We 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.

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 www.irs.gov/uac/Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision for more information on the individual requirement for 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.

See www.opm.gov/healthcare-insurance/healthcare for enrollment information as well as:

• Information on the FEHB Program and plans available to you
• A health plan comparison tool
• A list of agencies that participate in Employee Express
• A link to Employee Express
• 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:

• When you may change your enrollment
• How you can cover your family members
• What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire
• What happens when your enrollment ends
• 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.

Once enrolled in your FEHB Program Plan, you should contact your carrier directly for updates and questions about your benefit coverage.

Self Only coverage is only for the enrollee. Self Plus One coverage is for the enrollee and one eligible family member.  Self and Family coverage is for the enrollee and one or more eligible family members. Family members include 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 to your spouse 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.

Contact your carrier to obtain a Certificate of Creditable Coverage (COCC) or to add a dependent when there is already family Coverage.

Contact your employing or retirement office if you are changing from Self to Self Plus One or Self and Family or to add a newborn if you currently have a Self Only plan.

Your employing or retirement office will not notify you when a family member is no longer eligible to receive 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.

If you or one of your family members is enrolled in one FEHB plan, you or they cannot be enrolled in or covered as a family member by another enrollee in another FEHB plan.

If you have a qualifying life event (QLE) - such as marriage, divorce, or the birth of a child - outside of the Federal Benefits Open Season, you may be eligible to enroll in the FEHB Program, change your enrollment, or cancel coverage. For a complete list of QLEs, visit the FEHB website at http://www.opm.gov/healthcare-insurance/life-event. If you need assistance, please contact your employing agency, Tribal Benefits Officer, personnel/payroll office, or retirement office.

Family members covered under your Self and Family enrollment are your spouse (including your spouse by a valid common-law marriage from a state that recognizes common-law marriages) and children as described in the chart below. A Self Plus One enrollment covers you and your spouse, or one other eligible family member as described in the chart below.

Natural children, adopted children, and stepchildren
Coverage: Natural children, adopted children, and stepchildren are covered until their 26^th birthday.

Foster children
Coverage: Foster children are eligible for coverage until their 26^th birthday if you provide documentation of your regular and substantial support of the child and sign a certification stating that your foster child meets all the requirements. Contact your human resources office or retirement system for additional information.

Children incapable of self-support
Coverage: Children who are incapable of self-support because of a mental or physical disability that began before age 26 are eligible to continue coverage. Contact your human resources office or retirement system for additional information.

Married children
Coverage: Married children (but NOT their spouse or their own children) are covered until their 26^th birthday.

Children with or eligible for employer-provided health insurance
Coverage: Children who are eligible for or have their own employer-provided health insurance are covered until their 26^th birthday.

Newborns of covered children are insured only for routine nursery care during the covered portion of the mother's maternity stay.

You can find additional information at www.opm.gov/healthcare-insurance.

OPM has implemented the Federal Employees Health Benefits Children’s Equity Act of 2000. This law mandates that you be enrolled for Self Plus One or Self and Family coverage in the FEHB Program, if you are an employee subject to a court or administrative order requiring you to provide health benefits for your child(ren).

If this law applies to you, you must enroll in Self Plus One or for Self and Family coverage in a health plan that provides full benefits in the area where your children live or provide documentation to your employing office that you have obtained other health benefits coverage for your children. If you do not do so, your employing office will enroll you involuntarily as follows:

• If you have no FEHB coverage, your employing office will enroll you for Self Plus One or Self and Family coverage, as appropriate, in the lowest-cost nationwide plan option as determined by OPM;
• If you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the same option of the same plan; or
• If you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the lowest-cost nationwide plan option as determined by OPM.

As long as the court/administrative order is in effect, and you have at least one child identified in the order who is still eligible under the FEHB Program, you cannot cancel your enrollment, change to Self Only, or change to a plan that does not serve the area in which your children live, unless you provide documentation that you have other coverage for the children.

If the court/administrative order is still in effect when you retire, and you have at least one child still eligible for FEHB coverage, you must continue your FEHB coverage into retirement (if eligible) and cannot cancel your coverage, change to Self Only, or change to a plan that does not serve the area in which your children live as long as the court/administrative order is in effect. Similarly, you cannot change to Self Plus One if the court/administrative order identifies more than one child.  Contact your employing office for further information.

The benefits in this brochure are effective January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be processed according to the 2022 benefits of your prior plan or option.  If you have met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option.   When you are enrolled under this Plan's Consumer Driven Option.  Under this Plan's Consumer Driven Option, between January 1 and the effective date of your new plan (or change to High Option of this Plan) you will not receive a new Personal Care Account (PCA) for 2022 but any unused PCA benefits from 2021 will be available to you.  However, if your prior plan left the FEHB Program at the end of the year, you are covered under that plan’s 2021 benefits until the effective date of your coverage with your new plan. Annuitants’ coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective date of coverage.

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 for services received directly from your provider. 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 are no longer eligible to use your health insurance coverage.

Under the Consumer Driven Option, if you joined this Plan during Open Season, you receive the full Personal Care Account (PCA) as of your effective date of coverage.  If you joined at any other time during the year, your PCA and your Deductible for your first year will be prorated for each full month of coverage remaining in that calendar year.

When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the last five years of your Federal service. If you do not meet this requirement, you may be eligible for other forms of coverage, such as Temporary Continuation of Coverage (TCC).

You will receive an additional 31 days of coverage, for no additional premium, when:

• Your enrollment ends, unless you cancel your enrollment; or
• You or a family member no longer eligible for coverage.

Any person covered under the 31 day extension of coverage who is confined in a hospital or other institution for care or treatment on the 31^st day of the temporary extension is entitled to continuation of the benefits of the Plan during the continuance of the confinement but not beyond the 60^th day after the end of the 31 day temporary extension.

You may be eligible for spouse equity coverage or Temporary Continuation of Coverage (TCC), or a conversion policy (a non-FEHB individual policy).

If you are divorced from a Federal employee, or annuitant, you may not continue to get benefits under your former spouse’s enrollment. This is the case even when the court has ordered your former spouse to provide health coverage for you. However, you may be eligible for your own FEHB coverage under either the spouse equity law or Temporary Continuation of Coverage (TCC). If you are recently divorced or are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get additional information about your coverage choices, www.opm.gov/healthcare-insurance/healthcare/plan-information/guides.  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.

If you leave Federal service, Tribal employment, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC). The Affordable Care Act (ACA) did not eliminate TCC or change the TCC rules.  For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if you lose your Federal job, if you are a covered dependent child and you turn age 26, regardless of marital status, etc.

You may not elect TCC if you are fired from your Federal or Tribal job due to gross misconduct.

Enrolling in TCC. Get the RI 79-27, which describes TCC, from your employing or retirement office or from www.opm.gov/healthcare-insurance/healthcare/plan-information/guides. It explains what you have to do to enroll.

Alternatively, you can buy coverage through the Health Insurance Marketplace where, depending on your income, you could be eligible for a new kind of tax credit that lowers your monthly premiums.  Visit www.HealthCare.gov to compare plans and see what your premium, deductible, and out-of-pocket costs would be before you make a decision to enroll.  Finally, if you qualify for coverage under another group health plan (such as your spouse's plan), you may be able to enroll in that plan, as long as you apply within 30 days of losing FEHB Program coverage.

If you leave Federal or Tribal service, your employing office will notify you of your right to convert. You must contact us in writing within 31 days after you receive this notice. However, if you are a family member who is losing coverage, the employing or retirement office will not notify you. You must contact us in writing within 31 days after you are no longer eligible for coverage.

Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, a waiting period will not be imposed and your coverage will not be limited due to pre-existing conditions. When you contact us, we will assist you in obtaining information about health benefits coverage inside or outside the Affordable Care Act’s Health Insurance Marketplace in your state. For assistance in finding coverage, please contact us at 800-222-2798 or visit our website at www.apwuhp.com.

If you would like to purchase health insurance through the ACA's Health Insurance Marketplace, please visit www.HealthCare.gov.  This is a website provided by the U.S. Department of Health and Human Services that provides up-to-date information on the Marketplace.

The APWU Health Plan's Notice of Privacy Practices describes how medical information about you may be used by the Health Plan, your rights concerning your health information and how to exercise them, and APWU Health Plan's responsibilities in protecting your health information.  The Notice is posted on the Health Plan's website.  If you need to obtain a copy of the Health Plan's Notice of Privacy Practices, you may either contact the Health Plan via email through the website, www.apwuhp.com, or by calling 800-222-2798.

We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation (for annuitants), or your electronic enrollment system (such as Employee Express) confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, contact us as follows:

• High Option:  Call us at 800-222-2798 (TTY 800-622-2511) or write to us at P.O. Box 1358, Glen Burnie, MD 21060-1358 or through our website at www.apwuhp.com.  You may print or request an Identification Card via the Member Portal at www.myAPWUHP.com.
• Consumer Driven Option:  Call UnitedHealthcare at 800-718-1299 or write to us at P.O. Box 740800, Atlanta, GA 30374-0800 or request replacement cards through the website at www.myuhc.com. 

FEHB Carriers must have clauses in their in-network (participating) providers' agreements. These clauses provide that, for a service that is a covered benefit in the plan brochure or for services determined not medically necessary, the in-network provider agrees to hold the covered individual harmless (and may not bill) for the difference between the billed charge and the in-network contracted amount. If an in-network provider bills you for covered services over your normal cost share (deductible, copay, coinsurance) contact your Carrier to enforce the terms of its provider contract.

We provide benefits for the services of covered professional providers, as required by Section 2706(a) of the Public Health Service Act.  Coverage of practitioners is not determined by your state's designation as a medically underserved area.

Covered professional providers are medical practitioners who perform covered services when acting within the scope of their license or certification under applicable state law and who furnish, bill, or are paid for their healthcare services in the normal course of business.  Covered services must be provided in the state in which the practitioner is licensed or certified.

This plan recognizes that transsexual, transgender, and gender-nonconforming members require healthcare delivered by healthcare providers experienced in transgender health.  While gender reassignment surgeons (benefit details found in Section 5(b)) and hormone therapy providers (benefit details found in Section 5(f)) play important roles in preventive care, you should see a primary care provider familiar with your overall healthcare needs.  Benefits described in this brochure are available to all members meeting medical necessity guidelines.

