• No pre-existing condition limitation

• Minimum essential coverage (MEC)

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.   

• Minimum value standard (MVS)

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.  

• Where you can get information about enrolling in the FEHB Program

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; and
• 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; and
• When the next Open Season for enrollment begins.

We don’t 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.

• Types of coverage available for you and your family

Self Only coverage is for you alone. Self Plus One coverage is for you and one eligible family member. Self and Family coverage is for you and one eligible family member, or you, your spouse, and your dependent children under age 26, including any foster children authorized for coverage by your employing agency or retirement office. Under certain circumstances, you may also continue coverage for a disabled child 26 years of age or older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self Plus One or Self and Family enrollment if you marry, give birth, or add a child to your family. You may change your enrollment 31 days before to 60 days after that event. The Self Plus One or Self and Family enrollment begins on the first day of the pay period in which the child is born or becomes an eligible family member. When you change to Self Plus One or Self and Family because you marry, the change is effective on the first day of the pay period that begins after your employing office receives your enrollment form. Benefits will not be available 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.

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 www.opm.gov/healthcare-insurance/life-events. If you need assistance, please contact your employing agency, Tribal Benefits Officer, personnel/payroll office, or retirement office.

• Family member coverage 

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

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

Foster children
Coverage: Foster children are eligible for coverage until their 26th 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 26th 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 26th 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.

• Children’s Equity Act

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 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 this law applies to you, and only one child is involved in the court or administrative order, you may enroll for Self Plus One coverage in a health plan that provides full benefits in the area where your child lives or provide documentation to your employing office that you have obtained other health benefits coverage for the child. 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.

• When benefits and premiums start

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 2021 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. However, if your prior plan left the FEHB Program at the end of the year, you are covered under that plan’s 2020 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.

• When you retire

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).

• When FEHB coverage ends

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

• Your enrollment ends, unless you cancel your enrollment, or
• You are 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 31st 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 60th day after the end of the 31 day temporary extension.

You may be eligible for spouse equity coverage or assistance with enrolling in a conversion policy (a non-FEHB individual policy).

• Upon divorce

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. You can also visit OPM’s website, 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.

• Temporary Continuation of Coverage (TCC)

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 or Tribal 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 FEHBP coverage.

• Finding Replacement Coverage

When you contact GEHA, we will assist you with obtaining information about health benefits coverage inside or outside the Marketplace if:

• Your coverage under TCC or the spouse equity law ends;
• You decide not to receive coverage under TCC or the spouse equity law; or
• You are not eligible for coverage under TCC or the spouse equity law.

You must contact us in writing within 31 days after you are no longer eligible for coverage.    For assistance in finding coverage, please contact us at 800-821-6136 or visit our website at www.geha.com.

Benefits and rates under the replacement coverage will differ from benefits and rates under the FEHB Program. However, you will not have to answer questions about your health and we will not impose a waiting period or limit your coverage due to pre-existing conditions.

• Health Insurance Marketplace

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.   

Aetna Signature Administrators

Alaska, Arizona, California, Colorado, Connecticut, Georgia, Kentucky, Maine, Massachusetts, Michigan, Nevada, New Hampshire, New Jersey, New York, Ohio, Oregon, Pennsylvania, Rhode Island, Vermont and Washington

UnitedHealthcare Options PPO

Alabama, Arkansas, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Minnesota, Mississippi, Missouri, Montana, Nebraska, New Mexico, North Dakota, South Carolina, South Dakota, Tennessee, Utah and Wyoming

UnitedHealthcare Choice Plus

Delaware, Florida, Louisiana, Maryland, North Carolina, Oklahoma, Texas, Virginia, Washington DC, West Virginia and Wisconsin

Identification cards

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, call us at 800-821-6136 or write to us at GEHA, P. O. Box 21542, Eagan, MN 55121. You may also request replacement cards through our website: www.geha.com.

• Covered providers

We provide benefits for the services of covered 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.

Under the Plan, we consider covered providers to be medical practitioners who perform covered services when acting within the scope of their license or certification under applicable state law.  

These covered providers may include: a licensed doctor of medicine (M.D.) or a licensed doctor of osteopathy (D.O.); chiropractor; nurse midwife; nurse anesthetist; audiologist; dentist; optometrist; licensed clinical social worker; licensed clinical psychologist; licensed professional counselor; licensed marriage and family therapist; podiatrist; speech, physical and occupational therapist; nurse practitioner/clinical specialist; nursing school administered clinic; physician assistant; registered nurse first assistants; certified surgical assistants; board certified behavior analyst; board certified assistant behavior analyst; registered behavior technician; Christian Science practitioner, and a dietitian as long as they are providing covered services which fall within the scope of their state licensure or statutory certification.

The terms “doctor”, “physician”, “practitioner” or “professional provider” includes any provider when the covered service is performed within the scope of their license or certification. The term “primary care physician” includes family or general practitioners, pediatricians, obstetricians/gynecologists and medical internists, and mental health/substance use disorder treatment providers.

Practitioners must be licensed in the state where the patient is physically located at the time services are rendered.

• Covered facilities

Covered facilities include:

• Freestanding ambulatory facility
  • A facility which is licensed by the state as an ambulatory surgery center or has Medicare certification as an ambulatory surgical center, has permanent facilities and equipment for the primary purpose of performing surgical and/or renal dialysis procedures on an outpatient basis; provides treatment by or under the supervision of doctors and nursing services whenever the patient is in the facility; does not provide inpatient accommodations; and is not, other than incidentally, a facility used as an office or clinic for the private practice of a doctor or other professional.  
  • If the state does not license Ambulatory Surgical Centers and the facility is not Medicare certified as an ambulatory surgical center, then they must be accredited with AAAHC (Accreditation Association for Ambulatory Health Care), AAAASF (American Association for Accreditation for Ambulatory Surgery Facilities), IMQ (Institute for Medical Quality) or TJC (The Joint Commission).
  • Ambulatory Surgical Facilities in the state of California do not require a license if they are physician owned. To be covered these facilities must be accredited by one of the following: AAAHC (Accreditation Association for Ambulatory Health Care), AAAASF (American Association for Accreditation for Ambulatory Surgery Facilities), IMQ (Institute for Medical Quality) or TJC (The Joint Commission).
• Christian Science nursing organization/facilities that are accredited by The Commission for Accreditation of Christian Science Nursing Organization/Facilities Inc.
• Hospice
  A facility which meets all of the following:
  • Primarily provides inpatient hospice care to terminally ill persons; 
  • Is certified by Medicare as such, or is licensed or accredited as such, by the jurisdiction it is in;
  • Is supervised by a staff of M.D.’s or D.O.’s, at least one of whom must be on call at all times;
  • Provides 24-hour-a-day nursing services under the direction of an R.N. and has a full-time administrator; and
  • Provides an ongoing quality assurance program.
• Skilled Nursing Facility licensed by the state or certified by Medicare if the state does not license these facilities. See limitations on page (Applies to printed brochure only).
• Hospital
  • An institution which is accredited as a hospital under the Hospital Accreditation Program of The Joint Commission (TJC) or the Commission on Accreditation of Rehabilitation Facilities (CARF) or is certified by Medicare; or 
  • A medical institution which is operated pursuant to law, under the supervision of a staff of doctors, and with 24-hour-a-day nursing service, and which is primarily engaged in providing general inpatient acute 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 have such arrangements by contract or agreement; or
  • An institution which is operated pursuant to law, under the supervision of a staff of doctors and with 24-hour-a-day nursing service and which provides services on the premises for the diagnosis, treatment, and care of persons with mental/substance use disorders and has, for each patient, a written treatment plan which must include diagnostic assessment of the patient and a description of the treatment to be rendered and provides for follow-up assessments by, or under, the direction of the supervising doctor.

The term hospital does not include a convalescent home or skilled nursing facility, or any institution or part thereof which: a) is used principally as a convalescent facility, nursing facility, or facility for the aged; b) furnishes primarily domiciliary or custodial care, including training in the routines of daily living; or c) is operating as a school.

• Residential Treatment Centers (RTCs) must be accredited by a nationally recognized organization (e.g. CARF, Council on Accreditation (COA) or The Joint Commission (formerly JCAHO)) and licensed by the state, district or territory (if applicable) to provide residential treatment for medical conditions, mental health conditions and/or substance use disorder. If the RTC is not accredited nationally, or if state licensure is available but not obtained, the facility must be Medicare certified. Accredited health care facilities (see page (Applies to printed brochure only) for exclusions.) provide 24-hour residential evaluation, treatment, and comprehensive specialized services relating to the individual's medical, physical, mental health, and/or substance use disorder therapy needs.

• Partial Hospital Program or Intensive Outpatient Treatment Facility
  • Is licensed by the state, district or territory (if applicable) (See Section 5(e), Services we do not cover, page (Applies to printed brochure only));
  • And is accredited for behavioral health services by a nationally recognized organization.

• Transitional care

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 for 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 PPO 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.

