Blue Cross® and Blue Shield® Service Benefit Plan

Blue Cross? and Blue Shield? Service Benefit Plan



2021

A Fee-For-Service Plan (FEP Blue Standard and FEP Blue Basic Options) 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 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

IMPORTANT ? Rates: Back Cover ? Changes for 2021: Page 15 ? Summary of Benefits: Page 163

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

Authorized for distribution by the: United States Office of Personnel Management

Healthcare and Insurance

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 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 , 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 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 ? Covered professional providers ....................................................................................................................................17 ? Covered facility providers ............................................................................................................................................18 What you must do to get covered care ..............................................................................................................................20 ? Transitional care ...........................................................................................................................................................20 ? If you are hospitalized when your enrollment begins...................................................................................................20 You need prior Plan approval for certain services ............................................................................................................21 ? Inpatient hospital admission, inpatient residential treatment center admission, or skilled nursing facility admission ..........................................................................................................................................................................21 ? Other services ...............................................................................................................................................................22 ? Surgery by Non-participating providers under Standard Option..................................................................................24 How to request precertification for an admission or get prior approval for Other services .............................................24 ? Non-urgent care claims.................................................................................................................................................25 ? Urgent care claims ........................................................................................................................................................25 ? Concurrent care claims .................................................................................................................................................26

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? Emergency inpatient admission ....................................................................................................................................26 ? Maternity care ...............................................................................................................................................................26 ? If your facility stay needs to be extended .....................................................................................................................26 ? 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..........................................................................................................................27 ? To reconsider an urgent care claim ...............................................................................................................................27 ? To file an appeal with OPM ..........................................................................................................................................27 ? The Federal Flexible Spending Account Program ? 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 ? 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 ? TRICARE and CHAMPVA ........................................................................................................................................142 ? Workers' Compensation..............................................................................................................................................143 ? 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 ? The Original Medicare Plan (Part A or Part B)...........................................................................................................145 ? Tell us about your Medicare coverage ........................................................................................................................146 ? Private contract with your physician ..........................................................................................................................146 ? Medicare Advantage (Part C) .....................................................................................................................................146 ? Medicare prescription drug coverage (Part D) ...........................................................................................................147 ? 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 ? 2021 ..............................163

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Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan Basic Option ? 2021 ....................................165 2021 Rate Information for the Blue Cross and Blue Shield Service Benefit Plan....................................................................170

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