A Fee for Service High Deductible Health Plan (Consumer ...

MHBP



Customer Service - 800.694.9901

2019

A Fee for Service High Deductible Health Plan (Consumer Option) with a Provider Network

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 Section 1, How This Plan Works.

Sponsored by: The National Postal Mail Handlers Union, AFL-CIO, a Division of LIUNA.

IMPORTANT ? Rates: Back Cover ? Changes for 2019: Page 17 ? Summary of benefits: Page 123

Who may enroll in this Plan: All Federal employees and annuitants who are eligible to enroll in the Federal Employees Health Benefits Program and who are, or become, members or associate members of the National Postal Mail Handlers Union, AFL-CIO, a division of LIUNA.

To become a member or associate member: If you are a non-postal employee or an annuitant, you will automatically become an associate member of the National Postal Mail Handlers Union upon enrollment in MHBP. There is no membership charge for members of the National Postal Mail Handlers Union, AFL-CIO, a division of LIUNA.

Membership dues: $42 per year for an associate membership except where exempt by law. New associate members will be billed by the National Postal Mail Handlers Union for annual dues when the Plan receives notice of enrollment. Continuing associate members will be billed by the National Postal Mail Handlers Union for the annual membership.

Enrollment codes for this Plan:

481 Consumer Option - Self Only 483 Consumer Option - Self Plus One 482 Consumer Option - Self and Family

RI 71-016

Important Notice from MHBP About Our Prescription Drug Coverage and Medicare The US Office of Personnel Management has determined that MHBP'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 to be 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 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 Medicare Part D premium will go up at least 1% per month for each month 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 most other people pay. You will have to pay this higher premium as long as you have Medicare prescription drug coverage. In addition, you may also 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.

MHBP Notice of Privacy Practices We protect the privacy of your protected health information as described in our current MHBP Notice of Privacy Practices. You can obtain a copy of our Notice by calling us at 800-694-9901 or by visiting our website: .

Table of Contents

Introduction ...................................................................................................................................................................................4 Plain Language..............................................................................................................................................................................4 Stop Health Care Fraud! ...............................................................................................................................................................4 Discrimination is Against the Law ................................................................................................................................................5 Preventing Medical Mistakes ........................................................................................................................................................7 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.................................................................................................................................................................11 ? Temporary Continuation of Coverage (TCC) ...............................................................................................................12 ? Converting to individual coverage ...............................................................................................................................12 ? Finding replacement coverage ......................................................................................................................................12 ? Health Insurance Marketplace ......................................................................................................................................12 Section 1. How This Plan Works ................................................................................................................................................13 General features of our Consumer Option ........................................................................................................................13 How we pay providers ......................................................................................................................................................14 Your rights and responsibilities.........................................................................................................................................15 Your medical and claims records are confidential ............................................................................................................15 Section 2. Changes for 2019 .......................................................................................................................................................17 Changes to this Plan ..........................................................................................................................................................17 Clarifications .....................................................................................................................................................................17 Section 3. How You Get Care .....................................................................................................................................................18 Identification cards............................................................................................................................................................18 Where you get covered care..............................................................................................................................................18

? Covered providers...............................................................................................................................................18 ? Covered Facilities ...............................................................................................................................................18 ? Transitional care .................................................................................................................................................19 ? If you are hospitalized when your enrollment begins.........................................................................................19 You need prior Plan approval for certain services ............................................................................................................20 ? Inpatient facility admission ................................................................................................................................20 ? Outpatient imaging procedures...........................................................................................................................21 ? Organ/tissue transplants......................................................................................................................................21 ? Other services .....................................................................................................................................................22 How to request precertification for an admission or get prior approval for other services ..............................................23 ? Non-urgent care claims.......................................................................................................................................23 ? Urgent care claims ..............................................................................................................................................23 ? Concurrent care claims .......................................................................................................................................24 ? Emergency inpatient admission ..........................................................................................................................24 ? Maternity care.....................................................................................................................................................24 ? If your hospital stay needs to be extended..........................................................................................................24 ? If your treatment needs to be extended...............................................................................................................24 If you disagree with our pre-service claim decision .........................................................................................................24 ? To reconsider a non-urgent care claim................................................................................................................25