• If you are hospitalized when your enrollment begins

We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 800-821-6136. For members residing in Delaware, Florida, Louisiana, Maryland, North Carolina, Oklahoma, Texas, Virginia, Washington DC, West Virginia and Wisconsin, call UnitedHealthcare Clinical Services at 877-585-9643. 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 92nd 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 person's benefits under the new plan begin on the effective date of enrollment.

You need prior Plan approval for certain services

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 preauthorization and (2) will result in a reduction of benefits if you do not obtain precertification or preauthorization.

• Inpatient hospital admission
  (including Residential Treatment Centers, Skilled Nursing Facility, Long Term Acute Care, or Rehab Facility)

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.

How to precertify an admission to a Hospital, Residential Treatment Centers, Skilled Nursing Facility, Long Term Acute Care or Rehab Facility

First, you, your representative, your physician or your hospital must call Conifer Health Solutions (Medical Management Service – IMMS) before a hospital admission, residential treatment center admission, or services requiring precertification are rendered. The toll-free number is 800-242-1025. For members residing in Delaware, Florida, Louisiana, Maryland, North Carolina, Oklahoma, Texas, Virginia, Washington DC, West Virginia and Wisconsin, call UnitedHealthcare Clinical Services at 877-585-9643. 

For admissions to Skilled Nursing Facilities, Long Term Acute Care Facilities, or Rehabilitation Facilities please call OrthoNet to precertify at 877-304-4419. For members residing in Delaware, Florida, Louisiana, Maryland, North Carolina, Oklahoma, Texas, Virginia, Washington DC, West Virginia and Wisconsin, call UnitedHealthcare Clinical Services at 877-585-9643. 

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 doctor;
• name of hospital or facility; and
• number of days requested for hospital stay.

We will then tell the doctor and/or hospital the number of approved inpatient days and we will send written confirmation of our decision to you, your doctor, and the hospital.

Warning

You must get precertification for certain services. Failure to do so will result in the following penalties:

• We will reduce our benefits for the Inpatient Hospital stay, Long Term Acute Care stay or Rehabilitation Facility stay by $500 if no one contacts us for precertification. If the stay is not medically necessary, we will only pay for any covered medical services and supplies that are otherwise payable on an outpatient basis.
• We will reduce our benefits for the Skilled Nursing Facility stay if no one contacts us for precertification. If the stay is not medically necessary we will not pay any benefits.

Exceptions

 You do not need precertification in these cases:  

• You are admitted to a hospital outside the United States;
• You have another group health insurance policy that is the primary payor for the hospital stay; or
• 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.

• Non-urgent care claims

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 preauthorization. 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.

• Urgent care claims

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 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 800-821-6136. You may also call OPM’s FEHB 2 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, then call us at 800-821-6136. 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).

• Concurrent care claims

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.  

• The Federal Flexible Spending Account Program – FSAFEDS

• Health Care FSA (HCFSA) – Reimburses you for eligible out-of-pocket health care 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.

• Emergency inpatient admission

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 phone 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 phone the Plan within two business days, penalties may apply - see Warning under Inpatient hospital admission earlier in this Section and If your hospital stay needs to be extended below.

• Maternity care

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 his or her own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.

• NICU cases

Confinements of infants in the neonatal care unit require preauthorization. Your provider needs to call us at 800-821-6136 or visit  www.geha.com. For members residing in Delaware, Florida, Louisiana, Maryland, North Carolina, Oklahoma, Texas, Virginia, Washington DC, West Virginia and Wisconsin call UnitedHealthcare Clinical Services at 877-585-9643.

• If your hospital stay needs to be extended

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. 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.

• Other services that require preauthorization

Some surgeries and procedures, services and equipment require precertification or preauthorization. GEHA has coverage policies for many services and procedures; refer to www.geha.com/coverage-policies for a complete list.

For members residing in the following states, your provider must call UnitedHealthcare Clinical Services at 877-585-9643 for any services listed below, with the exception of those marked with an asterisk: Delaware, Florida, Louisiana, Maryland, North Carolina, Oklahoma, Texas, Virginia, Washington DC, West Virginia and Wisconsin.

For the asterisked (*) services, and for all other members, you or your provider need to call us at 800-821-6136 or visit www.geha.com for preauthorization information:

• ACI (Autologous Cultured Chrondrocytes), also called Genzyme tissue repair (or Carticel) for knee cartilage damage;
• Abdominoplasty/panniculectomy/lipectomy;
• Ablative and surgical treatment of venous insufficiency including sclerotherapy and microphlebectomy;
• Advanced wound therapy provided in an outpatient setting such as skin substitutes, negative pressure wound therapy (wound vac systems), hyperbaric oxygen therapy (HBO);
• *Applied behavioral therapy;
• Back/spine surgeries;
• Bariatric procedures;
• Blepharoplasty or any other type of eyelid surgery or brow lift;
• Botox injections;
• Breast reconstruction except immediate reconstruction for diagnosis of cancer;
• Certain prescription drugs including Total Parenteral Nutrition;
• Chronic dialysis provided at a dialysis unit, outpatient hospital facility or in the home;
• Coma stimulation;
• Durable medical equipment (DME);
• ECT (electroconvulsive therapy);
• Enteral nutrition;
• Epidural injections;
• Experimental/investigational surgery or treatment;
• Facet injections;
• Genetic testing;
• Growth hormone therapy (GHT);
• Gynecomastia treatment-cosmetic (see mammoplasty);
• *High tech outpatient radiology/imaging;
• Home health services provided by a qualified medical social worker (M.S.W.);
• Injectable drugs for arthritis, psoriasis or hepatitis;
• Injectable hematopoietic drugs (drugs for anemia, low white blood count);  
• Inpatient hospital mental health and substance use disorder benefits, inpatient care at residential treatment centers and intensive day treatment;
• Intrathecal pump insertion for pain management (morphine pump, baclofen pump);
• Low-dose computed tomography (LDCT);
• Mammoplasty, reduction (unilateral/bilateral);
• Mastectomy performed prophylactically;
• Morbid obesity surgeries;   
• *Non-surgical outpatient cancer treatment, including chemotherapy and radiation;
• *Organ and tissue transplant procedures;
• Orthognathic surgery (jaw), including TMJ;
• Other selected therapy services including cardiac and pulmonary rehabilitation;
• Prosthetic devices;
• Psychological testing;
• Rhinoplasty and septoplasty;
• Scar revisions;
• Skilled Nursing: Outpatient - Includes Home Skilled Nursing Care, intravenous (IV) therapy, and TPN; 
• Sleep studies (in-lab) attended or performed in a heath care facility (home sleep studies do not require preauthorization);
• Speech generating devices;
• Surgical correction of congenital anomalies;
• Surgical treatment of gender dysphoria;
• Surgical treatment of hyperhidrosis (benefits will not be approved unless alternative therapies such as botox injections or topical aluminum chloride and pharmacotherapy have been unsuccessful);
• Sympathectomy by thoracoscopy or laparoscopy;
• TMS (Transcranial Magnetic Stimulation);
• *Transplants, except cornea (for kidney transplant notification instructions, refer to Section 5(b), page (Applies to printed brochure only), under Organ/Tissue Transplants);
• UPPP Uvulopalatopharyngoplasty;
• *Ventricular assistive device (VAD) including post-hospital device supplies;
• Vision therapy; and
• Other surgeries, as identified by the Plan.

• Radiology/Imaging procedures preauthorization

Radiology preauthorization is the process by which prior to scheduling specific imaging procedures we evaluate the medical necessity of your proposed procedure to ensure the appropriate procedure is being requested for your condition. In most cases your physician will take care of preauthorization. Because you are still responsible for ensuring that we are asked to preauthorize your procedure, you should ask your doctor to contact us. 

The following outpatient radiology/imaging services need to be preauthorized:

• CT - Computerized Axial Tomography;
• MRI - Magnetic Resonance Imaging;
• MRA - Magnetic Resonance Angiography;
• NC - Nuclear Cardiac Imaging Studies; and
• PET - Positron Emission Tomography.

How to preauthorize a radiology/imaging procedure:

For outpatient CT, MRI, MRA, NC and PET studies, you, your representative or your doctor must call eviCore Healthcare before scheduling the procedure. The toll-free number is 866-879-8317. Provide the following information: patient's name, plan identification number, birth date, requested procedure, clinical support for request, name and phone number of ordering provider. Once you have received preauthorization approval, see below for scheduling services. 

After you obtain preauthorization from eviCore Healthcare, you may be contacted for optional assistance in scheduling your radiology/imaging procedure(s).   

You will not be contacted for this service if you have other primary coverage, Medicare A and B primary or Medicare Part B only. 

Warning

You must get preauthorization for certain services. Failure to do so will result in a reduction of our benefits for these procedures by $100 if no one contacts us for preauthorization. If the procedure is not medically necessary, we will not pay any benefits.

Exceptions:

You do not need preauthorization in these cases:

• You have another health insurance policy that is the primary payor, including Medicare Part A and B or Part B only;
• The procedure is performed outside the United States;
• You are an inpatient in a hospital or observation stay; or
• The procedure is performed as an emergency.

• If your treatment needs to be extended

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 disagree with our pre-service claims decision

If you have a pre-service claim and you do not agree with our decision regarding precertification of an inpatient admission or preauthorization 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.

