9 Ł Types of coverage available for you and your family .9 Ł Family member coverage 10 Ł Children™s Equity Act 10 Ł When benefits and premiums start ..11 Ł When you retire 11 When you lose benefits ..11 Ł When FEHB coverage ends 11 Ł Upon divorce .12 Ł Temporary Continuation of Coverage (TCC) 12 Ł Finding replacement coverage ..12 Ł Health Insurance Marketplace ..12 Section 1. How This Plan Works 13 General features of our Standard and Basic Options ..13 We have a Preferred Provider Organization (PPO) ..13 How we pay professional and facility providers 13 Your rights and responsibilities ..14 Your medical and claims records are confidential 14 Section 2. Changes for 2021 .15 Changes to our Standard Option only .15 Changes to our Basic Option only 15 Changes to both our Standard and Basic Options .16 Section 3. How You Get Care ..17 Identification cards 17 Where you get covered care .17 Ł Covered professional providers 17 Ł Covered facility providers ..18 What you must do to get covered care 20 Ł Transitional care ..20 Ł If you are hospitalized when your enrollment begins 20 You need prior Plan approval for certain services 21 Ł Inpatient hospital admission, inpatient residential treatment center admission, or skilled nursing facility admission ..21 Ł Other services 22 Ł Surgery by Non-participating providers under Standard Option .24 How to request precertification for an admission or get prior approval for Other services 24 Ł Non-urgent care claims .25 Ł Urgent care claims ..25 Ł Concurrent care claims .26 1 2021 Blue Cross® and Blue Shield® Service Benefit Plan Table of Contents
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Ł Emergency inpatient admission 26 Ł Maternity care 26 Ł If your facility stay needs to be extended 26 Ł If your treatment needs to be extended .27 If you disagree with our pre-service claim decision 27 Ł To reconsider a non-urgent care claim ..27 Ł To reconsider an urgent care claim .27 Ł To file an appeal with OPM 27 Ł The Federal Flexible Spending Account Program Œ FSAFEDS ..27 Section 4. Your Costs for Covered Services .28 Cost-share/Cost-sharing .28 Copayment 28 Deductible .28 Coinsurance ..29 If your provider routinely waives your cost .29 Waivers 29 Differences between our allowance and the bill 29 Important notice about Non-participating providers! .32 Your costs for other care 32 Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments 32 Carryover ..33 If we overpay you .34 When Government facilities bill us .34 Section 5. Benefits .35 Standard and Basic Option Overview .37 Non-FEHB Benefits Available to Plan Members ..133 Section 6. General Exclusions Œ Services, Drugs, and Supplies We Do Not Cover ..134 Section 7. Filing a Claim for Covered Services 136 Section 8. The Disputed Claims Process ..139 Section 9. Coordinating Benefits With Medicare and Other Coverage 142 When you have other health coverage .142 Ł TRICARE and CHAMPVA .142 Ł Workers™ Compensation .143 Ł Medicaid 143 When other Government agencies are responsible for your care ..143 When others are responsible for injuries .143 When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) ..144 Clinical trials .144 When you have Medicare ..145 Ł The Original Medicare Plan (Part A or Part B) ..145 Ł Tell us about your Medicare coverage 146 Ł Private contract with your physician ..146 Ł Medicare Advantage (Part C) .146 Ł Medicare prescription drug coverage (Part D) ..147 Ł Medicare prescription drug coverage (Part B) ..147 When you are age 65 or over and do not have Medicare 149 Physicians Who Opt-Out of Medicare .150 When you have the Original Medicare Plan (Part A, Part B, or both) .150 Section 10. Definitions of Terms We Use in This Brochure ..152 Index 161 Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan Standard Option Œ 2021 163 2 2021 Blue Cross® and Blue Shield® Service Benefit Plan Table of Contents
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Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan Basic Option Œ 2021 165 2021 Rate Information for the Blue Cross and Blue Shield Service Benefit Plan ..170 3 2021 Blue Cross® and Blue Shield® Service Benefit Plan Table of Contents
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Introduction This brochure describes the benefits of the Blue Cross and Blue Shield Service Benefit Plan – FEP Blue Standard and FEP Blue Basic Options under contract (CS 1039) with the United States Office of Personnel Management, as authorized by the Federal Employees Health Benefits law. This Plan is underwritten by participating Blue Cross and Blue Shield Plans (Local Plans) that administer this Plan in their individual localities. For customer service assistance, visit our website, www.fepblue.org, or contact your Local Plan at the phone number appearing on the back of your ID card. The Blue Cross and Blue Shield Association is the Carrier of the Plan. The address for the Blue Cross and Blue Shield Service Benefit Plan administrative office is: Blue Cross and Blue Shield Service Benefit Plan 1310 G Street NW, Suite 900 Washington, DC 20005 This brochure is the official statement of benefits. No verbal statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure. It is your responsibility to be informed about your healthcare benefits. If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self Plus One or Self and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that were available before January 1, 2021, unless those benefits are also shown in this brochure. OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2021, and changes are summarized on pages 15-16. Rates are shown on the back cover of this brochure. Plain Language All FEHB brochures are written in plain language to make them easy to understand. Here are some examples: ŁExcept for necessary technical terms, we use common words. For instance, fiyoufl means the enrollee and each covered family member; fiwefl means the Blue Cross and Blue Shield Service Benefit Plan. ŁWe limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the United States Office of Personnel Management. If we use others, we tell you what they mean. ŁOur brochure and other FEHB plans™ brochures have the same format