Covered facilities include:

• Freestanding ambulatory facility:  An out-of-hospital facility such as a medical, cancer, dialysis, or surgical center or clinic, and licensed outpatient facilities accredited by the Joint Commission on Accreditation of Healthcare Organizations for treatment of substance use disorder treatment. 
• Hospital
  • An institution which is accredited as a hospital under the Hospital Accreditation Program of the Joint Commission on Accreditation of Healthcare Organizations, or 
  • Any other institution which is operated pursuant to law, under the supervision of a staff of doctors and twenty-four hour a day nursing service, and which is primarily engaged in providing: a) general inpatient care and treatment of sick and injured persons through medical, diagnostic and major surgical facilities, all of which must be provided on its premises or under its control, or b) specialized inpatient medical care and treatment of sick or injured persons through medical and diagnostic facilities (including X-ray and laboratory) on its premises, under its control, or through a written agreement with a hospital (as defined above) or with a specialized provider of those facilities.

The term "hospital" shall not include a skilled nursing facility, a convalescent nursing home or institution or part thereof which 1) is used principally as a convalescent facility, rest facility, residential treatment center, nursing facility or facility for the aged; or 2) furnishes primarily domiciliary or custodial care, including training in the routines of daily living.
 

Specialty care:  If you have a chronic or disabling condition and

• lose access to your specialist because we drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB plan, or
• lose access to your PPO specialist because we terminate our contract with your specialist for reasons other than cause,
• you may be able to continue seeing your specialist and receiving any PPO benefits for up to 90 days after you receive notice of the change.  Contact us, or if we drop out of the Program, contact your new plan.

If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist and your PPO benefits will continue until the end of your postpartum care, even if it is beyond the 90 days.

We pay for covered services from the effective date of your enrollment.  However, if you are in the hospital when your enrollment in our High Option begins, call our Customer Service Department immediately at 800-222-2798.  For the Consumer Driven Option, please call UnitedHealthcare at 800-718-1299.  If you are new to the FEHB Program, we will reimburse you for your covered services while you are in the hospital beginning on the effective date of your coverage.

If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

• you are discharged, not merely moved to an alternative care center;
• the day your benefits from your former plan run out; or
• the 92^nd day after you become a member of this Plan, whichever happens first.

These provisions apply only to the benefits of the hospitalized person.  If your plan terminates participation in the FEHB in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply.  In such cases, the hospitalized family member’s benefits under the new plan begin on the effective date of enrollment.

The pre-service claim approval processes for inpatient hospital admissions (called precertification) and for other services, are detailed in this Section.  A pre-service claim is any claim, in whole or in part, that requires approval from us in advance of obtaining medical care or services.  In other words, a pre-service claim for benefits 1) requires precertification or prior approval and 2) will result in a reduction of benefits if you do not obtain precertification or prior approval.

You must get prior approval for certain services.  Failure to do so will result in a minimum $500 penalty for inpatient hospital (High Option and Consumer Driven Option) or $100 for certain outpatient radiology/imaging procedures (for High Option only).

Precertification is the process by which – prior to your inpatient hospital admission – we evaluate the medical necessity of your proposed stay and the number of days required to treat your condition. Unless we are misled by the information given to us, we won’t change our decision on medical necessity.

In most cases, your physician or hospital will take care of requesting precertification. Because you are still responsible for ensuring that your care is precertified, you should always ask your physician or hospital whether or not they have contacted us.

You do not need precertification in these cases:

• You are admitted to a hospital outside the United States and Puerto Rico.
• You have another group health insurance policy that is the primary payor for the hospital stay.
• Medicare Part A is the primary payor for the hospital stay. Note: If you exhaust your Medicare hospital benefits and do not want to use your Medicare lifetime reserve days, then we will become the primary payor and you do need precertification.

Some services require prior approval.

Under the High Option, call Cigna/CareAllies at 800-582-1314 if you need any of the services listed below:

• Applied Behavioral Analysis (ABA)
• Durable medical equipment such as wheelchairs, oxygen equipment and supplies, artificial limbs (prosthetic devices) and braces
• Gender reassignment surgery
• Gene Therapy
• Genetic testing, including BRCA testing (see Definitions, Section 10, page 146)
• Home healthcare such as nursing visits, infusion therapy, growth hormone therapy (GHT), rehabilitative and habilitative therapy (speech therapy) and pulmonary rehabilitation programs
• Minimally invasive treatment of back and neck pain.  This requirement applies to both the physician services and the facility.  The following services require prior approval:  epidural steroid injections, facet joint injections, sacroiliac joint injections.
• Organ transplantation - call before your first evaluation as a potential candidate
• Procedures which may be cosmetic in nature such as eyelid surgery (blepharoplasty), varicose vein surgery (sclerotherapy), or Botox injections for medical diagnosis
• Recognized surgery for morbid obesity (bariatric surgery) for organic impotence
• Residential Treatment Center (RTC)
• Services and supplies which may be experimental/investigational
• Skilled Nursing Facilities (SNF)
• Prior approval for outpatient services at Veterans Administration facilities is not needed 

Under the Consumer Driven Option, call UnitedHealthcare at 800-718-1299 if you need any of the services listed below:

• Air Ambulance - Non emergent
• Applied Behavioral Analysis (ABA)
• Bariatric surgery
• Clinical Trials
• Chemotherapy - outpatient
• Congenital Heart Disease
• Durable Medical Equipment (including Insulin pumps)
• Functional endoscopic sinus surgery
• Gender reassignment surgery
• Genetic testing
• Home healthcare - nursing visits, home infusion therapy
• Hospice - inpatient
• Hysterectomy
• Organ transplantation
• Orthognathic surgery
• Potential cosmetic procedures
• Residential Treatment Center (RTC)
• Services and supplies which may be experimental/investigational
• Sinuplasty
• Skilled Nursing Facilities (SNF)
• Sleep apnea procedures and surgery
• Therapeutics (outpatient) dialysis, IV infusion, radiation oncology, intensity modulated radiation therapy, MR-guided focused ultrasound

• Prior approval is required for certain classes of drugs and coverage authorization is required for some medications. This authorization uses Plan rules based on FDA-approved prescribing and safety information, clinical guidelines, and uses that are considered reasonable, safe, and effective. For example, prescription drugs used for cosmetic purposes such as Retin A or Botox may not be covered. Other medications might be limited to a certain amount (such as quantity or dosage) within a specific time period, or require authorization to confirm clinical use based on FDA labeling.  To inquire if your medication requires prior approval or authorization, call Express Scripts Customer Service at 800-841-2734 for the High Option (see Section 5(f), page 71), and Optum Rx at 800-718-1299 for the Consumer Driven Option (see Section 5(f), page 119).
• Prior approval is also required for mental health and substance use disorder benefits, inpatient, in-network or out-of-network. Prior approval is required for psychological and neuropsychological testing (CDHP Option only), Electroconvulsive therapy (CDHP Option only), Transcranial Magnetic Stimulation (TMS), and services such as partial or full day hospitalization or facility-based intensive outpatient treatment (Cigna Behavioral Health for the High Option and UHC Behavioral Health Solutions for the Consumer Driven Option).  Under the High Option, call Cigna Behavioral Health at 800-582-1314.  Under the Consumer Driven Option, call UHC Behavioral Health Solutions at 800-718-1299.

• High Option:  First you, your representative, your physician, or your hospital must call Cigna/CareAllies at 800-582-1314 at least 2 business days before admission or services requiring prior authorization are rendered.  For mental health and substance use disorder inpatient treatment, your physician or your hospital must call Cigna/CareAllies at 800-582-1314 at least 2 business days before admission or services requiring prior authorization.  These numbers are available 24 hours every day.
• Consumer Driven Option:  First you, your representative, your physician, or your hospital must call UnitedHealthcare at 800-718-1299 at least 2 business days before admission or services requiring prior authorization are rendered. For mental health and substance use disorder inpatient treatment, your doctor or your hospital must call UnitedHealthcare Behavioral Health Solutions at 800-718-1299 at least 2 business days before admission or services requiring prior authorization.  These numbers are available 24 hours every day.
• If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your representative, the physician, or the hospital must telephone the above number at least 2 business days for the High Option and the Consumer Driven Option following the day of the emergency admission, even if you have been discharged from the hospital.
• Next, provide the following information:
  • enrollee’s name and Plan identification number
  • patient’s name, birth date, and phone number
  • reason for hospitalization, proposed treatment, or surgery
  • name and phone number of admitting physician
  • name of hospital or facility; and
  • number of days requested for hospital stay
• We will then tell the physician and/or hospital the number of approved inpatient days and we will send written confirmation of our decision to you, your physician, and the hospital.

• If no one contacts us, we will decide whether the hospital stay was medically necessary.
• If we determine that the stay was medically necessary, we will pay the inpatient charges, less the $500 penalty.

If we determine that it was not medically necessary for you to be an inpatient, we will not pay inpatient hospital benefits. We will only pay for any covered medical supplies and services that are otherwise payable on an outpatient basis for High Option and Consumer Driven Option out-of-network stays.

If we denied the precertification request, we will not pay inpatient hospital benefits. We will only pay for any covered medical supplies and services that are otherwise payable on an outpatient basis for High Option and Consumer Driven Option out-of-network stays.

When we precertified the admission but you remained in the hospital beyond the number of days we approved and did not get the additional days precertified, then:

• For the part of the admission that was medically necessary, we will pay inpatient benefits, but
• For the part of the admission that was not medically necessary, we will pay only medical services and supplies otherwise payable on an outpatient basis and will not pay inpatient benefits for High Option and Consumer Driven Option out-of-network services.

High Option: Radiology precertification is required prior to scheduling specific imaging procedures. We evaluate the medical necessity of your proposed procedure to ensure that the appropriate procedure is being requested for your condition. In most cases your physician will take care of the precertification. Because you are responsible for ensuring that precertification is done, you should ask your doctor to contact us.

The following outpatient radiology services require precertification:

• CT/CAT Scan – Computerized Axial Tomography
• MRI – Magnetic Resonance Imaging
• MRA – Magnetic Resonance Angiography
• PET – Positron Emission Tomography

For these outpatient studies, you, your representative or doctor must call Cigna/CareAllies before scheduling the procedure. The toll free number is 800-582-1314.

• Provide the following information:
  • patient’s name, Plan identification number, and birth date
  • requested procedure and clinical support for request
  • name and phone number of ordering provider
  • name of requested imaging facility

You do not need precertification in these cases:

• You have another health insurance policy that is primary including Medicare Parts A&B or Part B Only
• The procedure is performed outside the United States or Puerto Rico
• You are an inpatient at a hospital
• The procedure is performed while in the Emergency Room

For non-urgent care claims, we will tell the physician and/or hospital the number of approved inpatient days, or the care that we approve for other services that must have prior authorization. We will make our decision within 15 days of receipt of the pre-service claim.

If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you of the need for an extension of time before the end of the original 15-day period. Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information.

