• No pre-existing condition limitation

• Minimum essential coverage

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

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
• Information on and links to other electronic enrollment systems

Also, your employing or retirement office can answer your questions, and give you brochures for other plans and other materials you need to make an informed decision about your FEHB coverage.  These materials tell you:

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

We 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 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-event.  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 in the chart below. A Self Plus One enrollment covers you and your spouse, or one other eligible family member as described in the chart below.

Natural children, adopted children, and stepchildren
Coverage: Natural children, adopted children, and stepchildren are covered until their 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 for Self and Family coverage in a health plan that provides full benefits in the area where your children live or provide documentation to your employing office that you have obtained other health benefits coverage for your children.  If you do not do so, your employing office will enroll you involuntarily as follows:

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

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

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

• 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 an 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 to 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 at 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 Patient Protection and 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 FEHB Program coverage.

• Converting to individual Coverage

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

Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, a waiting period will not be imposed and your coverage will not be limited due to pre-existing conditions.  When you contact us, we will assist you in obtaining information about health benefits coverage inside or outside the Affordable Care Act's Health Insurance Marketplace in your state.  For assistance in finding coverage, please contact us at 800-638-6589 or 301-984-1440 (for TTY, use 301-984-4155) or visit our website at www.SambaPlans.com.

• 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.

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 800-638-6589 or 301-984-1440 (for TTY, use 301-984-4155) or write to us at SAMBA, 11301 Old Georgetown Road, Rockville, MD 20852-2800.  You may also request replacement cards through our website: www.SambaPlans.com.

Where you get covered care

You can get care from any "covered provider" or "covered facility."  How much we pay – and you pay – depends on the type of covered provider or facility you use and who bills for the covered services.  If you use our preferred providers, you will pay less.

Covered providers

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

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

We consider the following to be covered providers  when they perform services within the scope of their license or certification:

• doctor of medicine (M.D.)
• doctor of osteopathy (D.O.)
• doctor of podiatry (D.P.M.)
• dentist (D.D.S., D.M.D.)
• chiropractor
• licensed registered physical therapist
• licensed occupational therapist
• licensed speech therapist
• qualified clinical psychologist
• clinical social worker
• optometrist
• audiologist
• respiratory therapist
• physician's assistant
• nurse midwife
• nurse practitioner/clinical specialist
• nursing school-administered clinic
• certified registered nurse anesthetist (C.R.N.A.) 
• licensed acupuncturist (LAC)
• licensed naturopathic doctor (ND) 

Covered facilities

Covered facilities include:

• Ambulatory surgical center —
  1. 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 a facility used as an office or clinic for the private practice of a doctor or other professional.
  2. In the State of California, ambulatory surgical facilities 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 JCAHO (Joint Commission on Accreditation of Healthcare Organizations).
• Birthing center — a licensed or certified facility approved by the Plan that provides services for nurse midwifery and related maternity services.  
• Hospital —

1. An institution that is accredited under the hospital accreditation program of the Joint Commission on Accreditation of Healthcare Organizations, or
2. Any other institution that is operated pursuant to law, under the supervision of a staff of doctors and with 24-hour-a-day nursing service by a registered graduate nurse (R.N.) or a licensed practical nurse (L.P.N.), and primarily engaged in providing acute inpatient care and treatment of sick and injured persons through medical, diagnostic and major surgical facilities, all of which must be provided on its premises or under its control.

In no event shall the term "hospital" include a skilled nursing facility, a convalescent nursing home, 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 operated as a school or residential treatment facility (except as listed in Section 5(e). Mental health and substance misuse disorder benefits).

• Residential Treatment Center — 

1. Is accredited by nationally recognized organizations.
2. Is licensed by the state, district or territory to provide residential treatment for medical conditions, mental health conditions and/or substance use disorders.
3. An accredited health care facility (excluding hospitals, skilled nursing facilities, group homes, halfway houses, and similar types of facilities) that provides 24 hour residential evaluation, treatment, and comprehensive specialized services relating to the individual's medical, physical, mental health, and/or substance use therapy needs.

• Rehabilitation facility — an institution specifically engaged in the rehabilitation of persons suffering from alcoholism or drug addiction which meets all of these requirements:

1. It is operated pursuant to law.
2. It mainly provides services for persons receiving treatment for alcoholism or drug addiction.  The services are provided for a fee from its patients, and include both: (a) room and board; and (b) 24-hour-a-day nursing service.
3. It provides the services under the full-time supervision of a doctor or registered graduate nurse (R.N.).
4. It keeps adequate patient records which include: (a) the course of treatment; and (b) the person’s progress; and (c) discharge summary; and (d) follow-up programs.