and similar descriptions to help you compare plans. Stop Health Care Fraud! Fraud increases the cost of healthcare for everyone and increases your Federal Employees Health Benefits Program premium. OPM™s Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of the agency that employs you or from which you retired. Protect Yourself From Fraud Œ Here are some things you can do to prevent fraud: ŁDo not give your plan identification (ID) number over the phone or to people you do not know, except for your healthcare provider, authorized health benefits plan, or OPM representative. ŁLet only the appropriate medical professionals review your medical record or recommend services. ŁAvoid using healthcare providers who say that an item or service is not usually covered, but they know how to bill us to get it paid. ŁCarefully review explanations of benefits (EOBs) statements that you receive from us. ŁPeriodically review your claim history for accuracy to ensure we have not been billed for services you did not receive. ŁDo not ask your doctor to make false entries on certificates, bills, or records in order to get us to pay for an item or service. 4 2021 Blue Cross® and Blue Shield® Service Benefit Plan Introduction/Plain Language/Advisory
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ŁProvide free language services to people whose primary language is not English, such as: – Qualified interpreters – Information written in other languages If you need these services, contact the Civil Rights Coordinator of your Local Plan by contacting your Local Plan at the phone number appearing on the back of your ID card. If you believe that we have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with the Civil Rights Coordinator of your Local Plan. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, your Local Plan™s Civil Rights Coordinator is available to help you. Members may file a complaint with the HHS Office of Civil Rights, OPM, or FEHB Program Carriers. You can also file a civil rights complaint with the Office of Personnel Management by mail at: Office of Personnel Management Healthcare and Insurance Federal Employee Insurance Operations Attention: Assistant Director, FEIO 1900 E Street NW, Suite 3400-S Washington, D.C. 20415-3610 For further information about how to file a civil rights complaint, go to www.fepblue.org/en/rights-and-responsibilities/, or call the customer service phone number on the back of your member ID card. For TTY, dial 711. Preventing Medical Mistakes Medical mistakes continue to be a significant cause of preventable deaths within the United States. While death is the most tragic outcome, medical mistakes cause other problems such as permanent disabilities, extended hospital stays, longer recoveries, and additional treatments. Medical mistakes and their consequences also add significantly to the overall cost of healthcare. Hospitals and healthcare providers are being held accountable for the quality of care and reduction in medical mistakes by their accrediting bodies. You can also improve the quality and safety of your own healthcare and that of your family members by learning more about and understanding your risks. Take these simple steps: 1. Ask questions if you have doubts or concerns. ŁAsk questions and make sure you understand the answers. ŁChoose a doctor with whom you feel comfortable talking. ŁTake a relative or friend with you to help you take notes, ask questions and understand answers. 2. Keep and bring a list of all the medications you take. ŁBring the actual medications or give your doctor and pharmacist a list of all the medications and dosages that you take, including non-prescription (over-the-counter) medications and nutritional supplements. ŁTell your doctor and pharmacist about any drug, food, and other allergies you have, such as to latex. ŁAsk about any risks or side effects of the medication and what to avoid while taking it. Be sure to write down what your doctor or pharmacist says. ŁMake sure your medication is what the doctor ordered. Ask the pharmacist about your medication if it looks different than you expected. ŁRead the label and patient package insert when you get your medication, including all warnings and instructions. ŁKnow how to use your medication. Especially note the times and conditions when your medication should and should not be taken. ŁContact your doctor or pharmacist if you have any questions. 6 2021 Blue Cross® and Blue Shield® Service Benefit Plan Introduction/Plain Language/Advisory
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ŁUnderstand both the generic and brand names of your medication. This helps ensure you do not receive double dosing from taking both a generic and a brand. It also helps prevent you from taking a medication to which you are allergic. 3. Get the results of any test or procedure. ŁAsk when and how you will get the results of tests or procedures. Will it be in person, by phone, mail, through the Plan or Provider™s portal? ŁDo not assume the results are fine if you do not get them when expected. Contact your healthcare provider and ask for your results. ŁAsk what the results mean for your care. 4. Talk to your doctor about which hospital or clinic is best for your health needs. ŁAsk your doctor about which hospital or clinic has the best care and results for your condition if you have more than one hospital or clinic to choose from to get the healthcare you need. ŁBe sure you understand the instructions you get about follow-up care when you leave the hospital or clinic. 