If you have an urgent care claim (i.e., when waiting for the regular time limit for your medical care or treatment could seriously jeopardize your life, health, or ability to regain maximum function, or in the opinion of a physician with knowledge of your medical condition, would subject you to severe pain that cannot be adequately managed without this care or treatment), we will expedite our review and notify you of our decision within 72 hours.  If you request that we review your claim as an urgent care claim, we will review the documentation you provide and decide whether or not it is an urgent care claim by applying the judgment of a prudent layperson that possesses an average knowledge of health and medicine.

If you fail to provide sufficient information, we will contact you within 24 hours after we receive the claim to let you know what information we need to complete our review of the claim.  You will then have up to 48 hours to provide the required information.  We will make our decision on the claim within 48 hours of (1) the time we received the additional information or (2) the end of the time frame, whichever is earlier.

We may provide our decision orally within these time frames, but we will follow up with written or electronic notification within three days of oral notification.

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM.  Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at 800-222-2798.  You may also call FEHB at 202-606-3818 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review.  We will cooperate with OPM so they can quickly review your claim on appeal.  In addition, if you did not indicate that your claim was a claim for urgent care, call us at 800-222-2798.  If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim).

A concurrent care claim involves care provided over a period of time or over a number of treatments. We will treat any reduction or termination of our pre-approved course of treatment before the end of the approved period of time or number of treatments as an appealable decision. This does not include reduction or termination due to benefit changes or if your enrollment ends. If we believe a reduction or termination is warranted, we will allow you sufficient time to appeal and obtain a decision from us before the reduction or termination takes effect.  

If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim.

• Health Care FSA (HCFSA) – Reimburses you for eligible out-of-pocket healthcare expenses (such as copayments, deductibles, physician prescribed over-the-counter drugs and medications, vision and dental expenses, and much more) for you and your tax dependents, including adult children (through the end of the calendar year in which they turn 26).
• FSAFEDS offers paperless reimbursement for your HCFSA through a number of FEHB and FEDVIP plans.  This means that when you or your provider files claims with your FEHB or FEDVIP plan, FSAFEDS will automatically reimburse your eligible out-of-pocket expenses based on the claim information it receives from your plan.

If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your representative, the physician, or the hospital must telephone us within two business days following the day of the emergency admission, even if you have been discharged from the hospital. If you do not telephone the Plan within two business days, penalties may apply - see Warning under Inpatient hospital admissions earlier in this Section and If your hospital stay needs to be extended below.

You do not need precertification of a maternity admission for a routine delivery. However, if your medical condition requires you to stay more than 48 hours after a vaginal delivery or 96 hours after a cesarean section, then your physician or the hospital must contact us for precertification of additional days. Further, if your baby stays after you are discharged, your physician or the hospital must contact us for precertification of additional days for your baby.

Note:  When a newborn requires definitive treatment during or after the mother's confinement, the newborn is considered a patient in their own right.  If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.

High Option: If your hospital stay – including for maternity care – needs to be extended, you, your representative, your physician or the hospital must ask us to approve the additional days by calling the precertification vendor Cigna/CareAllies at 800-582-1314. If you remain in the hospital beyond the number of days we approved and did not get the additional days precertified, then

• For the part of the admission that was medically necessary, we will pay inpatient benefits, but
• For the part of the admission that was not medically necessary, we will pay only medical services and supplies otherwise payable on an outpatient basis and will not pay inpatient benefits.

Consumer Driven Option: If your hospital stay – including for maternity care – needs to be extended, you, your representative, your doctor or the hospital must ask us to approve the additional days by calling UnitedHealthcare at 800-718-1299. If you remain in the hospital beyond the number of days we approved and did not get the additional days precertified, then

• For the part of the admission that was medically necessary, we will pay inpatient benefits, but
• For the part of the admission that was not medically necessary, we will pay only medical services and supplies otherwise payable on an outpatient basis and will not pay inpatient benefits for out-of-network services only.

If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim.

If you have a pre-service claim and you do not agree with our decision regarding precertification of an inpatient admission or prior approval of other services, you may request a review in accord with the procedures detailed below.

If you have already received the service, supply, or treatment, then you have a post-service claim and must follow the entire disputed claims process detailed in Section 8.

Within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure.

In the case of a pre-service claim and that is subject to a request for additional information, we have 30 days from the date we receive your written request for reconsideration to:

1. Precertify your hospital stay or, if applicable, arrange for the healthcare provider to give you the care or grant your request for prior approval for a service, drug, or supply; or

2. Ask you or your provider for more information.

You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days.

If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due. We will base our decision on the information we already have. We will write to you with our decision.

3. Write to you and maintain our denial.

In the case of an appeal of a pre-service urgent care claim, within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure.

Cost-sharing is the general term used to refer to your out-of-pocket costs (e.g., deductible, coinsurance, and copayments) for the covered care you receive.

High Option:  A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive certain services.

Example: Under the High Option, when you see your PPO physician you pay a copayment of $25 per office visit.

Consumer Driven Option:  There are no copayments under the Consumer Driven Option.

Note: If the billed amount (or the Plan allowance that providers we contract with have agreed to accept as payment in full), is less than your copayment, you pay the lower amount.

A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for them. Copayments and coinsurance amounts do not count toward any deductible.  When a covered service or supply is subject to a deductible, only the Plan allowance for the service or supply counts toward the deductible.

High Option

• If you use PPO providers, the calendar year deductible is $450 person.  Under a Self Only enrollment, the deductible is considered satisfied and benefits are payable for you when your covered expenses applied to the calendar year deductible for your enrollment reach $450. Under a Self Plus One enrollment, the deductible is considered satisfied and benefits are payable for you and one other eligible family member when the combined covered expenses applied to the calendar year deductible for your enrollment reach $800.  Under a Self and Family enrollment, the deductible is considered satisfied and benefits are payable for all family members when the combined covered expenses applied to the calendar year deductible for family members reach $800.  If you use non-PPO providers, your calendar year deductible increases to a maximum of $1,000 per person ($2,000 per Self Plus One and Self and Family).  Whether or not you use PPO providers, your calendar year deductible will not exceed $1,000 per person ($2,000 per Self Plus One and Self and Family).

If the billed amount (or the Plan allowance that providers we contract with have agreed to accept as payment in full) is less than the remaining portion of your deductible, you pay the lower amount.

Example: If the billed amount is $100, the provider has an agreement with us to accept $80, and you have not paid any amount toward meeting your calendar year deductible, you must pay $80. We will apply $80 to your deductible. We will begin paying benefits once the remaining portion of your calendar year deductible ($450) has been satisfied.

Note: If you change plans during Open Season, and the effective date of your new plan is after January 1 of the next year, you do not have to start a new deductible under your prior plan between January 1 and the effective date of your new plan.  If you change plans at another time during the year, you must begin a new deductible under your new plan.

If you change from Self Plus One or Self and Family to Self Only, or from Self Only to Self Plus One or Self and Family during the year, we will credit the amount of covered expenses already applied toward the deductible of your old enrollment to the deductible of your new enrollment. However, if you change from High Option to Consumer Driven Option or from Consumer Driven Option to High Option, during the year, expenses incurred as of the effective date of the option change are subject to the benefit provisions of your new option.

Consumer Driven Option:  Your Deductible is the amount of eligible expenses you are required to meet before Traditional Health Coverage begins.  Your plan's deductible is reduced by applying the funds in your Personal Care Account (PCA) which is funded in January by the APWU Health Plan.  Your Net Deductible is the remaining deductible amount you have to pay once the funds in your PCA have been exhausted.  By using the funds in your PCA to pay for eligible medical expenses you decrease your total deductible and out-of-pocket expenses.  Your Net Deductible for in-network providers is generally $1,000 for a Self Only enrollment or $2,000 for a Self Plus One or a Self and Family enrollment.  For Self Plus One or Self and Family coverage, once one individual meets the Self Only Net Deductible of $1,000, Traditional Health Coverage begins for that individual.  Once the other covered members meet the additional $1,000 Net Deductible, Traditional Health Coverage begins for them. If you use out-of-network providers, your calendar year Net Deductible increases to $1,500 Self Only and $3,000 for Self Plus One and Self and Family.  Your Deductible in subsequent years may be reduced by rolling over any unused portion of your Personal Care Account remaining at the end of the calendar year(s).  

In-Network Plan Deductible:
Self Only: $2,200
Self Plus One: $4,400
Self and Family: 4,400

In-Network PCA (APWU HP Funded)
Self Only: $1,200
Self Plus One: $2,400
Self and Family: $2,400

In-Network Net Deductible (You Pay)
Self Only: $1,000
Self Plus One: $2,000
Self and Family: $2,000

High Option:  Coinsurance is the percentage of our allowance that you must pay for your care. Coinsurance does not begin until you have met your calendar year deductible.

Example: You pay 40% of our allowance for office visits to a non-PPO physician.

Consumer Driven Option:  Coinsurance is the percentage of our allowance that you must pay for your care after you have used up your Personal Care Account (PCA) and paid your Deductible.

If your provider routinely waives (does not require you to pay) your copayments, deductibles, or coinsurance, the provider is misstating the fee and may be violating the law. In this case, when we calculate our share, we will reduce the provider’s fee by the amount waived.

For example, if your physician ordinarily charges $100 for a service but routinely waives your 40% coinsurance, the actual charge is $60. We will pay $36 (60% of the actual charge of $60).

In some instances, an APWU Health Plan provider may ask you to sign a “waiver” prior to receiving care. This waiver may state that you accept responsibility for the total charge for any care that is not covered by your health plan. If you sign such a waiver, whether or not you are responsible for the total charge depends on the contracts that the Plan has with its providers. If you are asked to sign this type of waiver, please be aware that, if benefits are denied for the services, you could be legally liable for the related expenses. If you would like more information about waivers, please contact us at 800-222-2798.

High Option:  Our “Plan allowance” is the amount we use to calculate our payment for covered services. Fee-for-service plans arrive at their allowances in different ways, so their allowances vary. For more information about how we determine our Plan allowance, see the definition of Plan allowance in Section 10.

Often, the provider’s bill is more than a fee-for-service plan’s allowance. Whether or not you have to pay the difference between our allowance and the bill will depend on the provider you use.

• PPO providers agree to limit what they will bill you. Because of that, when you use a preferred provider, your share of covered charges consists only of your deductible and coinsurance or copayment. Here is an example about coinsurance: You see a PPO physician who charges $150, but our allowance is $100. If you have met your deductible, you are only responsible for your coinsurance. That is, you pay just -- 15% of our $100 allowance ($15). Because of the agreement, your PPO physician will not bill you for the $50 difference between our allowance and the bill.
• Non-PPO providers, on the other hand, have no agreement to limit what they will bill you. When you use a non-PPO provider, you will pay your deductible and coinsurance -- plus any difference between our allowance and charges on the bill. Here is an example: You see a non-PPO physician who charges $150 and our allowance is again $100. Because you’ve met your deductible, you are responsible for your coinsurance, so you pay 40% of our $100 allowance ($40). Plus, because there is no agreement between the non-PPO physician and us, the physician can bill you for the $50 difference between our allowance and the bill.