• Skilled nursing facility — an institution or that part of an institution that provides skilled nursing care 24 hours a day and is classified as a skilled nursing care facility under Medicare. 
• Managed In-Network providers — The Plan may approve coverage of providers who are not currently shown as Covered providers, to provide mental health/substance use disorder treatment under the managed In-Network benefit.  Coverage of these providers is limited to circumstances where the Plan has approved the treatment plan.

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 specialist based on the above circumstances, you can continue to see your specialist and your PPO benefits 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 800-638-6589 or 301-984-1440 (for TTY, use 301-984-4155).  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 Program in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply.  In such cases, the hospitalized family member’s benefits under the new plan begin on the effective date of enrollment.

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, prior approval or a referral and (2) will result in a reduction of benefits if you do not obtain precertification, prior approval or a referral.

"You must get prior approval for certain services.  Failure to do so will result in a minimum $500 penalty for inpatient hospital admissions or 20% penalty for all other services."

Inpatient hospital admission

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.

Warning:

We will reduce our benefits for the inpatient hospital 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.

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.
• 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.

Other services

Certain services require prior authorization from us.  You must obtain prior authorization for:

• Certain drugs; see Section 5(f) on pages 70 and 72.  Contact Express Scripts at 855-315-8527 for additional information and prior authorization.
• Select drugs that are excluded from the Plan's prescription drug formulary (visit
  www.SambaPlans.com/health-benefit-plan/ for a list of these drugs).  Prior authorization for medical necessity is required for these excluded drugs.  Contact Express Scripts at 855-315-8527.  See Section 5(f). Prescription drug benefits for additional information.
• Surgical treatment of morbid obesity (bariatric surgery).  Contact Cigna/CareAllies at 800-887-9735.
• Organ/tissue transplants.  The prior authorization process for organ/tissue transplants is more extensive than the normal authorization process.  Before your initial evaluation as a potential candidate for a transplant procedure, you or your doctor must contact the CareAllies Cigna LIFESOURCE Transplant Unit at 800-668-9682 to initiate the pretransplant evaluation.  See Section 5(b) on page 57.
• Intensive outpatient program treatment, partial hospitalization, and electroconvulsive therapy for mental health or substance use disorder treatment.  Contact Cigna/CareAllies at 800-887-9735.
• Services for genetic testing.  Call SAMBA at 800-638-6589 or 301-984-1440 (for TTY, use 301-984-4155).
• Certain outpatient procedures, including services such as: skin removal or enhancement; treatment of varicose veins; and eye, ear, nose and throat procedures.  Contact Cigna/CareAllies at 800-887-9735.
• Unlisted outpatient procedures.  Contact Cigna/CareAllies at 800-887-9735.
• Certain musculoskeletal procedures, such as orthopedic surgeries and injections.  Contact Cigna/ CareAllies at 800-887-9735.
• Home infusion therapy.  Contact Cigna/CareAllies at 800-887-9735.
• Home nursing care.  Contact Cigna/CareAllies at 800-887-9735.
• Speech therapy.  Contact Cigna/CareAllies at 800-887-9735.
• Outpatient spinal procedures.  Call Cigna/CareAllies at 800-887-9735.
• Gender reassignment surgery to treat gender dysphoria supported by a qualified mental health professional.  You must obtain prior authorization for the surgery even if the proposed treatment is outside of the 50 United States.

You, your representative, your doctor or facility must call Cigna/CareAllies at 800-887-9735 prior to services being rendered.  See Section 5(b) on page 50.

Warning:

We will reduce our Plan allowance by 20% if no one contacts us for prior authorization for the listed "Other services."  In addition, if the services are not medically necessary, we will not pay any benefits.

Exceptions:

You do not need precertification, prior authorization, or prior approval in these cases:

• If you have other group health insurance, including Medicare, that is the primary payer.
• The procedure is performed outside the United States, except as noted above.

Radiology/Imaging procedures

The following outpatient radiology/imaging services require precertification.