5. Make sure you understand what will happen if you need surgery. ŁMake sure you, your doctor, and your surgeon all agree on exactly what will be done during the operation. ŁAsk your doctor, fiWho will manage my care when I am in the hospital?fl ŁAsk your surgeon: – fiExactly what will you be doing?fl – fiAbout how long will it take?fl – fiWhat will happen after surgery?fl – fiHow can I expect to feel during recovery?fl ŁTell the surgeon, anesthesiologist, and nurses about any allergies, bad reactions to anesthesia, and any medications or nutritional supplements you are taking. Patient Safety LinksFor more information on patient safety, please visit: Łwww.jointcommission.org/topics/patient_safety.aspx. The Joint Commission helps health care organizations to improve the quality and safety of the care they deliver. Łwww.ahrq.gov/patients-consumers/. The Agency for Healthcare Research and Quality makes available a wide-ranging list of topics not only to inform consumers about patient safety but to help choose quality healthcare providers and improve the quality of care you receive. Łwww.bemedwise.org. The National Council on Patient Information and Education is dedicated to improving communication about the safe, appropriate use of medications. Łwww.leapfroggroup.org. The Leapfrog Group is active in promoting safe practices in hospital care. Łwww.ahqa.org. The American Health Quality Association represents organizations and healthcare professionals working to improve patient safety. Preventable Healthcare Acquired Conditions (fiNever Eventsfl) When you enter the hospital for treatment of one medical problem, you do not expect to leave with additional injuries, infections, or other serious conditions that occur during the course of your stay. Although some of these complications may not be avoidable, patients do suffer from injuries or illnesses that could have been prevented if doctors or the hospital had taken proper precautions. Errors in medical care that are clearly identifiable, preventable and serious in their consequences for patients can indicate a significant problem in the safety and credibility of a healthcare facility. These conditions and errors are sometimes called fiNever Eventsfl or fiSerious Reportable Events.fl 7 2021 Blue Cross® and Blue Shield® Service Benefit Plan Introduction/Plain Language/Advisory
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We have a benefit payment policy that encourages hospitals to reduce the likelihood of hospital-acquired conditions such as certain infections, severe bedsores, and fractures, and to reduce medical errors that should never happen. When such an event occurs, neither you nor your FEHB Plan will incur costs to correct the medical error. You will not be billed for inpatient services when care is related to treatment of specific hospital-acquired conditions if you use Preferred or Member hospitals. This policy helps to protect you from having to pay for the cost of treating these conditions, and it encourages hospitals to improve the quality of care they provide. 8 2021 Blue Cross® and Blue Shield® Service Benefit Plan Introduction/Plain Language/Advisory
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FEHB Facts Coverage informationWe will not refuse to cover the treatment of a condition you had before you enrolled in this Plan solely because you had the condition before you enrolled. Ł No pre-existing condition limitationCoverage under this Plan qualifies as minimum essential coverage. Please visit the Internal Revenue Service (IRS) website at www.irs.gov/uac/Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision for more information on the individual requirement for MEC. Ł Minimum essential coverage (MEC)Our health coverage meets the minimum value standard of 60% established by the ACA. This means that we provide benefits to cover at least 60% of the total allowed costs of essential health benefits. The 60% standard is an actuarial value; your specific out-of-pocket costs are determined as explained in this brochure. Ł Minimum value standardSee www.opm.gov/healthcare-insurance/healthcare for enrollment information as well as: Ł Information on the FEHB Program and plans available to you Ł A health plan comparison tool Ł A list of agencies that participate in Employee Express Ł A link to Employee Express Ł Information on and links to other electronic enrollment systems Also, your employing or retirement office can answer your questions, and give you brochures for other plans and other materials you need to make an informed decision about your FEHB coverage. These materials tell you: Ł When you may change your enrollment Ł How you can cover your family members Ł What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire Ł What happens when your enrollment ends Ł When the next Open Season for enrollment begins We do not determine who is eligible for coverage and, in most cases, cannot change your enrollment status without information from your employing or retirement office. For information on your premium deductions, you must also contact your employing or retirement office. Ł Where you can get information about enrolling in the FEHB Program Self Only coverage is for you alone. Self Plus One coverage is for you and one eligible family member. Self and Family coverage is for you and one eligible family member, or you, your spouse, and your dependent children under age 26, including any foster children authorized for coverage by your employing agency or retirement office. Under certain circumstances, you may also continue coverage for a disabled child 26 years of age or older who is incapable of self-support. If you have a Self Only enrollment, you may change to a Self Plus One or Self and Family enrollment if you marry, give birth, or add a child to your family. You may change your enrollment 31 days before to 60 days after that event. The Self Plus One or Self and Family enrollment begins on the first day of the pay period in which the child is born or becomes an eligible family member. When you change to Self Plus One or Self and Family because you marry, the change is effective on the first day of the pay period that begins after your employing office receives your enrollment form. Benefits will not be available until you are married. A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee™s FEHB enrollment. Your employing or retirement office will not notify you when a family member is no longer eligible to receive health benefits, nor will we. Please tell us immediately of changes in family member status, including your marriage, divorce, annulment, or when your child reaches age 26. Ł Types of coverage available for you and your family 9 2021 Blue Cross® and Blue Shield® Service Benefit Plan FEHB Facts
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