The information below illustrates the examples of how much you have to pay out-of-pocket for services from a PPO physician vs. a non-PPO physician. The information uses our example of a service for which the physician charges $150 and our allowance is $100. It shows the amount you pay if you have met your calendar year deductible.

EXAMPLE

PPO physician
Physician's charge: $150 
Our allowance: We set it at:  $100 
We pay: 85% of our allowance:  $85
You owe: Coinsurance: 15% of our allowance: $15 
+ Difference up to charge?: No:  0 
TOTAL YOU PAY: $15

Non-PPO physician
Physician's charge: $150 
Our allowance: We set it at:  $100 
We pay: 60% of our allowance:  $60
You owe: Coinsurance: 40% of our allowance: $40 
+ Difference up to charge?: Yes:  $50 
TOTAL YOU PAY: $90

Consumer Driven Option:

In-network providers agree to accept our Plan allowance so if you use an in-network provider, you never have to worry about paying the difference between the Plan allowance and the billed amount for covered services. If your covered expenses are being paid out of your Personal Care Account or if you are receiving in-network covered preventive services, the Plan will pay 100%. If you have exhausted your Personal Care Account, you will be responsible for paying your Deductible and also coinsurance under the Traditional Health Coverage.

Out-of-network providers - If you use an out-of-network provider, you will have to pay the difference between the Plan allowance and the billed amount only if you use up your Personal Care Account for the year. Note that it usually makes sense to use in-network providers because it will make your Personal Care Account go much further since money left in your Personal Care Account can be rolled over to be used in the next year.

You should also see section Important Notice About Surprise Billing - Know Your Rights below that describes your protections against surprise billing under the No Surprises Act.

There is a limit to the amount you must pay out-of-pocket for combined medical and prescription drug coinsurance for the year for certain charges. When you have reached this limit, you pay no coinsurance for covered services for the remainder of the calendar year.

High Option:

PPO benefit:  Your out-of-pocket maximum is $6,500 for combined medical and prescription drugs for Self Only enrollment or $13,000 for a Self Plus One or a Self and Family enrollment if you are using PPO providers and in-network pharmacies. Only eligible expenses for PPO providers and in-network pharmacies count toward this limit.

Non-PPO benefit:  Your out-of-pocket maximum is $12,000 for combined medical and prescription drugs for Self Only enrollment, or $24,000 for a Self Plus One or a Self and Family enrollment if you are using non-PPO providers or out-of-network pharmacies. Eligible expenses for network providers or in-network pharmacies also count toward this limit. Your eligible out-of-pocket expenses will not exceed this amount whether or not you use network providers.

Note:  For Self Plus One or Self and Family coverage, the maximum out-of-pocket for any individual in the family will not exceed the maximum out-of-pocket for Self Only coverage. When an individual meets the Self Only out-of-pocket maximum, they pay no coinsurance for covered services for the remainder of the calendar year.  Once the other covered members in the family meet the remaining out-of-pocket family maximum, then they pay no coinsurance for covered services for the remainder of the calendar year.

Out-of-pocket expenses for the purposes of this benefit are:

• The 15% you pay (or the 5% you pay for Cancer Centers of Excellence) for PPO; inpatient medical services and supplies, surgical and anesthesia services, services provided by a hospital or other facility and ambulance services, emergency services/accidents, mental health and substance use disorder treatment; and the medical deductible
• The 40% you pay for non-PPO; medical services and supplies, surgical and anesthesia services, services provided by a hospital or other facility and ambulance services, mental health and substance use disorder treatment (dental 30%); and the medical deductible
• The copayment of $25 for outpatient visits to PPO physicians and $15 for virtual visits
• The copayment of $30 for outpatient facility charges in a PPO Urgent Care Center
• The 25% you pay for in-network preferred brand name prescription drugs (Tier 2), 45% for in-network non-preferred brand name prescription drugs (Tier 3) and the $10 and $20 you pay for in-network generic prescription drugs (Tier 1), and 25% for generic specialty drugs (Tier 4), 25% for preferred brand name drugs (Tier 5) and 45% non-preferred brand name drugs (Tier 6)

 The following cannot be included in the accumulation of out-of-pocket expenses:

• Expenses in excess of our allowance or maximum benefit limitations
• Any amounts you pay because benefits have been reduced for non-compliance with this Plan's cost containment requirements, (see Section 3, pages 18-20)
• The $300 per admission for non-PPO inpatient hospital charges or skilled nursing facility
• Expenses in excess of visit maximums for physical, occupational and speech therapy, see pages 41-42, and acupuncture, see page 46
• Expenses in excess of Hospice care and preventive care maximums
• The difference in cost when brand name drugs are purchased and a generic is available
• Drugs reimbursed at the non-network pharmacy level
• 50% coinsurance for retail drugs after the first two fills if mail order is not used
• 100% of the cost for targeted drugs if the Plan's step therapy is not followed
• Any associated costs when you purchase medications in excess of the Plan's dispensing limitations
• Cost associated with non-covered drugs and supplies

Consumer Driven Option:

If you have exceeded your Personal Care Account and met your Deductible the following would apply:

In-network benefit:  Your out-of-pocket maximum is $6,500 for combined medical and prescription drugs for a Self Only enrollment or $13,000 for a Self Plus One or Self and Family enrollment if you are using in-network providers and pharmacies. Only eligible expenses for network providers and pharmacies count toward this limit.

Out-of-network benefit:  Your out-of-pocket maximum is $12,000 for combined medical and prescription drugs for a Self Only enrollment or $24,000 for a Self Plus One or Self and Family enrollment if you are using out-of-network providers. Eligible expenses for network providers and pharmacies also count toward this limit. Your eligible out-of-pocket expenses will not exceed this amount whether or not you use network providers.

Note:  For Self Plus One or Self and Family coverage, the maximum out-of-pocket for any individual in the family will not exceed the maximum out-of-pocket for Self Only coverage. When an individual meets the Self Only out-of-pocket maximum, they pay no coinsurance for covered services for the remainder of the calendar year.  Once the other covered members in the family meet the remaining out-of-pocket family maximum, then they pay no coinsurance for covered services for the remainder of the calendar year.

Out-of-pocket expenses for the purposes of this benefit are:

• The 15% you pay (or the 10% you pay for Cancer Centers of Excellence) for in-network inpatient and outpatient hospital charges, surgical, medical, virtual visits and emergency services under the Traditional Health Coverage; and the Deductible
• The 50% you pay for out-of-network inpatient and outpatient hospital charges, surgical, medical, and maternity services under the Traditional Health Coverage; and the Deductible
• The 25% you pay for in-network Tier 1 and Tier 2 prescription drugs; and 40% for in-network Tier 3 drugs
• The Personal Care Account (PCA) of $1,200 for Self Only or $2,400 for Self Plus One or Self and Family

The following cannot be included in the accumulation of out-of-pocket expenses:

• Any expenses paid by the Plan under your in-network Preventive Care benefit
• Expenses in excess of our allowance or maximum benefit limitations or expenses not covered under the Traditional Health Coverage
• Dental care or Vision care expenses above the limitations provided under your Personal Care Account
• Any amounts you pay because benefits have been reduced for non-compliance with this Plan’s cost containment requirements (see Section 3, pages 18-20)
• Expenses in excess of Hospice care maximums
• Drugs purchased at a non-network pharmacy
• The difference in cost when brand name drugs are purchased and a generic is available
• Any associated costs when you purchase medications in excess of the Plan's dispensing limitations
• Cost associated with non-covered drugs and supplies

If you changed to this Plan during Open Season from a plan with a catastrophic protection benefit and the effective date of the change was after January 1, any expenses that would have applied to that plan’s catastrophic protection benefit during the prior year will be covered by your prior plan if they are for care you received in January before your effective date of coverage in this Plan. If you have already met your prior plan’s catastrophic protection benefit level in full, it will continue to apply until the effective date of your coverage in this Plan. If you have not met this expense level in full, your prior plan will first apply your covered out-of-pocket expenses until the prior year’s catastrophic level is reached and then apply the catastrophic protection benefit to covered out-of-pocket expenses incurred from that point until the effective date of your coverage in this Plan. Your prior plan will pay these covered expenses according to this year’s benefits; benefit changes are effective January 1.

Note:  If you change options in this Plan during the year, we will credit the amount of covered expenses already accumulated toward the catastrophic out-of-pocket limit of your old option to the catastrophic protection limit of your new option.

The No Surprises Act (NSA) is a federal law that provides you with protections against "surprise billing" and "balance billing" under certain circumstances.  A surprise bill is an unexpected bill you receive from a nonparticipating healthcare provider, facility, or air ambulance service for healthcare.  Surprise bills can happen when you receive emergency care - when you have little or no say in the facility or provider from whom you receive care.  They can also happen when you receive non-emergency services at participating facilities, but you receive some care from nonparticipating providers.

Balance billing happens when you receive a bill from the nonparticipating provider, facility, or air ambulance service for the difference between the nonparticipating provider's charge and the amount payable by your health plan.

Your health plan must comply with the NSA protections that hold you harmless from unexpected bills.

For specific information on surprise billing, the rights and protections you have, and your responsibilities go to www.apwuhp.com or contact your health plan at 800-222-2798.

Under the flexible benefits option, we determine the most effective way to provide services.

• We may identify medically appropriate alternatives to regular contract benefits as a less costly alternative. If we identify a less costly alternative, we will ask you to sign an alternative benefits agreement that will include all of the following terms in addition to other terms as necessary. Until you sign and return the agreement, regular contract benefits will continue.
• Alternative benefits will be made available for a limited time period and are subject to our ongoing review. You must cooperate with the review process.
• By approving an alternative benefit, we do not guarantee you will get it in the future.
• The decision to offer an alternative benefit is solely ours, and except as expressly provided in the agreement, we may withdraw it at any time and resume regular contract benefits.
• If you sign the agreement, we will provide the agreed-upon alternative benefits for the stated time period (unless circumstances change). You may request an extension of the time period, but regular contract benefits will resume if we do not approve your request.
• Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process.  However, if at the time we make a decision regarding alternative benefits, we also decide that regular contract benefits are not payable, then you may dispute our regular contract benefits under the OPM disputed claims process (see Section 8, pages 131-133).