• To reconsider a non-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.

In the case of a pre-service claim and 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 health care provider to give you the care or grant your request for preauthorization 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.

• To reconsider an urgent care claim

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. 

Unless we request additional information, we will notify you of our decision within 72 hours after receipt of your reconsideration request. We will expedite the review process, which allows oral or written requests for appeals and the exchange of information by phone, electronic mail, facsimile, or other expeditious methods.

• To file an appeal with OPM

After we reconsider your pre-service claim, if you do not agree with our decision, you may ask OPM to review it by following Step 3 of the disputed claims process detailed in Section 8 of this brochure.

Overseas Claims

For covered services you receive by physicians and hospitals outside the United States and Puerto Rico, send a completed Overseas Claim Form and the itemized bills to: GEHA, Foreign Claims Department, P.O. Box 21542, Eagan, MN 55121. Obtain Overseas Claim Forms from www.geha.com.

Precertification is not required when procedures are performed or you are admitted to a hospital outside of the United States. However, the procedure/service to be performed, the number of days required to treat your condition, and any other applicable benefit criteria, will be reviewed for benefit eligibility and/or medical necessity.

If you have questions about the processing of overseas claims, contact us at 877-320-9469 or by email at overseas@geha.com. If possible, include a receipt showing the exchange rate on the date the claimed services were performed. Covered providers outside the United States will be paid at the PPO level of benefits, subject to deductible and coinsurance.

When members living abroad are stateside and seeking medical care, contact us at 800-821-6136, or visit www.geha.com to locate an in-network provider. If you utilize an out-of-network provider, out-of-network benefits would apply.

Coinsurance

Coinsurance is the percentage of our allowance that you must pay for your care. Coinsurance doesn’t begin until you meet your deductible. We will base this percentage on either the billed charge or the Plan allowance, whichever is less.

Example: Under the HDHP, you pay 25% of our allowance for non-PPO office visits.

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

Deductible

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. 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.

PPO: 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 $1,500. Under a Self Plus One enrollment or a Self and Family enrollment, the deductible is considered satisfied and benefits are payable for you and other eligible family members when the combined covered expenses applied to the calendar year deductible for your enrollment reach $3,000. Only plan allowance paid for services or supplies from PPO providers counts toward this amount.

Non-PPO: 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 $3,000. Under a Self Plus One enrollment or a Self and Family enrollment, the deductible is considered satisfied and benefits are payable for you and other eligible family members when the combined covered expenses applied to the calendar year deductible for your enrollment reach $6,000. Any of the above expenses for PPO providers also count toward this non-PPO amount. Non-PPO expenses will not accumulate to the PPO deductible.

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 PPO 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 ($1,500 for Self Only and $3,000 for Self and Family and $3,000 Self Plus One) 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 options in this Plan during the year, we will credit the amount of covered expenses already applied toward the deductible of your old option to the deductible of your new option.

If your provider routinely waives (does not require you to pay) your 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 25% coinsurance, the actual charge is $75. We will pay $56.25 (75% of the actual charge of $75).

Waivers

In some instances, a 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 800-821-6136, or write to GEHA, P. O. Box 21542, Eagan, MN 55121.

Differences between our allowance and the bill

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. For more information about out-of-area services, see We have a Preferred Provider Organization (PPO) in Section 1. 

• 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. 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, with HDHP, you pay just 5% of our $100 allowance ($5). Because of the agreement, your PPO physician will not bill you for the $50 difference between our allowance and his/her 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 with HDHP you pay 25% of our $100 allowance ($25). 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 his/her bill.

The following table illustrates the examples of how much you have to pay out-of-pocket, under the HDHP, for services from a PPO physician vs. a non-PPO physician. The table uses our example of a service for which the physician charges $150 and our allowance is $100. The table 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: 95% of our allowance: $95
You owe:5% of our allowance: $5
+Difference up to charge?: no: $0
TOTAL YOU PAY: $5

Non-PPO physician
Physician's charge: $150
Our allowance: We set it at :100
We pay: 75% of our allowance: $75
You owe:25% of our allowance: $25
+Difference up to charge?: Yes: $50
TOTAL YOU PAY: $75

Your catastrophic protection out-of-pocket maximum for deductibles and coinsurance

For HDHP covered medical and surgical services with coinsurance, we pay 100% of our allowable amount for the remainder of the calendar year after out-of-pocket expenses for deductibles and coinsurance exceed:

PPO and Non-PPO

PPO

• The HDHP out-of-pocket maximum is $5,000 for Self Only enrollment, $10,000 when enrollment is Self Plus One or Self and Family when you use PPO providers. Only out-of-pocket expenses from PPO providers count toward those limits.
• An individual under Self Plus One and Self and Family enrollment will never have to satisfy more than what is required for the out-of-pocket maximum under a Self Only enrollment.

Non-PPO

• The HDHP out-of-pocket maximum is $7,000 for Self Only enrollment; $14,000 when enrollment is Self Plus One or Self and Family if you use non-PPO providers. Any of the above expenses for PPO providers also count toward this limit. Non-PPO coinsurance will not accumulate to the PPO maximum. Your eligible out-of-pocket expenses will not exceed this amount whether or not you use PPO Providers.
• An individual under Self Plus One and Self and Family enrollment will never have to satisfy more than what is required for the out-of-pocket maximum under a Self Only enrollment.

Out-of-pocket expenses for PPO and non-PPO benefits are the expenses you pay for covered services.

The following cannot be counted toward catastrophic protection out-of-pocket expenses:

• Expenses you pay for non-covered services;
• Expenses in excess of our allowable amount or maximum benefit limitations;
• Expenses in excess of plan limits for dental and manipulative therapy;
• The cost for non-approved medications and drugs that we exclude;
• Any amounts you pay because benefits have been reduced for non-compliance with our cost containment requirements (see Section 3); and
• The difference between the cost of generic and brand name medication.

Carryover

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.

When Government facilities bill us

Facilities of the Department of Veteran Affairs, the Department of Defense, and the Indian Health Service are entitled to seek reimbursement from us for certain services and supplies they provide to you or a covered family member. They may not seek more than their governing laws allow. You may be responsible to pay for certain services and charges. Contact the government facility directly for more information.

• Preventive care

The Plan covers preventive care services from preferred providers, such as periodic health evaluations (e.g., annual physicals), screening services (e.g., cancer screenings, cardiac screenings, and mammograms), well-child care, child and adult immunizations, and tobacco cessation programs. These services are covered at 100% if you use a network provider and the services are described in Section 5. Preventive care. Preventive care for children is covered at 100%. You do not have to meet the deductible before using these services.

This Plan also provides vision care benefits through EyeMed Vision Care, and provides dental coverage. You do not have to meet the deductible before using these services.

The calendar year deductible does not apply to the following services:

• Supplemental vision care through EyeMed Vision Care;
• Dental benefits (100% of Plan allowance for diagnostic and preventive services twice per person per calendar year).

• Traditional medical coverage

After you have paid the Plan’s deductible, we pay benefits under Traditional medical coverage described in Section 5. The Plan typically pays 95% for in-network and 75% for out-of-network care.

Covered services include:

• Medical services and supplies provided by physicians and other health care professionals;
• Surgical and anesthesia services provided by physicians and other health care professionals;
• Hospital services; other facility or ambulance services;
• Emergency services/accidents;
• Mental health and substance use disorder treatment; and
• Prescription drug benefits (covered at 75% or 60%).

• Savings

Health Savings Accounts or Health Reimbursement Arrangements provide a means to help you pay out-of-pocket expenses (see pages (Applies to printed brochure only) - (Applies to printed brochure only) for more details).

• Health Savings Accounts (HSAs)

By law, HSAs are available to members who are not enrolled in Medicare, cannot be claimed as a dependent on someone else’s tax return, have not received VA (except for veterans with a service-connected disability) and/or Indian Health Service (IHS) benefits within the last three months or do not have other health insurance coverage other than another High Deductible Health Plan. In 2021, for each month you are eligible for an HSA premium pass through, we will contribute $75 per month to your HSA for a Self Only enrollment or $150 per month for a Self and Family enrollment or $150 per month for Self Plus One enrollment. In addition to our monthly contribution, you have the option to make additional tax-free contributions to your HSA, so long as total contributions do not exceed the limit established by law, which is $3,600 for an individual and $7,200 for Self Plus One or Self and Family. See maximum contribution information on pages (Applies to printed brochure only) - (Applies to printed brochure only). You can use funds in your HSA to help pay your health plan deductible. You own your HSA, so the funds can go with you if you change plans or employment.

Federal tax tip: There are tax advantages to fully funding your HSA as quickly as possible. Your HSA contribution payments (not GEHA’s pass-through contributions) are fully deductible on your Federal tax return. By fully funding your HSA early in the year, you have the flexibility of paying qualified medical expenses from tax-free HSA dollars or after tax out-of-pocket dollars. If you don’t deplete your HSA and you allow the contributions and the tax-free interest to accumulate, your HSA grows more quickly for future expenses.