• CT/CAT scan – Computed Tomography/Computerized Axial Tomography
• MRA – Magnetic Resonance Angiography
• MRI – Magnetic Resonance Imaging
• NC – Nuclear Cardiology Studies
• PET – Positron Emission Tomography

For these outpatient procedures, you, your representative, your doctor or facility must call Cigna/CareAllies at 800-887-9735 before scheduling the procedure.  We will reduce our Plan allowance for these procedures by 20% if no one contacts us for precertification.  If the procedure is not medically necessary, we will not pay any benefits.  Refer to page 30 for additional information.

Exceptions:

You do not need precertification, prior authorization, or prior approval in these cases:

• If you have other group health insurance, including Medicare, that is the primary payer.
• The procedure is performed outside the United States.
• You are an inpatient in a hospital.

Applied Behavior Analysis (ABA) therapy

Applied Behavior Analysis (ABA) therapy services for children up to age 18 diagnosed with autism spectrum disorder requires prior authorization.

You, your representative, your doctor or facility must call Cigna/CareAllies at 800-887-9735 prior to services being rendered.

Warning:

If prior authorization is not obtained, no benefits will be payable and claims for these services will be denied.

First, you, your representative, your physician, or your hospital must call Cigna/CareAllies at 800-887-9735 before admission or services requiring prior authorization are rendered.

Next, provide the following information:

• enrollee’s name and Plan identification number;
• patient’s name, birth date, identification number and phone number;
• reason for hospitalization, proposed treatment, or surgery;
• name and phone number of admitting physician;
• name of hospital or facility; and
• number of days requested for hospital stay

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 prior authorization.  We will make our decision within 15 days of receipt of the pre-service claim.

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

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

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 800-638-6589 or 301-984-1440 (for TTY, use 301-984-4155).  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, call us at 800-638-6589 or 301-984-1440 (for TTY, use 301-984-4155).  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 telephone us within two business days following the day of the emergency admission, even if you have been discharged from the hospital.  If you do not telephone the Plan within two business days, penalties may apply — see Warning under Inpatient hospital admissions earlier in this Section and If your hospital stay needs to be extended on page 20.

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 you, your representative, your physician, or the hospital must contact us for precertification of additional days.  Further, if your baby stays after you are discharged, you, your representative, 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.

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.

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 claim decision

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

If you have already received the service, supply, or treatment, then you have a post-service claim and must to 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 prior approval for a service, drug, or supply; or
2. Ask you or your provider for more information.
   
   

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

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

3. Write to you and maintain our denial.

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.

Copayment

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

Example: When you see your PPO primary care physician you pay a copayment of $15 per visit under the High Option or $20 per visit under the Standard Option.

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

Other separate copayments include, but are not limited to:

• High Option inpatient hospital confinement; PPO: $200 per confinement; Non-PPO: $300 per confinement
• Standard Option inpatient hospital confinement; PPO: $200 per confinement; Non-PPO:  $400 per confinement

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.  Copayments and coinsurance amounts do not count toward any deductible.  When a covered service or supply is subject to a deductible, only the Plan allowance for the service or supply counts toward the deductible.  Covered expenses are applied to the deductible in the order in which they are processed, which may differ from when services were actually rendered.

• The High Option PPO and Non-PPO calendar year deductibles are as follows:  
• PPO: $300 per person, limited to $600 for a Self Plus One or a Self and Family enrollment.  The PPO deductible applies only to services received from PPO providers or when the Plan pays PPO benefits.  
• Non-PPO: $300 per person, limited to $600 for a Self Plus One or a Self and Family enrollment.  The Non-PPO deductible applies only to services received from Non-PPO providers.

The calendar year deductible will not exceed the per person limit for any covered individual.  Under a Self and Family enrollment, the deductible is satisfied for all family members when the combined covered expenses applied to the calendar year deductible for family members reach $600.

• The Standard Option PPO and Non-PPO calendar year deductibles are as follows:  
  • PPO: $350 per person, limited to $700 for a Self Plus One or $900 for a Self and Family enrollment.  The PPO deductible applies only to services received from PPO providers or when the Plan pays PPO benefits.  
  • Non-PPO: $350 per person, limited to $700 for a Self Plus One or $900 for a Self and Family enrollment.  The Non-PPO deductible applies only to services received from Non-PPO providers. 

The calendar year deductible will not exceed the per person limit for any covered individual.  Under a Self and Family enrollment, the deductible is satisfied for all family members when the combined covered expenses applied to the calendar year deductible for family members reach $900.