We offer a 24-hour nurse advisory service for your use. This program is strictly voluntary and confidential. You may call toll-free at 800-582-1314 and reach registered nurses to discuss an existing medical concern or to receive information about numerous healthcare issues.

A voluntary program that provides a variety of services to help you manage a chronic condition with outpatient treatment and avoid unnecessary emergency care or inpatient admissions. As an example, members with cardiac conditions can participate in this program.  We use medical and/or pharmacy claims data as well as interactions with you and your physician(s). If you have a chronic condition and would like additional information, call Cigna/CareAllies at 800-582-1314.

If you send us a corrected hospital billing, we will credit 20% of any hospital charge over $20 for covered services and supplies that were not actually provided to a covered person. The maximum amount payable under this program is $100 per person per calendar year.

$0 copay for in-network office visit to a registered Dietician/Nutritionist 

• Lifestyle Programs - Wellness Coaches help you develop a personalized plan for tobacco cessation and weight management.  For information, call Cigna/CareAllies at 800-582-1314, select Weight Management/Tobacco Cessation option.
• Healthy Rewards - MyCigna provides non-FEHB savings on gym memberships, tobacco cessation, weight reduction programs, and more. Visit www.apwuhp.com or call 800-558-9443.
  • Tobacco cessation - find discounts on smoking cessation products
  • Weight and nutrition - get help to lose weight with discounts on weight reduction programs from Jenny Craig
  • Fitness - get fit and save on gym memberships
  • Vision and hearing care - receive vision and hearing exams and discounts on hearing aids, discounts on glasses and frames, and discounts on Lasik vision corrections
  • Wellness products - enjoy 40% savings on herbal supplements and vitamins, and 5% at checkout from www.drugstore.com
  • Alternative medicine - find discounts for acupuncture, chiropractor, and massage
  • Dental care - save on dental care with discounts on anti-cavity products and toothbrushes

Online tools are available at www.myAPWUHP.com:

• www.myAPWUHP.com - online information for member services and claims to view claims and find year-to-date information with claim details
• HealthVault - an online tool to organize important medical information in one secure and central location to share with family and doctors
• Health Risk Assessment - answer questions about your health and receive a personalized health program through MyCigna

A Health Risk Assessment (HRA) is available at www.apwuhp.com, click Take a Health Risk Assessment, click High Option, click Register Now.  Access to the Health Risk Assessment is also available via the Member Portal at www.myAPWUHP.com.  The HRA is an online program that analyzes your health related responses and gives you a personalized plan to achieve specific health goals.  Your HRA profile provides information to put you on a path to good physical and mental health.

When you complete the HRA, we will enroll you in the CignaPlus Savings discount dental program.  For Self Only coverage, we will pay the Self Only CignaPlus Savings discount dental premium; and for Self Plus One and Self and Family, when at least two family members complete the HRA, we will pay the family CignaPlus Savings discount dental premium.  We will pay these discount dental premiums for the remainder of the calendar year in which the HRAs were completed provided you remain enrolled in our Plan.

CignaPlus Savings is a discount dental program that provides members access to discounted fees with participating dental providers.  For more information on this program, call 877-521-0244 or visit www.cignaplussavings.com.

Access by Internet (www.apwuhp.com) is provided to support your important health and wellness decisions, including:

• Online Preferrred Organization (PPO) Directory - nationwide PPO network to find doctors, hospitals and other outpatient providers anywhere in the country
• Hospital Quality Ratings Guide - Compare hospitals for quality in your area or anywhere in the country
• Treatment Cost Estimator - receive cost estimates for the most common medical conditions, tests and procedures
• Prescription drug information, pricing, and network retail pharmacies

Under the flexible benefits option, we determine the most effective way to provide services.

• We may identify medically appropriate alternatives to regular contract benefits as a less costly alternative. If we identify a less costly alternative, we will ask you to sign an alternative benefits agreement that will include all of the following terms in addition to other terms as necessary. Until you sign and return the agreement, regular contract benefits will continue.
• Alternative benefits will be made available for a limited time period and are subject to our ongoing review. You must cooperate with the review process.
• By approving an alternative benefit, we do not guarantee you will get it in the future.
• The decision to offer an alternative benefit is solely ours, and except as expressly provided in the agreement, we may withdraw it at any time and resume regular contract benefits.
• If you sign the agreement, we will provide the agreed-upon alternative benefits for the stated time period (unless circumstances change). You may request an extension of the time period, but regular contract benefits will resume if we do not approve your request.
• Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process.  However, if at the time we make a decision regarding alternative benefits, we also decide that regular contract benefits are not payable, then you may dispute our regular contract benefits decision under the OPM disputed claim process, see Section 8.

• Your Personal Care Account balance and activity (also mailed quarterly)
• Your complete claims payment history
• A consumer health encyclopedia and interactive services
• Online health risk assessment to help determine your risk for certain conditions and steps to manage them
• Personal Health Record
• You can also download UHC Mobile app for the same great features 

Each member is provided access by Internet (www.myuhc.com) or telephone 800-718-1299 to information which you may use to support your important health and wellness decisions, including:

• Online provider directory with complete national network and provider information
  (i.e., address, telephone, specialty, practice hours, languages spoken)
• Network provider discounted pricing for comparative shopping
• Pricing information for prescription drugs
• General cost information for surgical and diagnostic procedures and for comparison of different treatment options
• Provider quality information
• Health calculators on medical and wellness topics

Online programs and services provide extra support and savings, at www.myuhc.com or call 800-718-1299.

• Maternity Support Program - Mothers-to-be receive support through every stage of pregnancy and delivery.
• Kidney Resources Program - For those diagnosed with end-stage renal disease or those who are currently receiving dialysis treatment, this program will help you manage your care for the best outcome.
• Orthopedic Health Support - Orthopedic health support provides support for back, hip, knee, shoulder and neck conditions.
• Cancer Support Program - Enroll in the program, and receive enhanced benefits at Cancer Centers of Excellence.
• Real Appeal - This intensive, multi-component behavioral intervention provides a 52-week virtual approach that includes one-on-one coaching and online group participation with supporting video content, delivered by a live virtual coach. ACCESS BY: Calling UHC Member Services or visit the website at https://member.realappeal.com/
• AbleTo - Customized Behavioral Health 6-8 week digital treatment program.  Includes evidence-based treatment, care plan, digital reinforcement, and clinician/coaching.  24/7 access. ACCESS BY: Calling UHC Member Services or visit the website at https://www.ableto.com/

Receive $25 when you complete an annual physical with a clinical professional each year.

When you complete an annual physical, if you have Self Only coverage, we will add $25 to your Personal Care Account (PCA).  If you have Self Plus One or Self and Family coverage we will add $25 to the Personal Care Account (PCA) for the member, spouse, and each covered dependent who completes the Wellness Exam.  We will add these amounts in the calendar year in which the physical was completed.

A Health Risk Assessment (HRA) is available at www.myuhc.com or call 800-718-1299. The HRA is an online program that analyzes your health related responses and gives you a personalized plan to achieve specific health goals. Your HRA profile provides information to put you on a path to good physical and mental health.

High Option: To obtain claim forms, claims filing advice or answers about our benefits, contact us at 800-222-2798, or at our website at www.apwuhp.com.

Mail to:

• Cigna Healthcare, P.O. Box 188004, Chattanooga, TN  37422, or Payor ID 62308
   

Express Scripts claims mail to:

• APWU Health Plan, P.O. Box 1358, Glen Burnie, MD  21060-1358

Consumer Driven Option: Contact UnitedHealthcare at 800-718-1299 or visit their website at www.myuhc.com.

Mail to:

• UnitedHealthcare,  P.O. Box 740800, Atlanta, GA 30374-0800

Mental Health/Substance Use Disorder Treatment:  Mail to:

High Option

• Cigna Healthcare, P.O. Box 188004, Chattanooga, TN  37422 or Payor ID 62308

Consumer Driven Option

• UnitedHealthcare, P.O. Box 740800, Atlanta, GA  30374-0800

In most cases, providers and facilities file claims for you. Your provider must file on the form CMS-1500, Health Insurance Claim Form. Your facility will file on the UB-04 form. For claims questions and assistance, call us at 800-222-2798.

When you must file a claim - such as when you use non-PPO providers, for services you received overseas or when another group health plan is primary - submit it on the CMS-1500 or a claim form that includes the information shown below. Bills and receipts should be itemized and show:

• Patient’s name, date of birth, address, phone number and relationship to enrollee
• Patient’s plan identification number
• Name and address of person or company providing the service or supply
• Dates that services or supplies were furnished
• Diagnosis
• Type of each service or supply
• Charge for each service or supply

Note: Canceled checks, cash register receipts, or balance due statements are not acceptable substitutes for itemized bills.

In addition:

• If another health plan is your primary payor, you must send a copy of the explanation of benefits (EOB) statement you received from your primary payor (such as the Medicare Summary Notice (MSN)) with your claim.
• Bills for home nursing care must show that the nurse is a registered or licensed practical nurse.
• If your claim is for the rental or purchase of durable medical equipment; private duty nursing; physical therapy, occupational therapy, or speech therapy, you must provide a written statement from the provider specifying the medical necessity for the service or supply and the length of time needed.
• Claims for prescription drugs and supplies must include receipts that show the prescription number, name of drug or supply, prescribing provider name, date, and charge.
• We will provide translation and currency conversion services for claims for overseas (foreign) services.

We will notify you of our decision within 30 days after we receive your post-service claim.  If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you before the expiration of the original 30-day period.  Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information.

If you do not agree with our initial decision, you may ask us to review it by following the disputed claims process detailed in Section 8 of this brochure.

For covered services you receive by providers and hospitals outside the United States and Puerto Rico, send a completed Claim Form and the itemized bills to the following address. Also, send any written inquiries concerning the processing of overseas claims to:

• High Option: APWU Health Plan, P.O. Box 1358, Glen Burnie, MD 21060-1358.
• Consumer Driven Option: UnitedHealthcare at the claims address shown on the back of your UnitedHealthcare ID card.

You may designate an authorized representative to act on your behalf for filing a claim or to appeal claims decisions to us.  For urgent care claims, a healthcare professional with knowledge of your medical condition will be permitted to act as your authorized representative without your express consent.  For the purposes of this section, we are also referring to your authorized representative when we refer to you.

The Secretary of Health and Human Services has identified counties where at least 10 percent of the population is literate only in certain non-English languages.  The non-English languages meeting this threshold in certain counties are Spanish, Chinese, Navajo and Tagalog.  If you live in one of these counties, we will provide language assistance in the applicable non-English language.  You can request a copy of your Explanation of Benefits (EOB) statement, related correspondence, oral language services (such as telephone customer assistance), and help with filing claims and appeals (including external reviews) in the applicable non-English language.  The English versions of your EOBs and related correspondence will include information in the non-English language about how to access language services in that non-English language.