HSA features include:

• Your HSA is administered by FDIC-insured HSA Bank^™.
• Your contributions to the HSA are tax deductible.
• You may establish pre-tax HSA deductions from your paycheck to fund your HSA up to IRS limits using the same method that you use to establish other deductions (i.e., Employee Express, MyPay, etc.).
• Your HSA earns tax-free interest.
• You can make tax-free withdrawals for qualified medical expenses for you, your spouse and dependents (see IRS Publication 502 for a complete list of eligible expenses).
• Your unused HSA funds and interest accumulate from year-to-year.
• It’s portable - the HSA is owned by you and is yours to keep, even when you leave Federal employment or retire.
• When you need it, funds up to the actual HSA balance are available.

Important consideration if you want to participate in a Health Care Flexible Spending Account (HCFSA): If you are enrolled in this HDHP with a Health Savings Account (HSA), and start or become covered by a HCFSA (such as FSAFEDS offers – see Section
3), this HDHP cannot continue to contribute to your HSA. Similarly, you cannot contribute to an HSA if your spouse enrolls in an HCFSA. Instead, when you inform us of your coverage in an HCFSA, we will establish an HRA for you.

• Health Reimbursement Arrangements (HRA)

If you are not eligible for an HSA, for example you are enrolled in Medicare or have another health plan, we will administer and provide an HRA instead. You must notify us that you are ineligible for an HSA. 

In 2021, we will give you an HRA credit of $900 per calendar year for a Self Only enrollment and $1,800 per calendar year for a Self and Family enrollment and $1,800 for Self Plus One enrollment. You can use funds in your HRA to help pay your health plan deductible and/or for certain expenses that don’t count toward the deductible. 

HRA features include:

• For our HDHP option, the HRA is administered by GEHA
• Entire HRA credit (prorated from your effective date to the end of the plan year) is available from your effective date of enrollment
• Tax-free credit can be used to pay for qualified medical expenses for you and any individuals covered by this HDHP
• Unused credits carryover from year-to-year
• HRA credit does not earn interest
• HRA credit is forfeited if you leave Federal employment or switch health insurance plans. Members leaving GEHA mid-year will be expected to return a portion of the annual contribution to GEHA only if they have filed claims against the funds (prorated based on the number of months in the Plan) and will forfeit their remaining HRA account balance at that time.
• An HRA does not affect your ability to participate in an FSAFEDS Health Care Flexible Spending Account (HCFSA). However, you must meet FSAFEDS eligibility requirements. 

• Net deductible after pass through

“Net deductible after pass through” means the remaining deductible amount if you use the GEHA premium pass through contribution to help pay your health plan deductible. By using the premium pass through to pay first dollar costs for qualified medical expenses, your out-of-pocket deductible cost on this plan is substantially reduced.

Annual In-Network Deductible: Self Only $1,500/Self Plus One/Self and Family $3,000
GEHA's HSA/HRA premium pass through contribution: Self Only $900/Self Plus One/Self and Family $1,800
Net deductible after pass through: Self Only $600/Self Plus One/Self and Family $1,200

• Catastrophic protection for out-of-pocket expenses

Your annual maximum for out-of-pocket expenses (deductibles and coinsurance) for covered services is limited to $5,000 per person for Self Only or $10,000 for Self Plus One (not to exceed $5,000 per person) and $10,000 when enrollment is Self and Family enrollment (any combination of family members, not to exceed $5,000 per person) when you use PPO providers. If you use a non-PPO provider the annual maximum for out-of-pocket expenses is $7,000 for Self Only or $14,000 for Self Plus One (not to exceed $7,000 per person) and $14,000 when enrollment is Self and Family (any combination of family members, not to exceed $7,000 per person). However, certain expenses do not count toward your out-of-pocket maximum and you must continue to pay these expenses once you reach your out-of-pocket maximum (such as expenses in excess of the Plan’s allowable amount or benefit maximum). Refer to Section 4, Your catastrophic protection out-of-pocket maximum, and Section 5, Traditional medical coverage subject to the deductible, for more details.

• Health education resources and account management tools

Section 5(h) describes the health education resources and account management tools available to you to help you manage your health care and your health care dollars.  

Administrator

The Plan will provide you the documents required to establish an HSA for you with HSA Bank™ (P. O. Box 939, Sheboygan, WI 53082-0939, toll-free 866-471-5964, www.hsabank.com), this is HDHP's fiduciary (an administrator, trustee or custodian as defined by Federal tax code and approved by IRS).

GEHA is the HRA fiduciary for this Plan. (P.O. Box 168, Independence, MO,  64051-0168, toll-free 800-821-6136, www.geha.com ).

Fees

Set-up and monthly administrative fees are paid by the HDHP.

None

Eligibility

Eligibility for an HSA is determined on the first day of the month coincident to or following your effective date of enrollment.

You must:

• Enroll in this HDHP;
• Have no other health insurance coverage (does not apply to specific injury, accident, disability, dental, vision or long-term care coverage);
• Not be enrolled in Medicare;
• Not be claimed as a dependent on someone else's tax return;
• Not have received VA (except for veterans with a service-connected disability) benefits in the last three months; 
• Not have received Indian Health Services (IHS) benefits in the last three months; and
• Complete and return all banking paperwork.

If you do not set up your health savings account with HSA Bank within 60 days we will enroll you in the HRA.

Eligibility is determined on the first day of the month following your effective date of enrollment and will be prorated for length of enrollment.

You must enroll in this HDHP.

If you enroll in our HDHP and do not qualify for an HSA, we will establish an HRA for you.

If your eligibility changes mid-year, please contact GEHA at 800-821-6136.

Funding

If you are eligible for HSA contributions, a portion of your monthly health plan premium is deposited to your HSA each month. Premium pass through contributions are based on the effective date of your enrollment in the HDHP.

Note: If your effective date in the HDHP is after the 1st of the month, the earliest your HSA will be established is the 1st of the following month. If you are new to this Plan based on an Open Season change, your first premium pass through will be made available no earlier than February as new enrollees and terminations from Open Season are still being received in January. Your last HSA pass through contribution for the current plan year will fund in January of the following plan year as long as you maintain eligibility through the end of the current plan year.

In addition, you may establish pre-tax HSA deductions from your paycheck to fund your HSA up to IRS limits using the same method that you use to establish other deductions (i.e., Employee Express, MyPay, etc).

The entire amount of your HRA will be available to you upon your enrollment. Eligibility for the annual credit will be determined on the last day of the month following your effective date of enrollment and will be prorated for length of enrollment.

Members leaving GEHA mid-year will be expected to return a portion of the annual contribution to GEHA only if they have filed claims against the funds (prorated based on the number of months in the Plan), and will forfeit their remaining HRA account balance at that time.

• Self Only enrollment

For 2021, a monthly premium pass through of $75 will be made by the HDHP directly into your HSA.

For 2021, your HRA annual credit is $900 (prorated for mid-year enrollment).

Members leaving GEHA mid-year will be expected to return a portion of the annual contribution to GEHA only if they have filed claims against the funds (prorated based on the number of months in the Plan), and will forfeit their remaining HRA account balance at that time.

• Self Plus One enrollment

For 2021, a monthly premium pass through of $150 will be made by the HDHP directly into your HSA.

For 2021, your HRA annual credit is $1,800 (prorated for mid-year enrollment).

Members leaving GEHA mid-year will be expected to return a portion of the annual contribution to GEHA only if they have filed claims against the funds (prorated based on the number of months in the Plan), and will forfeit their remaining HRA account balance at that time.

• Self and Family enrollment

For 2021, a monthly premium pass through of $150 will be made by the HDHP directly into your HSA.

For 2021, your HRA annual credit is $1,800 (prorated for mid-year enrollment).

Members leaving GEHA mid-year will be expected to return a portion of the annual contribution to GEHA only if they have filed claims against the funds (prorated based on the number of months in the Plan), and will forfeit their remaining HRA account balance at that time.

Contributions/credits

The maximum that can be contributed to your HSA is an annual combination of HDHP premium pass through and your contribution funds, which when combined, do not exceed the maximum contribution amount set by the IRS of $3,600 for an individual and $7,200 for Self Plus One or Self and Family.

If you enroll during Open Season, you are eligible to fund your account up to the maximum contribution limit set by the IRS. To determine the amount you may contribute, subtract the amount the Plan will contribute to your account for the year from the maximum allowable contribution.

You are eligible to contribute up to the IRS limit for partial year coverage as long as you maintain your HDHP enrollment for 12 months following the last month of the year of your first year of eligibility. To determine the amount you may contribute, take the IRS limit and subtract the amount the Plan will contribute to your account for the year.

If you do not meet the 12 month requirement, the maximum contribution amount is reduced by 1/12 for any month you were ineligible to contribute to an HSA. If you exceed the maximum contribution amount, a portion of your tax reduction is lost and a 10% penalty is imposed. There is an exception for death or disability. Contact HSA Bank™ (P. O. Box 939, Sheboygan, WI 53082-0939, toll free 866-471-5964, www.hsabank.com) for more details.

You may rollover funds you have in other HSAs to this HDHP HSA (rollover funds do not affect your annual maximum contribution under this HDHP).

