A Fee-For-Service Plan (Standard and Basic Option) with a ...

Blue Cross? and Blue Shield? Service Benefit Plan



2019

A Fee-For-Service Plan (Standard and Basic Option) with a Preferred Provider Organization

This Plan's health coverage qualifies as minimum essential coverage and meets the minimum value standard for the benefits it provides. See pages 4 and 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

IMPORTANT ? Rates: Back Cover ? Changes for 2019: Page 15 ? Summary of benefits: Page 170

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

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 advised If you lose or drop your FEHB coverage and go 63 days or longer without prescription drug coverage that's 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 , 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:

? Visit for personalized help. ? Call 800-MEDICARE 800-633-4227, TTY 877-486-2048.

RI 71-005

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 ? No pre-existing condition limitation...............................................................................................................................9 ? Minimum essential coverage (MEC)..............................................................................................................................9 ? Minimum value standard ................................................................................................................................................9 ? Where you can get information about enrolling in the FEHB Program .........................................................................9 ? Types of coverage available for you and your family ....................................................................................................9 ? Family member coverage .............................................................................................................................................10 ? Children's Equity Act ...................................................................................................................................................10 ? When benefits and premiums start................................................................................................................................11 ? When you retire ............................................................................................................................................................11 When you lose benefits .....................................................................................................................................................11 ? When FEHB coverage ends ..........................................................................................................................................11 ? Upon divorce ................................................................................................................................................................12 ? Temporary Continuation of Coverage (TCC) ...............................................................................................................12 ? Finding replacement coverage ......................................................................................................................................12 ? 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 2019 .......................................................................................................................................................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 .....................................................................................................................................................18 Identification cards............................................................................................................................................................18 Where you get covered care..............................................................................................................................................18 ? Covered professional providers ....................................................................................................................................18 ? Covered facility providers ............................................................................................................................................19 What you must do to get covered care ..............................................................................................................................21 ? Transitional care ...........................................................................................................................................................21 ? If you are hospitalized when your enrollment begins...................................................................................................22 You need prior Plan approval for certain services ............................................................................................................22 ? Inpatient hospital admission, inpatient residential treatment center admission, or skilled nursing facility admission ..........................................................................................................................................................................22 ? Other services ...............................................................................................................................................................23 ? Surgery by Non-participating providers under Standard Option..................................................................................25 ? How to request precertification for an admission or get prior approval for Other services .........................................25 ? Non-urgent care claims.................................................................................................................................................26 ? Urgent care claims ........................................................................................................................................................26 ? Concurrent care claims .................................................................................................................................................27

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? Emergency inpatient admission ....................................................................................................................................27 ? Maternity care ...............................................................................................................................................................27 ? If your facility stay needs to be extended .....................................................................................................................27 ? If your treatment needs to be extended.........................................................................................................................27 If you disagree with our pre-service claim decision .........................................................................................................27 ? To reconsider a non-urgent care claim..........................................................................................................................28 ? To reconsider an urgent care claim ...............................................................................................................................28 ? To file an appeal with OPM ..........................................................................................................................................28 Section 4. Your Costs for Covered Services ...............................................................................................................................29 Cost share/Cost-sharing ....................................................................................................................................................29 Copayment ........................................................................................................................................................................29 Deductible .........................................................................................................................................................................29 Coinsurance .......................................................................................................................................................................30 If your provider routinely waives your cost......................................................................................................................30 Waivers ..............................................................................................................................................................................30 Differences between our allowance and the bill ...............................................................................................................30 Important notice about Non-participating providers! .......................................................................................................33 Your costs for other care ...................................................................................................................................................33 Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments ...........................33 Carryover ..........................................................................................................................................................................34 If we overpay you .............................................................................................................................................................35 When Government facilities bill us ..................................................................................................................................35 Section 5. Benefits ......................................................................................................................................................................36 Standard and Basic Option Overview ...............................................................................................................................38 Non-FEHB Benefits Available to Plan Members ...........................................................................................................138 Section 6. General Exclusions ? Services, Drugs, and Supplies We Do Not Cover.................................................................139 Section 7. Filing a Claim for Covered Services ........................................................................................................................141 Section 8. The Disputed Claims Process...................................................................................................................................144 Section 9. Coordinating Benefits With Medicare and Other Coverage ....................................................................................147 When you have other health coverage ............................................................................................................................147 ? TRICARE and CHAMPVA ........................................................................................................................................147 ? Workers' Compensation..............................................................................................................................................148 ? Medicaid .....................................................................................................................................................................148 When other Government agencies are responsible for your care ...................................................................................148 When others are responsible for injuries.........................................................................................................................148 When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP)........................................................149 Clinical trials ...................................................................................................................................................................149 When you have Medicare ...............................................................................................................................................150 ? What is Medicare? ......................................................................................................................................................150 ? Should I enroll in Medicare? ......................................................................................................................................151 ? The Original Medicare Plan (Part A or Part B)...........................................................................................................151 ? Tell us about your Medicare coverage ........................................................................................................................152 ? Private contract with your physician ..........................................................................................................................152 ? Medicare Advantage (Part C) .....................................................................................................................................153 ? Medicare prescription drug coverage (Part D) ...........................................................................................................153 ? Medicare prescription drug coverage (Part B) ...........................................................................................................153 When you are age 65 or over and do not have Medicare................................................................................................155 Physicians Who Opt-Out of Medicare ............................................................................................................................156 When you have the Original Medicare Plan (Part A, Part B, or both)............................................................................156 Section 10. Definitions of Terms We Use in This Brochure .....................................................................................................157 Section 11. Other Federal Programs .........................................................................................................................................165