Any notice of an adverse benefit determination or correspondence from us confirming an adverse benefit determination will include information sufficient to identify the claim involved (including the date of service, the healthcare provider, and the claim amount, if applicable), and a statement describing the availability, upon request, of the diagnosis and procedure codes and its corresponding meaning, and the treatment code and its corresponding meaning.

Ask us in writing to reconsider our initial decision. You must:

(a) Write to us within 6 months from the date of our decision; and

(b) Send your High Option request to us at: APWU Health Plan, P.O. Box 1358, Glen Burnie, MD  21060-1358 or send your Consumer Driven Option request to: UnitedHealthcare Appeals, P.O. Box 740816, Atlanta, GA  30374-0816; and

(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and

(d) Include copies of documents that support your claim, such as physicians’ letters, operative reports, bills, medical records, and explanation of benefits (EOB) statements.

(e) Include your email address (optional), if you would like to receive our decision via email.  Please note that by giving us your email, we may be able to provide our decision more quickly. 

We will provide you, free of charge and in a timely manner, with any new or additional evidence considered, relied upon, or generated by us or at our direction in connection with your claim and any new rationale for our claim decision.  We will provide you with this information sufficiently in advance of the date that we are required to provide you with our reconsideration decision to allow you a reasonable opportunity to respond to us before that date.  However, our failure to provide you with new evidence or rationale in sufficient time to allow you to timely respond shall not invalidate our decision on reconsideration.  You may respond to that new evidence or rationale at the OPM review stage described in step 4.

In the case of a post-service claim, we have 30 days from the date we receive your request to:

a) Pay the claim or  

b) Write to you and maintain our denial or

c) Ask you or your provider for more information. 

You or your provider must send the information so that we receive it within 60 days of our request.  We will then decide within 30 more days.

If we do not receive the information within 60 days we will decide within 30 days of the date the information was due.  We will base our decision on the information we already have.  We will write to you with our decision. 

If you do not agree with our decision, you may ask OPM to review it.

You must write to OPM within:

• 90 days after the date of our letter upholding our intial decision; or
• 120 days after you first wrote to us -- if we did not answer that request in some way within 30 days; or
• 120 days after we asked for additional information.

Write to OPM at:  United States Office of Personnel Management, Healthcare and Insurance, Federal Employee Insurance Operations, FEHB2, 1900 E Street, NW, Washington, DC  20415-3620.

Send OPM the following information:

• A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
• Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;
• Copies of all letters you sent to us about the claim;
• Copies of all letters we sent to you about the claim; and 
• Your daytime phone number and the best time to call; 
• Your email address, if you would like to receive OPM’s decision via email.  Please note that by providing your email address, you may receive OPM’s decision more quickly.

Note:  If you want OPM to review more than one claim, you must clearly identify which documents apply to which claim.

Note:  You are the only person who has a right to file a disputed claim with OPM.  Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review request.  However, for urgent care claims, a healthcare professional with knowledge of your medical condition may act as your authorized representative without your express consent.

Note:  The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control.

OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other administrative appeals.

If you do not agree with OPM’s decision, your only recourse is to sue. If you decide to file a lawsuit, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or supplies or from the year in which you were denied precertification or prior approval. This is the only deadline that may not be extended.

OPM may disclose the information it collects during the review process to support their disputed claim decision. This information will become part of the court record.

You may not file a lawsuit until you have completed the disputed claims process. Further, Federal law governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was before OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of benefits in dispute.

Note: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and you did not indicate that your claim was a claim for urgent care, then, call us at 800-222-2798. We will expedite our review (if we have not yet responded to your claim): or we will inform OPM so they can quickly review your claim on appeal. You may call FEHB2 at 202-606-3818 between 8 a.m. and 5 p.m. Eastern Time.

You must tell us if you or a covered family member has coverage under any other health plan or has automobile insurance that pays healthcare expenses without regard to fault.  This is called “double coverage.”

When you have double coverage, one plan normally pays its benefits in full as the primary payor and the other plan pays a reduced benefit as the secondary payor.  We, like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners’ (NAIC) guidelines. For example:

• If you are covered under our Plan as a dependent, any group health insurance you have from your employer will pay primary and we will pay secondary,
• If you are an annuitant under our Plan and also are actively employed, any group health insurance you have from your employer will pay primary and we will pay secondary.

This Plan always pays secondary to:

• Any medical payment, PIP or No-Fault coverage under any automobile policy available to you,
• Any plan or program which is required by law.  You should review your automobile insurance policy to ensure that uncoordinated medical benefits have been chosen so that the automobile insurance policy is the primary payer.

For more information on NAIC rules regarding the coordinating of benefits, visit our website at www.apwuhp.com.

When we are the primary payor, we will pay the benefits described in this brochure.

When we are the secondary payor, we will determine our allowance.  After the primary plan pays, we will pay what is left of our allowance, up to our regular benefit.  We will not pay more than our allowance.  When we are the secondary payor, we will not waive specified visit limits.

Please see Section 4, Your costs for covered services, for more information about how we pay claims.

TRICARE is the healthcare program for eligible dependents of military persons, and retirees of the military.  TRICARE includes the CHAMPUS program.  CHAMPVA provides health coverage to disabled Veterans and their eligible dependents.  If TRICARE or CHAMPVA and this Plan cover you, we pay first.  See your TRICARE or CHAMPVA Health Benefits Advisor if you have questions about these programs.

Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these programs, eliminating your FEHB premium.  (OPM does not contribute to any applicable plan premiums).  For information on suspending your FEHB enrollment, contact your retirement office.  If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under TRICARE or CHAMPVA.

We do not cover services that:

• You (or a covered family member) need because of a workplace-related illness or injury that the Office of Workers’ Compensation Programs (OWCP) or a similar Federal or State agency determines they must provide; or
• OWCP or a similar agency pays for through a third-party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws.

When you have this Plan and Medicaid, we pay first.

Suspended FEHB coverage to enroll in Medicaid or a similar State-sponsored program of medical assistance: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these State programs, eliminating your FEHB premium.  For information on suspending your FEHB enrollment, contact your retirement office.  If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under the State program.

The terms “Reimbursement” and “Subrogation” are defined by the U.S. Office of Personnel Management in Part 890 of the Code of Federal Regulations, 89 C.F.R. § 890.101(a), and those definitions are hereby incorporated into this brochure. Our subrogation and reimbursement rights arise when the individual who suffers an injury or illness has a right to be compensated from another source for that injury or illness as described below.

Reimbursement means a carrier’s pursuit of a recovery if a covered individual has suffered an illness or injury and has received, in connection with that illness or injury, a payment from any party that may be liable, any applicable insurance policy, or a Workers' Compensation program or insurance policy, and the terms of the carrier’s health insurance plan require the covered individual, as a result of such payment, to reimburse the carrier out of the payment to the extent of the benefits initially paid or provided. The right of reimbursement is cumulative with and not exclusive of the right of subrogation.

Subrogation means a carrier’s pursuit of a recovery from any party that may be liable, any applicable insurance policy, or a Workers' compensation program or insurance policy, as successor to the rights of a covered individual who suffered an illness or injury and has obtained benefits from that carrier’s health benefits plan.

The terms reimbursement and subrogation have the same meaning in this brochure as they do in the OPM Rules. Our right to pursue and receive subrogation and reimbursement recoveries is a condition of and a limitation on the nature of benefits or benefit payments and on the provision of benefits under our coverage. This section explains your basic obligations and procedures related to this reimbursement requirement. The funds the Plan recovers through reimbursement and subrogation help lower the subscription charges for all enrollees.

If we pay benefits for an injury or illness suffered by a covered individual, and monetary compensation related to that injury or illness is received from someone else (referred to as a “third party”), the Plan must be reimbursed out of the compensation received for the total amount of benefits it paid or reasonably expects to pay. The amount the Plan is entitled to recover is sometimes referred to as the Plan’s "lien", and the Plan may ask a court to issue an order confirming the Plan’s lien. Reimbursement to the Plan is a requirement and condition on a covered individual obtaining benefits from the Plan under this brochure. The Plan’s recoveries through reimbursement and subrogation help lower subscription charges for all enrollees in the Plan. 

By enrolling in the Plan and in accordance with the FEHB Program and this brochure, you agree that the Plan’s right to pursue and receive subrogation and reimbursement recoveries is a condition of and a limitation on the nature of benefits or benefit payments and on the provision of benefits under our coverage, and you agree to the following:

• The Plan must be reimbursed in any and all situations where a covered individual, or their representatives, heirs, administrators, successors or assignees receive payment from any source related to an injury or illness for which the individual has received benefits or benefit payments from the Plan. This may include money recovered from another party who may be liable, a third party’s insurance policy, your own insurance policy, or a Workers' Compensation program or policy, through a lawsuit, a judgment, settlement, or other recovery. The Plan must be reimbursed to the extent of the benefits we have paid or provided, or reasonably expect to pay or provide, in connection with the injury or illness.
• Reimbursement of the Plan must be done on a first priority basis (before any of the rights of any other party are honored) out of any recovery obtained no matter the source (litigation, judgment, settlement, insurance claim or otherwise) and no matter how the recovery is characterized, designated, or apportioned (such as your claim against the third party being for “pain and suffering”).
• The Plan’s right to reimbursement applies even if the Plan paid benefits before we knew of the accident or illness.
• Restrictive endorsements or other statements on checks accepted by the Plan or its agents to reimburse the Plan in a subrogation matter will not bind the Plan.
• Neither you nor your representatives, heirs, administrators, successors or assignees will do anything that would prevent us from being fully reimbursed for the benefits we paid, and you and your representatives, heirs, administrators, successors and assignees will cooperate in assisting us in recovering the cost of the benefits we paid.
• You agree and authorize the Plan to communicate directly with any involved insurance carriers regarding your injury or illness and their reimbursements.
• This reimbursement responsibility covers benefits for you and any other person on your membership.

The Plan is entitled to be reimbursed fully even if the amount received does not compensate the injured individual fully or if there are other liens or expenses. We are entitled to be reimbursed for our benefit payments even if the injured individual is not legally “made whole” for all damages arising out of the injury or illness. Our right of recovery is also not subject to reductions for attorney’s fees or costs in recovering the money under the “common fund” or other legal doctrines.

If you wish to discuss the amount of reimbursement to pay to the Plan, please contact Customer Service (High Option, 800-222-2798; Consumer Driven Option, 800-718-1299) or our subrogation representatives at the contact information at the end of this section.

If you or your representatives, heirs, administrators, successors or assignees do not pursue a claim or demand against a third party, we may, at our option, choose to exercise our right of subrogation and pursue a recovery from any liable party as successor to your rights.