HSAs earn tax-free interest (does not affect your annual maximum contribution).

Catch-up contribution are discussed on page (Applies to printed brochure only).

The full HRA credit will be available, subject to proration, on the effective date of enrollment. The HRA does not earn interest.

Members leaving GEHA mid-year will be expected to return a portion of the annual contribution to GEHA only if they have filed claims against the funds (prorated based on the number of months in the Plan), and will forfeit their remaining HRA account balance at that time.

• Self Only enrollment

You may make an annual maximum contribution of $2,700.

You cannot contribute to the HRA.

• Self Plus One enrollment

You may make an annual maximum contribution of $5,400.

You cannot contribute to the HRA.

• Self and Family enrollment

You may make an annual maximum contribution of $5,400.

You cannot contribute to the HRA.

Access funds

You can access your HSA by the following methods:

• Debit card
• Withdrawal form
• Checks
• Online banking

For qualified medical expenses covered by your health plan, your provider is automatically reimbursed when claims are submitted through our HDHP plan. For expenses not covered by the HDHP, such as orthodontia, our Health Reimbursement Arrangement Claim Form is located online at www.geha.com or by request to Customer Service at 800-821-6136. This form is used to get reimbursement from your HRA for qualified out-of-pocket medical expenses that are not submitted to GEHA by your doctor, hospital, dentist or pharmacy. It can also be used to request reimbursement for paid Medicare premiums.

Distributions/withdrawals

• Medical

You can pay the out-of-pocket expenses for yourself, your spouse or your dependents (even if they are not covered by the HDHP) from the funds available in your HSA. These distributions are tax-free if used for qualified medical expenses. 

Note: Medical expenses are not allowable if they occur before the first full month your enrollment is effective, and they are not reimbursable from your HSA until the first of the month following the effective date of your enrollment in this HDHP and the date your HSA account is established.

See IRS Publication 502 for a list of eligible medical expenses.

You can pay the out-of-pocket expenses for qualified medical expenses for individuals covered under the HDHP.

Non-reimbursed qualified medical expenses are allowable if they occur after the effective date of your enrollment in this Plan.

See Availability of funds below for information on when funds are available in the HRA.

See IRS Publication 502 for a list of eligible medical expenses. Physician prescribed over-the-counter drugs and Medicare premiums are also reimbursable. Most other types of medical insurance premiums are not reimbursable.

• Non-medical

If you are under age 65, withdrawal of funds for non-medical expenses will create a 20% income tax penalty in addition to any other income taxes you may owe on the withdrawn funds.

When you turn age 65, distributions can be used for any reason without being subject to the 20% penalty, however they will be subject to ordinary income tax.

Not applicable - distributions will not be made for anything other than non-reimbursed qualified medical expenses.

Medicare premiums are reimbursable.

Availability of funds

Funds are not available for withdrawal until all the following steps are completed:

• Your enrollment in this HDHP is effective (effective date is determined by your agency in accordance with the event permitting the enrollment change);
• You must complete and send the HSA application to HSA Bank^TM. You complete the HSA application process either online or via paper forms;
• The fiduciary receives your application, and sends record of the account to GEHA; and
• GEHA contributes funds by the 15th of the month following the month of your effective date.

The entire amount of your HRA will be available to you upon your enrollment in the HDHP.

Portable

You can take this account with you when you change plans, separate or retire.

If you do not enroll in another HDHP, you can no longer contribute to your HSA. See pages (Applies to printed brochure only) and (Applies to printed brochure only) for HSA eligibility.

If you retire and remain in this HDHP, you may continue to use and accumulate credits in your HRA.

If you terminate employment or change health plans, only eligible expenses incurred while covered under the HDHP will be eligible for reimbursement subject to timely filing requirements. Unused funds are forfeited.

Annual rollover

Yes, accumulates without a maximum cap.

Yes, accumulates without a maximum cap.

If you have an HSA

• Contributions

All contributions are aggregated and cannot exceed the maximum contribution amount set by the IRS. You may contribute your own money to your account through payroll deductions, or you may make lump sum contributions at any time, in any amount not to exceed an annual maximum limit. If you contribute, you can claim the amount you contributed for the year as a tax deduction when you file your income taxes. Your own HSA contributions are either tax-deductible or pre-tax (if made by payroll deduction). You receive tax advantages in either case. To determine the amount you may contribute, subtract the amount the Plan will contribute to your account for the year from the maximum contribution amount set by the IRS. You have until April 15^th of the following year to make HSA contributions for the current year.

If you newly enroll in an HDHP during Open Season and your effective date is after January1^st or you otherwise have partial year coverage, you are eligible to fund your account up to the maximum contribution limit set by the IRS as long as you maintain your HDHP enrollment for 12 months following the last month of the year of your first year of eligibility. If you do not meet this requirement, a portion of your tax reduction is lost and a 10% penalty is imposed. There is an exception for death or disability. Contact HSA Bank^™ (P. O. Box 939, Sheboygan, WI 53082-0939, toll free 866-471-5964, www.hsabank.com) for more details.

• Catch-up contributions

If you are age 55 or older, the IRS permits you to make additional “catch-up” contributions to your HSA. The allowable catch-up contribution is $1,000. Contributions must stop once an individual is enrolled in Medicare. Additional details are available on the U.S. Department of Treasury website at www.treasury.gov/resource-center/faqs/Taxes/Pages/Health-Savings-Accounts.aspx.

• If you die

If you have not named a beneficiary and you are married, your HSA becomes your spouse’s; otherwise, your HSA becomes part of your taxable estate.

• Qualified expenses

You can pay for “qualified medical expenses” as defined by IRS Code 213(d). These expenses include, but are not limited to, medical plan deductibles, diagnostic services covered by your plan, long-term care premiums, health insurance premiums if you are receiving Federal unemployment compensation, physician prescribed over-the-counter drugs, LASIK surgery, and some nursing services. 

When you enroll in Medicare, you can use the account to pay Medicare premiums or to purchase health insurance other than a Medigap policy. You may not, however, continue to make contributions to your HSA once you are enrolled in Medicare.

For a detailed list of IRS-allowable expenses, request a copy of IRS Publication 502 by calling 800-829-3676, or visit the IRS website at www.irs.gov and click on “Forms and Instructions.” Note: Although physician prescribed over-the-counter drugs are not listed in the publication, they are reimbursable from your HSA. Also, insurance premiums are reimbursable under limited circumstances.

• Non-qualified expenses

• Tracking your HSA balance

You will receive a periodic statement that shows the “premium pass through”, withdrawals, and interest earned on your account. In addition, you will receive an Explanation of Payment statement when you withdraw money from your HSA.

• Minimum reimbursements from your HSA

You can request reimbursement in any amount. Just like a normal bank account, you cannot reimburse yourself for expenses that are greater than the balance in the account.

If you have an HRA

• Why an HRA is established

If you don’t qualify for an HSA when you enroll in this HDHP, or later become ineligible for an HSA, we will establish an HRA for you. If you are enrolled in Medicare, you are ineligible for an HSA and we will establish an HRA for you. You must tell us if you become ineligible to contribute to an HSA.

• How an HRA differs

Please review the chart on pages 35-39, which details the differences between an HRA and an HSA. The major differences are:

• You cannot make contributions to an HRA;
• Funds in your HRA are forfeited if you leave the HDHP;
• An HRA does not earn interest; and
• HRAs can only pay for qualified medical expenses, such as deductibles and coinsurance expenses, for individuals covered by the HDHP. FEHB law does not permit qualified medical expenses to include services, drugs, or supplies related to abortions; except when the life of the mother would be endangered if the fetus were carried to term, or when the pregnancy is the result of an act of rape or incest.

Precertification

To be eligible to receive full benefits for mental health and substance use disorder treatment, you must follow the authorization process:

• For members residing in Delaware, Florida, Louisiana, Maryland, North Carolina, Oklahoma, Texas, Virginia, Washington DC, West Virginia and Wisconsin, call UnitedHealthcare Clinical Services at 877-585-9643.
• For all other members, you must call Conifer Health Solutions at 800-242-1025 to receive authorization for inpatient care and outpatient intensive day treatment. They will authorize any covered treatment.
• You should call our Care Management Department 800-821-6136 to precertify benefits for psychological testing. Psychological testing claims will be denied if we determine the testing is not medically necessary.

If you do not obtain precertification for inpatient care and outpatient intensive day treatment, we will decide whether the stay was medically necessary. If we determine the stay was medically necessary, we will pay the services less the $500 penalty. If we determine that it was not medically necessary, we will only pay for any covered services that are otherwise payable on an outpatient basis. If you remain in the hospital beyond the days we approved and did not get the additional days precertified, we will pay inpatient benefits for the part of the admission that was medically necessary. See Section 3 for details.

Flexible benefits option

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).

Services for deaf and hearing impaired

TTY service is available at 800-821-4833 for members who are hearing impaired.

High risk pregnancies

GEHA makes various maternity resources available to you or your covered dependent.  Visit www.geha.com/maternity to order your packet on pregnancy and prenatal care.