2019 MHBP

1

Table of Contents

? To reconsider an urgent care claim .....................................................................................................................25 ? To file an appeal with OPM................................................................................................................................25 Section 4. Your Costs for Covered Services ...............................................................................................................................26 Cost sharing.......................................................................................................................................................................26 Copayment ........................................................................................................................................................................26 Deductible .........................................................................................................................................................................26 Coinsurance .......................................................................................................................................................................26 If your provider routinely waives your cost......................................................................................................................27 Waivers ..............................................................................................................................................................................27 Differences between our allowance and the bill ...............................................................................................................27 Your catastrophic protection out-of-pocket maximum .....................................................................................................28 Carryover ..........................................................................................................................................................................29 If we overpay you .............................................................................................................................................................29 When Government facilities bill us ..................................................................................................................................29 Section 5. Consumer Option Benefits .........................................................................................................................................30 Consumer Option Benefits Overview .........................................................................................................................................32 Savings - HSAs and HRAs .........................................................................................................................................................35 Section 5. Network Preventive Care ...........................................................................................................................................41 Traditional Medical Coverage Subject to the Deductible ...........................................................................................................46 Non-FEHB Benefits Available to Plan Members........................................................................................................................95 Section 6. General Exclusions ? Services, Drugs and Supplies We Do Not Cover....................................................................97 Section 7. Filing a Claim for Covered Services ..........................................................................................................................98 How to claim benefits .......................................................................................................................................................98 Post-service claim procedures...........................................................................................................................................99 Records ..............................................................................................................................................................................99 Deadline for filing your claim...........................................................................................................................................99 Direct Payment to hospital or provider of care .................................................................................................................99 When we need more information....................................................................................................................................100 Authorized representative ...............................................................................................................................................100 Notice Requirements.......................................................................................................................................................100 Section 8. The Disputed Claims Process...................................................................................................................................101 Section 9. Coordinating Benefits with Medicare and Other Coverage .....................................................................................104 When you have other health coverage ............................................................................................................................104 ? TRICARE and CHAMPVA ........................................................................................................................................104 ? Workers' Compensation..............................................................................................................................................104 ? Medicaid .....................................................................................................................................................................104 When other Government agencies are responsible for your care ...................................................................................104 When others are responsible for injuries.........................................................................................................................105 When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP)........................................................106 Clinical trials ...................................................................................................................................................................106 When you have Medicare ...............................................................................................................................................106 ? What is Medicare? ......................................................................................................................................................106 ? Should I enroll in Medicare? ......................................................................................................................................107 ? The Original Medicare Plan (Part A or Part B)...........................................................................................................107 ? Tell us about your Medicare coverage ........................................................................................................................108 ? Private contract with your physician ..........................................................................................................................108 ? Medicare Advantage (Part C) .....................................................................................................................................108 ? Medicare prescription drug coverage (Part D) ...........................................................................................................108 When you are age 65 or over and do not have Medicare ................................................................................................110 When you have the Original Medicare Plan (Part A, Part B, or both) ............................................................................111 Section 10. Definitions of Terms We Use in This Brochure .....................................................................................................112 Section 11. Other Federal Programs..........................................................................................................................................118 ? The Federal Flexible Spending Account Program ? FSAFEDS .................................................................................118 ? The Federal Employees Dental and Vision Insurance Program ? FEDVIP ...............................................................119 ? The Federal Long Term Care Insurance Program ? FLTCIP......................................................................................119

2019 MHBP

2

Table of Contents

? The Federal Employees Group Life Insurance Program - FEGLI .............................................................................120 Index ..........................................................................................................................................................................................121 Summary of MHBP Consumer Option Benefits ? 2019...........................................................................................................123 2019 Rate Information for MHBP Consumer Option ...............................................................................................................125

2019 MHBP

3

Table of Contents

Introduction

This brochure describes the benefits of the Mail Handlers Benefit Plan (MHBP). The National Postal Mail Handlers Union, AFL-CIO, a division of LIUNA, has entered into a contract (CS1146) with the United States Office of Personnel Management as authorized by the Federal Employees Health Benefit law. This plan is underwritten by First Health Life & Health Insurance Company (a wholly owned subsidiary of Aetna Inc.). Claims Administration Corp, a wholly owned subsidiary of Aetna, Inc. administers the Plan. Customer service may be reached at 800-694-9901 and through our website . The address for the administrative offices is:

MHBP PO Box 981106 El Paso, TX 79998-1106

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 health benefits.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in a 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 page 17. Rates are shown at the end 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 meetsthe minimum value standard for the benefits the plan provides.

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 MHBP.

? 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 health care 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 that 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 to your health care

provider, authorized health benefits plan or OPM representative.

? Let only the appropriate medical professionals review your medical record or recommend services. ? Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to get it paid. ? Carefully review explanations of benefits (EOBs) that you receive from us. ? Periodically review your claims history for accuracy to ensure services we have not been billed for services you did not receive.

2019 MHBP

4

Introduction/Plain Language/Advisory

? 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 us at 800-694-9901 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 reporting form is the desired method of reporting fraud in order to ensure accuracy, and a quicker 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); or - 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 material 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 services 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

MHBP 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 (ACA). Pursuant to Section 1557 MHBP does not discriminate, exclude people, or treat them differently on the basis of race, color, national origin, age, disability, or sex.

The Plan provides free aid/services to people with disabilities and to people who need language assistance.

If you need a qualified interpreter, written information in other formats, translation or other services, call 1-800-694-9901.

If you believe we have failed to provide these services or otherwise discriminated based on a protected class noted above, you can also file a grievance with the Civil Rights Coordinator by contacting:

Civil Rights Coordinator P.O. Box 14462 Lexington, KY 40512 1-800-648-7817, TTY: 711 Fax: 859-425-3379 CRCoordinator@

2019 MHBP

5

Introduction/Plain Language/Advisory

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights Complaint Portal, available at, or at: U.S. Department of Health and HumanServices, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, or at 1-800-368-1019, 800-537-7697 (TDD), TTY: 711.

You may file a 1557 complaint with the HHS Office of Civil Rights, an FEHB Program carrier, or OPM. You may file a civil rights complaint with OPM by mail at:

Office of Personnel Management Healthcare and Insurance Federal Employee Insurance Operations Attention: Assistant Director 1900 E Street NW Suite 3400 Washington, D.C. 20415-3610

2019 MHBP

6

Introduction/Plain Language/Advisory

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download