What to communicate to the Plan

• Promptly inform us if a covered individual has an injury or illness for which benefits paid by the Plan might be reimbursed or subrogated as described here. This includes reporting third party cases to Customer Service or responding to any questionnaires or surveys inquiring about benefit claims paid by the Plan. We or our subrogation representatives will communicate with you about whether you owe the Plan any reimbursement. Failure to provide information related to reimbursements may delay the processing of your benefits.
• If you or your representatives, heirs, administrators, successors or assignees make a claim or demand on a third party for compensation for an injury or illness for which the Plan has paid benefits, notify us immediately. We will communicate with you to keep the status of the claim or demand updated in our systems so that there is no delay in processing your claims. We may seek a first priority lien on the proceeds of your claim in order to ensure that the Plan is reimbursed for the benefits we paid or will pay. We may also require you to assign to us (1) your claim or demand or (2) your right to the proceeds of your claim or demand. In all cases, we may enforce our right of recovery and reimbursement by offsetting any undisputed amount owed the Plan as a result of recovering money from a third party against future benefit payments by the Plan.

If you need more information  or wish to report or discuss a subrogation or reimbursement matter, please contact Customer Service or our subrogation representatives.

High Option:  ODSA, P.O. Box 34188, Washington, DC  20043-4188; or subroinfo@odsalaw.com, 877-535-1075 or 202-898-1075

Consumer Driven Option: UnitedHealthcare, 800-718-1299

Some FEHB plans already cover some dental and vision services.  When you are covered by more than one vision/dental plan, coverage provided under your FEHB plan remains as your primary coverage.  FEDVIP coverage pays secondary to that coverage.  When you enroll in a dental and/or vision plan on BENEFEDS.com or by phone at 877-888-3337, (TTY 877-889-5680), you will be asked to provide information on your FEHB plan so that your plans can coordinate benefits.  Providing your FEHB information may reduce your out-of-pocket cost.

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition, and is either Federally-funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration (FDA); or is a drug trial that is exempt from the requirement of an investigational new drug application.

If you are a participant in a clinical trial, this health plan will provide related care as follows, if it is not provided by the clinical trial:

• Routine care costs - costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient's condition, whether the patient is in a clinical trial or is receiving standard therapy
• Extra care costs - costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient's routine care
• Research costs - costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes. These costs are generally covered by the clinical trials. This Plan does not cover these costs

For more detailed information on "What is Medicare?" and "Should I Enroll in Medicare?" please contact Medicare at 1-800-MEDICARE (1-800-633-4227), (TTY 1-877-486-2048) or at  www.medicare.gov.

The Original Medicare Plan (Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medicare benefits and is the way most people get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay
your share.

All physicians and other providers are required by law to file claims directly to Medicare for members with Medicare Part B, when Medicare is primary. This is true whether or not they accept Medicare.

When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care.

Claims process when you have the Original Medicare Plan – You will probably not need to file a claim form when you have both our Plan and the Original Medicare Plan. When we are the primary payor, we process the claim first. In this case, we do not waive any out-of-pocket costs.

When Original Medicare is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. To find out if you need to do something to file your claim, call us at 800-222-2798 or see our website at www.apwuhp.com.

We waive some costs if the Original Medicare Plan is your primary payor.

Under the High Option, we will waive some out-of-pocket costs as follows:

• Inpatient hospital service. If you are enrolled in Medicare Part A, we will waive the deductible and coinsurance.
• Medical services and supplies provided by physicians and other healthcare professionals. If you are enrolled in Medicare Part B, we will waive the deductible, coinsurance and copayment.
• We offer a Medicare Advantage plan, UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan for Federal members.  Please review the information on coordinating benefits with Medicare Advantage plans below.

Under the Consumer Driven Option, when Original Medicare (either Medicare Part A or Medicare Part B) is the primary payer, we will not waive any out-of-pocket costs.

Note: We do not waive our deductible, copayments or coinsurance for prescription drugs or for services and supplies that Medicare does not cover. Also, we do not waive benefit limitations, such as the 24-visit limit for chiropractic services or the 60-visit limit for physical, occupational or speech therapy.

You can find more information about how our Plan coordinates benefits with Medicare in APWU Health Plan's Blueprint to Medicare at www.apwuhp.com. We do not waive any costs if the Original Medicare Plan is your primary carrier.

Please review the information on page 140.  It illustrates your cost share if you are enrolled in Medicare Part B. Medicare will be primary for all Medicare eligible services. Members must use providers who accept Medicare's assignment.

We offer a plan designed to help members with their Medicare Part B premium.  This plan is called UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan.  If you have Medicare Parts A and B and enroll in the UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan, you will be reimbursed $50.00 of your Medicare Part B monthly premium.  This will be sent from Centers for Medicare & Medicaid Services (CMS) directly to your Social Security.

To learn more about this plan and how to enroll, call us at 1-855-383-8793, 8 a.m. to        8 p.m., local time, Monday through Friday. For TTY for the deaf, hard of hearing, or speech impaired, call 711.  We will send you additional information and an application for enrollment.

If you are enrolled in Medicare Part B, a physician may ask you to sign a private contract agreeing that you can be billed directly for services ordinarily covered by Original Medicare.  Should you sign an agreement, Medicare will not pay any portion of the charges, and we will not increase our payment.  We will still limit our payment to the amount we would have paid after Original Medicare’s payment.  You may be responsible for paying the difference between the billed amount and the amount we paid.

If you are eligible for Medicare, you may choose to enroll and get your Medicare benefits from a Medicare Advantage plan.  These are private healthcare choices (like HMOs and regional PPOs) in some areas of the country.  To learn more about Medicare Advantage plans, contact Medicare at 800-MEDICARE (800-633-4227), (TTY: 877-486-2048) or at www.medicare.gov.

If you enroll in a Medicare Advantage plan, the following options are available to you:

This Plan and our Medicare Advantage plan:  You may enroll in our Medicare Advantage plan and also remain enrolled in our FEHB plan.  For more information on our Medicare Advantage plan, please contact 855-383-8793.  Enrollment in UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan is voluntary.  Members must complete an application for enrollment.  Eligible enrollees voluntarily opt into UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan and may opt out at any time.  You may enroll in the UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan, if:

• You are a retiree or annuitant enrolled in the High Option and have both Medicare Part A and Part B.
• You are a United States citizen or are lawfully present in the United States.
• You do NOT have End-Stage Renal Disease (ESRD).  Enrollees who have ESRD cannot enroll until after the 30-month grace period has expired.  Members diagnosed with ESRD while enrolled in UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan may remain enrolled and ESRD services will be covered.
• You complete an application for enrollment in the UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan.

Medicare B Premium Reimbursement

• We offer a plan designed to help members with their Medicare Part B premium.  This plan is called UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan.  If you have Medicare Part A and B and enroll in this plan, you will be reimbursed $50.00 of your Medicare Part B monthly premium.  This will be sent from Centers for Medicare and Medicaid Services (CMS) directly to your Social Security.  Please review the information below.  It illustrates your cost share if you are enrolled in the High Option only, the High Option with Medicare Part B or the UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan.  Medicare will be primary for all Medicare eligible services.  Members must use providers who accept Medicare's assignment. 

Benefit Description: Deductible
High Option You Pay without Medicare (In-Network): $450 Self Only/$800 Family 
High Option You Pay with Medicare B (In-Network): $0
UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan -  (UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan) (In-network): $0

Benefit Description: Out-of-Pocket Maximum
High Option You Pay without Medicare (In-Network): $6,500 Self Only/$13,000 Family 
High Option You Pay with Medicare B (In-Network): $6,500 Self Only/$13,000 Family 
UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan -  (UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan) (In-network): $0

Benefit Description: Part B Premium Reimbursement Offered
High Option You Pay without Medicare (In-Network): N/A
High Option You Pay with Medicare B (In-Network): N/A
UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan -  (UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan) (In-network): $50 per month

Benefit Description: Primary Care Physician
High Option You Pay without Medicare (In-Network): $25
High Option You Pay with Medicare B (In-Network): $0
UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan -  (UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan) (In-network): $0

Benefit Description: Specialist
High Option You Pay without Medicare (In-Network): $25 
High Option You Pay with Medicare B (In-Network): $0
UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan -  (UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan) (In-network): $0

Benefit Description: Inpatient Hospital 
High Option You Pay without Medicare (In-Network): 15%
High Option You Pay with Medicare B (In-Network): $0
UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan -  (UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan) (In-network): $0

Benefit Description: Outpatient Hospital
High Option You Pay without  Medicare (In-Network): 15%
High Option You Pay with Medicare B (In-Network): $0
UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan -  (UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan) (In-network): $0

Benefit Description: Incentives offered
High Option You Pay without Medicare (In-Network): N/A
High Option You Pay with Medicare B (In-Network): Waive deductible, coinsurance and copayment
UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan -  (UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan) (In-network): Silver Sneakers, Podiatry, Hearing aids, Nationwide network

To learn more about the UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan and how to enroll, call us at 855-383-8793, 8 a.m. to 8 p.m., local time, Monday through Friday. For TTY for the deaf, hard of hearing, or speech impaired, call 711.  We will send you additional information and an application for enrollment.

This Plan and another plan’s Medicare Advantage plan:  You may enroll in another plan’s Medicare Advantage plan and also remain enrolled in our FEHB plan.  We will still provide benefits when your Medicare Advantage plan is primary, even out of the Medicare Advantage plan’s network and/or service area (if you use our Plan providers).  For the High Option, we waive some costs if Medicare Advantage is your primary payor.  We will waive our copayments, coinsurance, or deductibles. For the Consumer Driven Option, we will not waive any of our copayments, coinsurance, or deductibles.  If you enroll in a Medicare Advantage plan, tell us.  We will need to know whether you are in the Original Medicare Plan or in a Medicare Advantage plan so we can correctly coordinate benefits with Medicare.

Suspended FEHB coverage to enroll in a Medicare Advantage plan: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a Medicare Advantage plan, eliminating your FEHB premium.  (OPM does not contribute to your Medicare Advantage plan premium.)  For information on suspending your FEHB enrollment, contact your retirement office.  If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage or move out of the Medicare Advantage plan’s service area.

We limit our payment to an amount that supplements the benefits that Medicare would pay under Medicare Part A (Hospital insurance) and Medicare Part B (Medical insurance), regardless of whether Medicare pays.  Note: We pay our regular benefits for emergency services to an institutional provider, such as a hospital, that does not participate with Medicare and is not reimbursed by Medicare.