24-hour Health Advice Line

Call the toll-free GEHA 24-hour Health Advice Line number 888-257-4342 and speak with a registered nurse – any time, 24 hours a day. The nurse can help you understand your symptoms and determine appropriate care for your needs.

The 24-hour Health Advice Line allows you to conveniently manage your symptoms and treatment anywhere you have access to a phone.

Telehealth

Telehealth is available at a reduced cost through MDLIVE. Go to https://members.mdlive.com/geha-callmd/ or call 888-912-1183 to access on demand, affordable, high-quality care for adults and children experiencing non-emergency medical issues, including treatment of minor acute conditions (see Section 10 for definition), dermatology conditions (see Section 10 for definition) and counseling for behavioral health and substance use disorder.

Note: This benefit is available at reduced cost only through the MDLIVE contracted telehealth provider network.

Note: Practitioners must be licensed in the state where the patient is physically located at the time services are rendered.

Health Rewards/Health Assessment   

Members over age 18, in Self Only, Self Plus One and Self and Family enrollments are eligible to take the health risk assessment, which will provide the member with valuable information about health status and steps to consider to improve their health. The GEHA Health Rewards program provides rewards for participation in activities that promote health improvements. The Health Rewards program is limited to two adults, over age 18, in Self Plus One and Self and Family enrollments.

Members can earn health rewards up to a total of $250 for the following activities:

1. Completion of the annual health assessment ($75);
2. Completion of the annual biometric screening provided by GEHA ($75);
3. Completion of wellness portal classes; such as weight management, stress management, smoking cessation; or
4. Participation in a targeted health program (by invitation) (up to $100)

Members will be issued a Health Rewards Savings card, which can be used to purchase eligible medical services and medical care items.

For detailed information about how to access the health risk assessment and incentives that may be available through the Health Rewards program, visit:  www.geha.com/rewards.

Obesity screening and management    

GEHA offers a number of services and tools for weight management.

• BMI calculation through on-line health risk assessment
• Nutrition counseling (see Educational Classes and Programs, Section 5a)
• Behavior change programs with coaching for members who qualify
• Discounts for gym memberships and other services through Connection Fitness
• Bariatric surgery, when medically necessary. Bariatric surgery must be precertified.

Value Added Programs and Services

GEHA offers a number of programs and services to members to assist with special conditions and needs. Members can work with a nurse or health coach to deal with obesity, chronic conditions, cancer while in active treatment, and others. Visit www.geha.com for a list of programs, program criteria, and contact information.

Chronic Condition Management

GEHA offers services and tools for qualifying members to assist with chronic condition management such as:

• Diabetes management
• Weight management
• Hypertension management

Health education resources

Visit our website at www.geha.com for the Health e-Report^® Newsletter. 

Visit www.geha.com/blog for information on:

• General health topics
• Links to health care news
• Cancer and other specific diseases
• Drugs/medication interactions
• Kids health
• Patient safety information
• Helpful website links

Account management tools

If you have an HDHP (with either the HSA or HRA):
- Complete claims payment history is available online through www.geha.com; and
- You will also receive an (EOB) after every claim.

If you have an HSA under the HDHP:

• You will receive a monthly statement from the HSA Bank^™ outlining your HSA account balance and activity for the month; and
• You may also access your HSA account on-line at www.hsabank.com.

If you have an HRA under the HDHP:

• Your HRA account balance will be available on-line through your Member Account at www.geha.com; and
• To request reimbursement from your HRA account for qualified out-of-pocket medical expenses that are not submitted to GEHA by your doctor, hospital, dentist or pharmacy, call GEHA’s Customer Service at 800-821-6136 or go to www.geha.com to obtain our Health Reimbursement Arrangement Claim Form. This form is also used to request reimbursement from your HRA for Medicare premiums.

Consumer choice information

• If you have our HDHP, you may choose any provider. However, you will receive discounts when you see a network provider. You can find network providers online at www.geha.com.
• Pricing information for prescription drugs is available at www.caremark.com.    
• Link to online pharmacy through CVS Caremark at www.caremark.com.
• Educational materials on the topics of HSAs, HRAs and HDHPs are available at      www.geha.com.

Care support

• GEHA has a strong patient safety program. Pharmacy initiatives help ensure that members have fewer health complications related to prescription drugs. Disease management programs help our members with specific health conditions such as heart disease and diabetes. Medical case managers assist patients with high risk pregnancies, durable medical equipment, transplants and other special needs.
• Patient safety information is available online at www.geha.com.

How to claim benefits

To obtain claim forms, claims questions or assistance, or answers about our benefits, contact us at 800-821-6136, or at our website at www.geha.com.

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. Submit claims to the network address on the back of the GEHA ID card, for both in and out-of-network claims.

Submit dental and Medicare primary claims, or out-of-network charges that you have paid in full to: 

GEHA
P.O. Box 21542
Eagan, MN 55121

When you must file a claim - such as 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; itemized bill including valid ADA, CPT, HCPCS (including NDC numbers for all Drug type charges);
• The charge for each service or supply; and
• Provider signature.

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) form you received from any 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 and should include nursing notes.
• If your claim is for rental or purchase of durable medical equipment; private duty nursing; or 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’s name, date, and charge. A copy of the provider’s script must be included with prescription drugs purchased outside the United States.
• We will provide translation and currency conversion services for claims for overseas (foreign) services.

Post-service claims procedures

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.

Keep a record of the medical expenses of all covered family members as deductibles and maximum allowances apply. Save copies of all medical bills, including those you accumulate to satisfy a deductible. In most instances they will serve as evidence of your claim. We will not provide duplicate or year-end statements.

Deadline for filing your claim

Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you received the service. If you could not file on time because of Government administrative operations or legal incapacity, you must submit your claim as soon as reasonably possible. Once we pay benefits, there is a three-year limitation on the re-issuance of uncashed checks.

Overseas claims

For covered services you receive by providers and hospitals outside the United States and Puerto Rico, send a completed Overseas Claim Form and the itemized bills to: GEHA, Foreign Claims Department, P.O. Box 21542, Eagan, MN 55121. Obtain Overseas Claim Forms from www.geha.com. 

Precertification is not required when procedures are performed or you are admitted to a hospital outside of the United States. However, the procedure/service to be performed, the number of days required to treat your condition, and any other applicable benefit criteria, will be reviewed for benefit eligibility and/or medical necessity.

If you have questions about the processing of overseas claims, contact us at 877-320-9469 or by email overseas@geha.com. If possible, include a receipt showing the exchange rate on the date the claimed services were performed. Covered providers outside the United States will be paid at the PPO level of benefits, subject to deductible and coinsurance.

When members living abroad are stateside and seeking medical care, contact us at 800-821-6136, or visit www.geha.com to locate an in-network provider. If you utilize an out-of-network provider, out-of-network benefits would apply.

When we need more information

Please reply promptly when we ask for additional information. We may delay processing or deny benefits for your claim if you do not respond. Our deadline for responding to your claim is stayed while we await all of the additional information needed to process your claim.

Authorized Representative

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 health care 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.

Notice Requirements

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 phone 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 health care 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.

1

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 request to us at: GEHA, P.O. Box 21542, Eagan, MN 55121; 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) forms.

e) Include your email address (optional for member), 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.

2

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.

3

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 initial 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, FEHB 2, 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;
• Your daytime phone number and the best time to call; and
• 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 health care 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.

4

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 file a lawsuit. If you decide to sue, 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 preauthorization. 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.

When you have other health coverage or auto insurance

You must tell us if you or a covered family member has coverage under any other health plan or has automobile insurance that pays health care 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 more information on NAIC rules regarding the coordinating of benefits, visit our website at www.geha.com/cob.

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

In certain circumstances when we are secondary, we will also take advantage of any provider discount arrangements your primary plan may have. For medical and dental services, we will coordinate benefits to the allowable expense of your primary plan.

• Refer to Section 5(f) under Coordinating with other drug coverage when you have other primary prescription coverage.

If your primary payor requires preauthorization or requires you use designated facilities or provider for benefits to be approved, it is your responsibility to comply with these requirements. In addition you must file the claim to your primary payor within the required time period. If you fail to comply with any of these requirements and benefits are denied by the primary payor, we will pay secondary benefits based on an estimate of what the primary carrier would have paid if you followed their requirements.

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

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.

• TRICARE and CHAMPVA

TRICARE is the health care 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.

• Workers’ Compensation

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.

Once OWCP or similar agency pays its maximum benefits for your treatment, we will cover your care.

• Medicaid

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.

When other Government agencies are responsible for your care

We do not cover services and supplies when a local, state, or federal government agency directly or indirectly pays for them.