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The Federal Flexible Spending Account Program ? FSAFEDS .....................................................................................165 The Federal Employees Dental and Vision Insurance Program ? FEDVIP....................................................................166 The Federal Long Term Care Insurance Program ? FLTCIP ..........................................................................................167 The Federal Employees' Group Life Insurance Program ? FEGLI ................................................................................167 Index ..........................................................................................................................................................................................168 Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan Standard Option ? 2019 ..............................170 Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan Basic Option ? 2019 ....................................172 2019 Rate Information for the Blue Cross and Blue Shield Service Benefit Plan....................................................................174

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Introduction

This brochure describes the benefits of the Blue Cross and Blue Shield Service Benefit Plan under our 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, , or contact your Local Plan at the telephone 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, 2019, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2019, and changes are summarized on pages 15-17. Rates are shown on the back cover of this brochure.

Coverage under this Plan qualifies as minimum essential coverage (MEC) and satisfies the Patient Protection and Affordable Care Act's (ACA) individual shared responsibility requirement. Please visit the Internal Revenue Service (IRS) website at uac/Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision for more information on the individual requirement for MEC.

The ACA establishes a minimum value for the standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). The health coverage of this Plan meets the minimum value standard for the benefits the Plan provides. (See page 9.)

Plain Language

All FEHB brochures are written in plain language to make them easy to understand. Here are some examples:

? Except for necessary technical terms, we use common words. For instance, "you" means the enrollee or family member; "we"

means the Blue Cross and Blue Shield Service Benefit Plan.

? We 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.

? Our 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 ? Here are some things you can do to prevent fraud:

? Do not give your plan identification (ID) number over the telephone or to people you do not know, except for your healthcare

provider, authorized health benefits plan, or OPM representative.

? Let only the appropriate medical professionals review your medical record or recommend services. ? Avoid 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.

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? Carefully review explanations of benefits (EOBs) statements that you receive from us. ? Periodically review your claim history for accuracy to ensure we have not been billed for services you did not receive. ? Do 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. ? If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or

misrepresented any information, do the following: - Call the provider and ask for an explanation. There may be an error. - If the provider does not resolve the matter, call the FEP Fraud Hotline at 800-FEP-8440 (800-337-8440) and explain the

situation. - If we do not resolve the issue:

CALL ? THE HEALTH CARE FRAUD HOTLINE

877-499-7295

OR go to our-inspector-general/hotline-to-report-fraud-waste-or-abuse/complaint-form

The online form is the desired method of reporting fraud in order to ensure accuracy, and a quick response time.

You can also write to:

United States Office of Personnel Management Office of the Inspector General Fraud Hotline

1900 E Street NW Room 6400 Washington, DC 20415-1100

? Do not maintain as a family member on your policy:

- Your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise) - Your child age 26 or over (unless he/she was disabled and incapable of self-support prior to age 26)

? If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed, with your

retirement office (such as OPM) if you are retired, or with the National Finance Center if you are enrolled under Temporary Continuation of Coverage (TCC).

? Fraud or intentional misrepresentation of material fact is prohibited under the Plan. You can be prosecuted for fraud and your

agency may take action against you. Examples of fraud include falsifying a claim to obtain FEHB benefits, trying to or obtaining service or coverage for yourself or for someone who is not eligible for coverage, or enrolling in the Plan when you are no longer eligible.

? If your enrollment continues after you are no longer eligible for coverage (i.e., you have separated from Federal service) and

premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not paid. You may be billed by your provider for services received. You may be prosecuted for fraud for knowingly using health insurance benefits for which you have not paid premiums. It is your responsibility to know when you or a family member is no longer eligible to use your health insurance coverage.

Discrimination is Against the Law

The Blue Cross and Blue Shield Service Benefit Plan complies with all applicable Federal civil rights laws, to include both Title VII of the Civil Rights Act of 1964 and Section 1557 of the Affordable Care Act. Pursuant to Section 1557, we do not discriminate, exclude people, or treat them differently on the basis of race, color, national origin, age, disability, or sex.

We:

? Provide free aids and services to people with disabilities to communicate effectively with us, such as:

- Qualified sign language interpreters - Written information in other formats (large print, audio, accessible electronic formats, other formats)

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? Provide 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 telephone 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 en/rights-and-responsibilities/, or call the customer service telephone 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.

? Ask questions and make sure you understand the answers. ? Choose a doctor with whom you feel comfortable talking. ? Take 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.

? Bring 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.

? Tell your doctor and pharmacist about any drug, food, and other allergies you have, such as to latex. ? Ask 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.

? Make sure your medication is what the doctor ordered. Ask the pharmacist about your medication if it looks different than you

expected.

? Read the label and patient package insert when you get your medication, including all warnings and instructions. ? Know how to use your medication. Especially note the times and conditions when your medication should and should not be taken. ? Contact your doctor or pharmacist if you have any questions.

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