We use the Department of Veterans Affairs (VA) Medicare-equivalent Remittance Advice (MRA) when the statement is submitted to determine our payment for covered services provided to you if Medicare is primary, when Medicare does not pay the VA facility.

If you are covered by Medicare Part B and it is primary, your out-of-pocket costs for services that both Medicare Part B and we cover depend on whether your physician accepts Medicare assignment for the claim.

High Option:  If your physician accepts Medicare assignment, then you pay nothing for covered charges up to our allowance.

Consumer Driven Option:  If your physician accepts Medicare assignment, then you pay nothing if you have unused benefits available under your Personal Care Account (PCA) to pay the difference between the Medicare approved amount and Medicare's payment.  If your PCA is exhausted, you must pay either this full difference under your Deductible or the lesser of your coinsurance or the full difference if your Deductible has been met.

If your physician does not accept Medicare assignment, you pay the difference between the “limiting charge” or the physician’s charge (whichever is less) and our payment combined with Medicare’s payment.

It is important to know that a physician who does not accept Medicare assignment may not bill you for more than 115% of the amount Medicare bases its payment on, called the “limiting charge.”  The Medicare Summary Notice (MSN) that Medicare will send you will have more information about the limiting charge.  If your physician tries to collect more than allowed by law, ask the physician to reduce the charges.  If the physician does not, report the physician to the Medicare carrier that sent you the MSN form.  Call us if you need further assistance.

Please see Section 9, Coordinating benefits with Medicare and other coverage, for more information about how we coordinate benefits with Medicare.

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition, and is either Federally-funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration (FDA); or is a drug trial that is exempt from the requirement of an investigational new drug application. If you are a participant in a clinical trial, this health plan will provide related care as follows, if it is not provided by the clinical trial:

• Routine care costs - costs for routine services such as doctors visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient's condition, whether the patient is in a clinical trial or is receiving standard therapy 
• Extra care costs - costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient's routine care
• Research costs - costs related to conducting the clinical trial such as research physician and nurse time, analysis or results, and clinical tests performed only for research purposes.  These costs are generally covered by the clinical trials.  This Plan does not cover these costs.

See Section 4, page 26.

See Section 4, page 25.

See Section 4, page 25.

Treatment or services, regardless of who recommends them or where they are provided, that could be rendered safely and reasonably by a person not medically skilled, or that are designed mainly to help the patient with daily living activities. These activities include, but are not limited to:

• Personal care such as help in: walking; getting in and out of bed; bathing; eating by spoon, tube or gastrostomy; exercising; dressing
• Homemaking, such as preparing meals or special diets
• Moving the patient
• Acting as a companion or sitter
• Supervising medication that can usually be self administered; or
• Treatment or services that any person may be able to perform with minimal instruction, including but not limited to recording temperature, pulse, and respirations, or administration and monitoring of feeding systems

We determine which services are custodial care. Custodial care that lasts 90 days or more is sometimes known as long term care.

See Section 4, page 25.

A drug, device, or biological product is experimental or investigational if the drug, device, or biological product cannot be lawfully marketed without approval of the U.S. Food and Drug Administration (FDA) and approval for marketing has not been given at the time it is furnished. Approval means all forms of acceptance by the FDA.

A medical treatment or procedure, or a drug, device, or biological product is experimental or investigational if 1) reliable evidence shows that it is the subject of ongoing phase I, II, or III clinical trials or under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis; or 2) reliable evidence shows that the consensus of opinion among experts regarding the drug, device, or biological product or medical treatment or procedure is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis.

Reliable evidence shall mean only published reports and articles in the authoritative medical and scientific literature; the written protocol or protocols used by the treating facility or the protocols of another facility studying substantially the same drug, device, or medical treatment or procedure; or the written informed consent used by the treating facility or by another facility studying substantially the same drug, device, or medical treatment or procedure.

Determination of experimental/investigational status may require review by a specialty appropriate board-certified healthcare provider or appropriate government publications such as those of the National Institutes of Health, National Cancer Institute, Food and Drug Administration, Agency for Healthcare Research and Quality, and the National Library of Medicine.

Healthcare that can include therapy to address feelings of gender dysphoria, as well as medical treatments that help individuals achieve physical characteristics that better align with their gender identity.

Healthcare coverage that a member is eligible for because of employment by, membership in, or connection with, a particular organization or group that provides payment for hospital, medical, or other healthcare services or supplies, or that pays a specific amount for each day or period of hospitalization if that specified amount exceeds $200 per day, including extension of any of these benefits through COBRA.

Healthcare services that help a person keep, learn or improve skills and functioning for daily living.  Examples include therapy for a child who isn't walking or talking at the expected age.  These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.

A physician or other healthcare professional licensed, accredited, or certified to perform specified health services consistent with state law.

An agency which meets all of the following:

• Is primarily engaged in providing, and is duly licensed or certified to provide, skilled nursing care and therapeutic services
• Has policies established by a professional group associated with the agency or organization. This professional group must include at least one registered nurse (R.N.) to direct the services provided and it must provide for full-time supervision of each service by a physician or registered nurse
• Maintains a complete medical record on each individual; and
• Has a full-time administrator

Services, drugs, supplies or equipment provided by a hospital or covered provider of healthcare services that we determine:

• Are appropriate to diagnose or treat the patient's condition, illness or injury
• Are consistent with standards of good medical practice in the United States
• Are not primarily for the personal comfort or convenience of the patient, the family, or the provider
• Are not a part of or associated with the scholastic education or vocational training of the patient; and
• In the case of inpatient care, cannot be provided safely on an outpatient basis

The fact that a covered provider has prescribed, recommended, or approved a service, supply, drug or equipment does not, in itself, make it medically necessary.

Our Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Fee-for-service plans determine their allowances in different ways. We determine our allowance as follows:

For PPO providers, our allowance is based on negotiated rates. PPO providers always accept the Plan’s allowance as their charges for covered services.

For non-PPO providers, we base the Plan allowance on the lesser of the provider's actual charges or the allowed amount for the service you received.  We determine the allowed amount by using healthcare charge guides which compare charges of other providers for similar services in the same geographical area.  We update these charge guides at least once a year.  For surgery, doctor's services, X-ray, lab and therapies (physical, speech and occupational), we use the following:

• For the High Option Plan we use guides specifically prepared by Context4Healthcare at the 70^th percentile.
• For the Consumer Driven Option we use guides specifically prepared by Fair Health at the 80^th percentile.
• If this information is not available, we will use other credible sources including our own data.

For more information, see Differences between our allowance and the bill in Section 4.

You should also see section Important Notice About Surprise Billing - Know Your Rights below that describes your protections against surprise billing under the No Surprises Act.

A carrier's pursuit of a recovery if a covered individual has suffered an illness or injury and has received, in connection with that illness or injury, a payment from any party that may be liable, any applicable insurance policy, or a workers' compensation program or insurance policy, and the terms of the carrier's health benefits plan require the covered individual, as a result of such payment, to reimburse the carrier out of the payment to the extent of the benefits initially paid or provided. The right of reimbursement is cumulative with, and not exclusive of, the right of subrogation.

Residential Treatment Centers (RTCs) are accredited by a nationally recognized organization and licensed by the state, district, or territory to provide short-term transitional residential treatment for medical conditions, mental health conditions, and/or substance use.  Accredited healthcare facilities (excluding hospitals, skilled nursing facilities, group homes, halfway houses, and similar types of facilities) provide 24-hour residential evaluation, treatment and comprehensive specialized services relating to the individual's medical, physical, mental health, and/or substance use therapy needs.

A claim for medical care or treatment is an urgent care claim if waiting for the regular time limit for non-urgent care claims could have one of the following impacts:

• Waiting could seriously jeopardize your life or health;
• Waiting could seriously jeopardize your ability to regain maximum function; or
• In the opinion of a physician with knowledge of your medical condition, waiting would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.

Urgent care claims usually involve pre-service claims and not post-service claims.  We will determine whether or not a claim is an urgent care claim by applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine.

If you believe your claim qualifies as an urgent care claim, please contact our Customer Service Department at 800-222-2798.  You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care.

A fee-for-service option under the FEHB that offers you greater control over choices of your healthcare expenditures. You decide what healthcare services will be reimbursed under the Health Plan funded Personal Care Account (PCA). Unused funds from the PCA will roll over at the end of the year. If you spend the entire PCA fund before the end of the year, then you must satisfy a deductible before benefits are payable under the traditional type of insurance covered by your Plan. You decide whether to use in-network or out-of-network providers to reach the maximum fund allowed under your PCA.

Under the Consumer Driven Option, your plan's deductible is reduced by applying the funds in your Personal Care Account (PCA) which is funded in January by APWU Health Plan. Your Net Deductible is the remaining deductible amount you have to pay once the funds in your PCA have been exhausted. By using the funds in your PCA to pay for eligible medical expenses you decrease your total deductible and out-of-pocket expenses.  See page 25.

Under the Consumer Driven Option, your Personal Care Account (PCA) is an established benefit amount which is available for you to use first to pay for covered hospital, medical, dental and vision care expenses. You determine how your PCA will be spent and any unused amount at the end of the year may be rolled over to increase your available PCA in the subsequent year(s).

As long as you remain in this Plan, any unused remaining balance in your PCA at the end of the calendar year may be rolled over to subsequent years. The maximum amount allowed in your PCA may not exceed $5,000 per Self Only enrollment and $10,000 per Self Plus One or Self and Family enrollment.

PPO: $25 copay per visit (No deductible); 15% of Plan allowance

Non-PPO: 40% of our allowance plus amount over our allowance

35

PPO: 15% of Plan allowance

Non-PPO: $300 per admission and 40% of our allowance plus amount over our allowance

55

PPO: 15% of Plan allowance

Non-PPO: 40% of our allowance plus amount over our allowance

57

PPO: Nothing

Non-PPO: Nothing

60

PPO: 15% of Plan allowance

Non-PPO:  15% of Plan allowance

60

PPO: $25 copay per visit (No deductible); 15% of Plan allowance

Non-PPO: 40% of our allowance plus amount over our allowance

63

$10 Tier 1/25% Tier 2/45% Tier 3/Specialty drugs 25% Tier 4/25% Tier 5/45% Tier 6

68

50% of cost

68

$20 Tier 1/25% Tier 2/45% Tier 3 Specialty drugs 25% Tier 4/25% Tier 5/45% Tier 6

68

30% of Plan allowance plus amount over our allowance

73

See Section 5(h)

74

PPO: Nothing after $6,500 for Self Only or $13,000 for a Self Plus One or Self and Family enrollment per year

Non-PPO: Nothing after $12,000 for Self Only, or $24,000 for a Self Plus One or Family enrollment per year

Some costs do not count toward this protection

28