When others are responsible for injuries

If GEHA pays benefits for an illness or injury for which you accrue a right of action, are entitled to compensation, or receive a settlement, judgment, or recovery from another party, you must agree to the provisions below. All GEHA benefit payments in these circumstances are a condition of and a limitation on the nature, provision, or extent of coverage or benefits under the Plan, and remain subject to all of our contractual benefit limitations, exclusions, and maximums. By accepting these conditional benefits, you agree to the following:

• You or your representative must contact GEHA’s Subrogation Vendor, The Rawlings Company, LLC, at 855-967-6609 as soon as possible after the event(s) that resulted in the illness or injury, and provide all requested information, including prompt disclosure of the terms of all settlements, judgments, or other recoveries. You must sign any releases GEHA requires to obtain information about any claim(s) for compensation from other sources you may have.
• You must include all benefits paid by GEHA in any claim for compensation you or your representative assert against any tortfeasor, insurer, or other party for the injury or illness, and assign all proceeds recovered from any party, including your own and/or other insurance, to GEHA for up to the amount of the benefits paid.
• When benefits are payable under the Plan in relation to the illness or injury, GEHA may, at its option:

Enforce its right of subrogation, that is, take over your right to receive payments from other parties. You will transfer to GEHA any rights you or your representative may have to take legal action arising from the illness or injury, and to recover any sums paid on your behalf as a result of that action; or

Enforce its right of reimbursement, that is, recover any sums paid on your behalf from any payment(s) you or your representative obtain from other parties. The right of reimbursement is cumulative with and not exclusive of the right of subrogation.

You must cooperate in doing what is reasonably necessary to assist us, and you must not take any action that may prejudice these rights of recovery. It is your duty to notify the plan within 30 days of the date when notice is given to any party, including an insurance company or attorney, of your intention to pursue or investigate a claim to recover damages or obtain compensation due to your injury, illness or condition. You and your agents or representatives shall provide all information requested by the plan or its representatives. You shall do nothing to prejudice your FEHB plan’s subrogation or recovery interest or to prejudice the plan’s ability to enforce the terms of this provision. This includes, but is not limited to, refraining from making any settlement or recovery that attempts to reduce or exclude the full cost of all benefits provided by the plan.

• To reimburse GEHA on a first priority basis (i.e., before any other party) in full, up to the amount of benefits paid, out of any and all settlements, judgments, or other recoveries that you or your representative obtain, from any source and no matter how characterized, designated, or apportioned (for example, as “pain and suffering only”). GEHA enforces this right of reimbursement by asserting a lien against any and all recoveries obtained, including, but not limited to, first party Medpay, Personal Injury Protection, No-Fault coverage, Third-Party liability coverage, Uninsured and Underinsured coverage, personal liability umbrella coverage, and a workers' compensation program or insurance policy. GEHA’s lien consists of the total benefits paid to diagnose or treat the illness or injury. GEHA’s lien applies first, regardless of the “make whole” and “common fund” doctrines. Your plan is not required to participate in or pay court costs or attorney fees to any attorney hired by you to pursue your damage claims.

GEHA’s lien extends to all expenses incurred prior to the settlement or judgment date, even if those expenses were not submitted to GEHA for payment at the time you reimbursed GEHA. The lien remains your obligation until it is satisfied in full. Failure to refund GEHA or cooperate with our recovery efforts may result in an overpayment that can be collected from you.

The provisions of this section apply to all current or former plan participants and also to the parents, guardian, or other representative of a dependent child who incurs claims and is or has been covered by the plan. The plan’s right to recover (whether by subrogation or reimbursement) shall apply to the personal representative of your estate, heirs or beneficiaries, administrators, legal representatives, successors, assignees, minors, and incompetent or disabled persons. “You” or “your” includes anyone on whose behalf the plan pays benefits. No adult covered person hereunder may assign any rights that it may have to recover medical expenses from any tortfeasor or other person or entity to any minor child or children of said adult covered person without the prior express written consent of the plan.

When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP)

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 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.

Clinical trials

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. These costs are covered by this Plan.
• 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. This Plan does not cover these costs.
• 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.

When you have Medicare

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

• The Original Medicare Plan (Part A or Part B)

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.

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 800-821-6136 or see our website at www.geha.com.

We do NOT waive deductibles or coinsurance for Medicare members enrolled in the High Deductible Health Plan.

If you obtain services from a non-Medicare provider, we will limit our payment to the coinsurance amount we would have paid after Original Medicare’s payment based on our Plan allowable and the type of service you receive.

Please review the following table that illustrates your cost share if you are enrolled in Medicare Part B. We do not waive deductibles or coinsurance for Medicare members enrolled in the High Deductible Health Plan.

Member Cost without Medicare (In-Network) 
Deductible: $1,500 Self Only/$3,000 Self Plus One or Self and Family
Catastrophic Protection Out-of-Pocket Maximum: High: $5,000 Self Only/ $10,000 Self Plus One or Self and Family;
Part B Premium Reimbursement Offered:  N/A
Primary Care Physician: 5% of Plan allowance
Specialist:  5% of Plan allowance
Inpatient Hospital: 5% of Plan allowance
Outpatient Hospital: High: 5% of Plan allowance
Rx  Retail (30-day supply): Generic: 25% of Plan allowance, Preferred: 25% of Plan allowance, Non-Preferred: 40% of Plan allowance; 
Specialty (30-day supply) Generic/Preferred: 25% of Plan allowance,  Non-Preferred: 40% of Plan allowance 

Member Cost with Medicare Part B primary (In-Network) 
Deductible: $1,500 Self Only/$3,000 Self Plus One or Self and Family
Catastrophic Protection Out-of-Pocket Maximum: High: $5,000 Self Only/ $10,000 Self Plus One or Self and Family;
Part B Premium Reimbursement Offered:  Up to $900
Primary Care Physician: 5% of Plan allowance
Specialist:  5% of Plan allowance
Inpatient Hospital: 5% of Plan allowance
Outpatient Hospital: High: 5% of Plan allowance
Rx  Retail (30-day supply): Generic/Preferred: 25% of Plan allowance, Non-Preferred: 40% of Plan allowance; 
Specialty (30-day supply) Generic/Preferred: 25% of Plan allowance,  Non-Preferred: 40% of Plan allowance 

You can find more information about how our Plan coordinates benefits with Medicare as outlined in our Medicare + GEHA booklet at www.geha.com/medicare.

• Tell us about your Medicare coverage

You must tell us if you or a covered family member has Medicare coverage, and let us obtain information about services denied or paid under Medicare if we ask. You must also tell us about other coverage you or your covered family members may have, as this coverage may affect the primary/secondary status of this Plan and Medicare.

• Private contract with your physician

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. Regardless of whether the physician requires you to sign an agreement, we will still limit our payment to the coinsurance amount we would have paid after Original Medicare’s payment based on our Plan allowable and the type of service you receive. You may be responsible for paying the difference between the billed amount and the amount we paid.

• Medicare Advantage (Part C)

If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage plan. These are private health care 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 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). However, we will not waive any of our 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 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.

• Medicare prescription drug coverage
  (Part D)

When we are the primary payor, we process the claim first. If you enroll in Medicare Part D and we are the secondary payor, we will review claims for your prescription drug costs that are not covered by Medicare Part D and consider them for payment under the FEHB plan.

When you have the Original Medicare Plan (Part A, Part B, or both)

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.

Although your physician accepts Medicare assignment, we do not waive your deductibles and coinsurance for covered charges.

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.

An injury caused by an external force or element such as a blow or fall that requires immediate medical attention. Also included are animal bites, poisonings, and dental care required to repair injuries to sound natural teeth as a result of an accidental injury, not from biting or chewing.

Calendar year deductible

There is a PPO deductible and a non-PPO deductible for the entire Plan year for covered services - medical, prescription, inpatient, outpatient, mental health and manipulative therapy - you must incur for almost all covered services and supplies before we start paying benefits.

Catastrophic limit

For those covered services with coinsurance, we pay 100% of our allowable amount for the remainder of the calendar year after your out-of-pocket expenses for deductibles and coinsurance exceed $5,000 for Self Only coverage or $10,000 for Self Plus One and Self and Family coverage when you use PPO providers. And if you use a non-PPO provider, the annual maximum for out-of-pocket expenses is $7,000 for Self Only or $14,000 for Self Plus One and Self and Family coverage.

Clinical trials cost categories

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. These costs are covered by this Plan.
• 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. This Plan does not cover these costs.
• 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 are generally covered by the clinical trials. This Plan does not cover these costs.

Coinsurance

See Section 4 page (Applies to printed brochure only). 

Compound medications

A compound medication includes more than one ingredient and is custom made by a pharmacist according to your doctor's instructions. Compound prescriptions must contain a Federal legend drug and the ingredients must be covered by the GEHA benefit. 

Cost-sharing

See Section 4 page (Applies to printed brochure only).

Custodial care

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, exercise, and dressing;
• Homemaking, such as preparing meals or special diets;
• Moving the patient;
• Acting as companion or sitter;
• Supervising medication that can usually be self-administered; and
• 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.

The Carrier determines which services are custodial care. (Custodial care that lasts 90 days or more is sometimes known as long-term care.)

Deductible

See Section 4 page (Applies to printed brochure only).

Dermatology conditions (telehealth)

Under the telehealth benefit, dermatologic conditions seen and treated include but are not limited to acne, rashes, eczema, suspicious spots/moles, warts and other abnormal bumps, rosacea, inflamed or enlarged hair follicles, psoriasis, cold sore, alopecia, insect bites.

Equipment and supplies that:

• Are prescribed by your attending doctor;
• Are medically necessary;
• Are primarily and customarily used only for a medical purpose;
• Are generally useful only to a person with an illness or injury;
• Are designed for prolonged use; or
• Serve a specific therapeutic purpose in the treatment of an illness or injury.

The date the benefits described in this brochure are effective:

• January 1 for continuing enrollments and for all annuitant enrollments;
• The first day of the first full pay period of the new year for enrollees who change plans or options or elect FEHB coverage during the open season for the first time; and
• For new enrollees during the calendar year, but not during the open season, the effective date of enrollment as determined by the employing office or retirement system.

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 protocol(s) 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 of appropriate Government publications such as those of the National Institute of Health, National Cancer Institute, Agency for Health Care Policy and Research, Food and Drug Administration, and National Library of Medicine. Independent evaluation and opinion by Board Certified Physicians who are professors, associate professors, or assistant professors of medicine at recognized United States Medical Schools may be obtained for their expertise in subspecialty areas.

Health care coverage that a member or covered dependent is eligible for because of employment by, membership in, or connection with, a particular organization or group that provides payment for hospital, medical, dental or other health care services or supplies, including extension of any of these benefits through COBRA.

Health Savings Account (HSA)

A tax-free account with monthly contributions made by us which earn interest for you to accumulate funds to help cover the deductible and other medical out-of-pocket expenses that roll over from year to year when not used for medical expenses. You have the option to make additional contributions to your account up to the maximum allowed by law.

The condition of an individual who is unable to conceive or produce conception during a period of one year.

Inpatient care

Inpatient care is care rendered to a person who has been admitted to a hospital for bed occupancy for purposes of receiving inpatient hospital services. Generally, a patient is considered an inpatient if formally admitted as an inpatient with the expectation that he or she will remain at least overnight and occupy a bed even if it later develops that the patient can be safely discharged or transferred to another hospital and not actually use a hospital bed overnight. This Plan uses Milliman Care Guidelines to evaluate the appropriateness of observation services. See Section 3, How you get care, Covered facilities, for the definition of an Acute Inpatient and Residential Treatment Center.

Medical necessity

Services, drugs, supplies or equipment provided by a hospital or covered provider of the health care services that the Plan determines:

• Are appropriate to diagnose or treat the patient’s condition, illness or injury;
• Are consistent with generally accepted standards of medical practice in the United States.
  • Generally accepted standards of medical practice are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, national physician specialty society recommendations and the views of medical practitioners practicing in relevant clinical areas, and any other relevant factors.
• 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; or
• 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.

Mental health/substance use disorder

Conditions and diseases listed in the most recent edition of the International Classification of Diseases (ICD) as psychoses, neurotic disorders, or personality disorders; other nonpsychotic mental disorders listed in the ICD, to be determined by the Plan; or disorders listed in the ICD requiring treatment for misuse or dependence upon substances such as alcohol, narcotics, or hallucinogens. Precertification is required for all of the following services and must be provided by a covered facility or covered provider as defined in section 3: How you get care.

Inpatient Mental Health:

• Acute Care Hospital: See page (Applies to printed brochure only) under Covered Facilities.
• Residential Treatment Center (RTC): See page (Applies to printed brochure only) under Covered Facilities.

Intensive Day Treatment:

• Partial Hospital Program (PHP): An intensive facility based outpatient treatment program for mental health or substance use disorder conditions. The facility providing the service must meet GEHA’s definition of a covered provider in section 3. Sessions typically are 6-8 hours/day, 5 days per week. Time frames and frequency will vary based on upon diagnosis and severity of illness.
• Intensive Outpatient Treatment (IOP): A comprehensive, structured outpatient treatment program that includes extended periods of individual or group therapy sessions designed to assist members with mental health and/or substance use disorders. It is an intermediate level of care between traditional outpatient therapy and partial hospitalization, delivered in an outpatient facility or outpatient professional office setting. If delivered in an outpatient facility, the facility must meet GEHA’s definition of a covered facility in Section 3. Sessions typically do not exceed 3-4 hours/day, 3-5 days per week. Time frames and frequency will vary based upon diagnosis and severity of illness. If performed in a professional office setting the provider must meet GEHA’s definition of a covered provider in Section 3.

Minor acute conditions

Common, non-emergent conditions. Examples of common conditions include sinus problems, rashes, allergies, cold and flu symptoms, etc.

Observation care

Observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short-term treatment, assessment, and reassessment, that are furnished while a decision is being made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital. Observation services are commonly ordered for patients who present to the emergency department and who then require a significant period of treatment or monitoring in order to make a decision concerning their admission or discharge. This Plan uses Milliman Care Guidelines to evaluate the appropriateness of observation services.

The Plan provides outpatient hospital benefits for observation care. If you are in the hospital for more than a few hours, confirm with your physician whether your stay is inpatient or outpatient so that you are aware of how your hospital claim will be processed.

Plan allowance

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 Plan allowance as follows: 

PPO providers: Our PPO allowances are negotiated with each provider who participates in the network. PPO allowances may be based on a standard reduction or on a negotiated fee schedule. For these allowances, the PPO provider has agreed to accept the negotiated reduction and you are not responsible for this discounted amount. In these instances, the benefit paid plus your coinsurance equals payment in full.

Non-PPO providers: To determine our non-PPO Plan allowance, we must first be provided an itemized bill that includes your diagnosis, the services or supplies you received, and the provider’s charge for each, using the same types of standard codes, descriptions and other information required for processing by public health care plans like Medicare. If we are not provided the itemization of the services or supplies you received, we will assume they were equivalent to the level and extent of services and supplies typically provided by the providers or facilities most commonly used to treat other Plan members with the same principal diagnosis as yours. We will base these equivalent services on claims submitted to the Plan by providers in the same geographic region or a combination of similar geographic regions across the United States.

Based on the itemization of services or supplies you received, we will determine the amount of the maximum non-PPO Plan allowance by applying the following rules, in order:

 1. We consult standard industry guides, such as national databases of prevailing health 
     care charges from FAIR Health or another identified data source, that are available for 
     our use in a given state or geographic area. After the data supplier removes outliers 
     from the claim data they collect, they group the remaining data by percentiles. We use 
     the 70th percentile. This means that out of every 100 reports remaining after outliers 
     were removed, 30 charges billed may be more, but 70 charges will be the allowed 
     amount or less.

 2. For services or supplies obtained in a state or geographic area where the above data 
     source is unavailable for our use, and also for dialysis centers and outpatient dialysis 
     performed at a hospital our non-PPO Plan allowance is two times the Medicare 
     participating provider allowance for the service or supply in the geographic area in 
     which it was performed or obtained. This Medicare-based allowance is not used for 
     those services where Medicare sets a fixed national payment amount that does not 
     vary geographically (such as blood draws). Medicare fee schedule information for 
     physician services may be obtained at www.cms.hhs.gov/PFSlookup.

Note: Labs drawn during the week of dialysis treatments and drugs provided on the day of dialysis are part of the bundled dialysis payment.

 3. Some Plan allowances may be submitted to medical consultants who recommend
     allowances based on standard industry relative value guidelines. For services
     or supplies for which Medicare does not provide an allowance amount, we
     may use the current fee schedule used by the Federal Office of Workers
     Compensation (OWCP). OWCP fee schedule information may be obtained
     at www.dol.gov/OWCP/regs/feeschedule/fee.htm. For services or supplies
     that do not have a value currently established by public health care plans such as
     Medicare or Medicaid, or for implantable devices and surgical hardware, we may
     use medical consultants to determine an appropriate allowance. We may also
     conduct independent studies to determine the usual cost of a service or supply
     in a geographic area, or to establish allowances for services or supplies
     provided outside the United States.

Non-PPO Plan allowance amounts determined according to these guidelines include, but are not limited to, hospitals, ambulance, ambulatory surgery centers, dialysis centers, surgery, doctor’s services, physical therapy, occupational therapy, speech therapy, lab testing and X-ray expenses, implantable devices and surgical hardware and diagnostic and preventive dental services. For more information about the source of the data we are currently using you may call us at 800-821-6136.

Plan allowance for prescription drugs is determined using Average Wholesale Price or other industry-standard reference price data.

Charges for some Plan allowances are stated in this brochure. These include limited benefits such as chiropractic care and routine dental care.

If we negotiate a reduced fee amount on an individual claim for services or supplies which is lower than the Plan allowance, covered benefits will be limited to the negotiated amount. Your coinsurance will be based on the reduced fee amount. If you choose to use a provider other than the one we negotiated a reduction with, you will be responsible for the difference in these amounts.

To estimate our maximum Plan allowance for a non-PPO provider before you receive services from them, call us at 800-821-6136.

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

Post-service claims

Any claims that are not pre-service claims. In other words, post-service claims are those claims where treatment has been performed and the claims have been sent to us in order to apply for benefits.

Pre-service claims

Those claims 1) that require precertification or preauthorization and 2) where failure to obtain precertification or preauthorization results in a reduction of benefits.

Preauthorization

A decision made by your health plan that a health care service, treatment plan, drug, surgery, or durable medical equipment is medically necessary after review of medical information. Sometimes called prior approval.

Precertification