If the billed amount (or 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 and the provider has an agreement with us to accept $80, and you have not paid any amount toward meeting your calendar year deductible, you must pay $80.  We will apply $80 to your deductible.  We will begin paying benefits once the remaining portion of your calendar year deductible ($270) 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.

Coinsurance

Coinsurance is the percentage of our allowance that you must pay for your care. In most cases, coinsurance does not begin until you have met your calendar year deductible.

Example: You pay 15% of the Plan allowance for in-network surgical services under High Option or 20% of the Plan allowance under Standard Option.

If your provider routinely waives your cost

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

For example, if your physician ordinarily charges $100 for a service but routinely waives your 35% High Option out-of-network coinsurance, the actual charge is $65. We will pay $42.25 (65% of the actual charge of $65).

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 800-638-6589 or 301-984-1440 (for TTY, use 301-984-4155).

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.

• PPO providers agree to limit what they will bill you.  Because of that, when you use a preferred provider, your share of covered charges consists only of your deductible and coinsurance or copayment.  Here is an example about coinsurance: You see a PPO surgeon who charges $150, but our allowance is $100.  If you have met your deductible, you are only responsible for your coinsurance.  That is, under High Option, you pay just 15% of our $100 allowance ($15).  Because of the agreement, your PPO physician will not bill you for the $50 difference between our allowance and 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 under High Option, you pay 35% of our $100 allowance ($35).  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 High Option for services from a PPO physician and 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 provider

Surgical charge: $150

Our allowance: We set it at: 100

We pay: 85% of our allowance: 85

You owe: Coinsurance: 15% of our allowance: 15

+Difference up to charge?: No:  0

TOTAL YOU PAY: $15

Non-PPO provider

Surgical charge: $150

Our allowance: We set it at: 100

We pay: 65% of our allowance: 65

You owe: Coinsurance: 35% of our allowance: 35

+Difference up to charge?: Yes:  50

TOTAL YOU PAY: $85

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

For those services with cost-sharing, we pay 100% of the plan allowance for the remainder of the calendar year after out-of-pocket expenses for you and your covered family members for the expenses listed below in that calendar year exceed:

High Option

• PPO: $5,000 for one person or $10,000 for you and any covered family members when PPO providers are used.  Only eligible out-of-pocket expenses from PPO providers and in-network pharmacies count toward this limit.
• Non-PPO: $6,000 for one person or $14,000 for you and any covered family members.  Only eligible expenses from Non-PPO providers and out-of-network pharmacies count toward this limit.

Standard Option

• PPO: $6,000 for one person or $12,000 for you and any covered family members when PPO providers are used.  Only eligible out-of-pocket expenses from PPO providers and in-network pharmacies count toward this limit. 
• Non-PPO: $8,500 for one person or $14,000 for you and any covered family members.  Only eligible expenses from Non-PPO providers and out-of-network pharmacies count toward this limit.

High Option:

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

• $300 per person ($600 per Self Plus One or Self and Family enrollment) PPO calendar year deductible;
• $300 per person ($600 per Self Plus One or Self and Family enrollment) Non-PPO calendar year deductible;
• $200 PPO and $300 Non-PPO per inpatient hospital confinement copayment;
• $15 office visit copayment to primary care physicians under PPO;
• $25 office visit copayment to specialists under PPO benefits;
• $10 telehealth service copayment under PPO benefits; 
• $5 Medicare, $10 non-Medicare retail and $10 Medicare, $15 non-Medicare mail order generic per prescription copayments; and
• the coinsurance you pay for:
  • Medical services and supplies provided by physicians and other health care professionals;
  • Surgical and anesthesia services provided by physicians and other health care professionals;
  • Services provided by a hospital or other facility, and ambulance services;
  • Emergency services/accidents (after 24 hours);
  • Mental health and substance use disorder benefits; and
  • In-network preferred and non-preferred brand name prescription drugs. 

The following cannot be counted toward High Option out-of-pocket expenses:

• expenses in excess of the Plan allowance or maximum benefit limitations;
• amounts you pay for non-compliance with this Plan’s prior authorization requirements; and
• the cost difference between a brand name drug and its generic equivalent.

Standard Option:

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

• $350 per person ($700 per Self Plus One enrollment or $900 per Self and Family enrollment) PPO calendar year deductible;
• $350 per person ($700 per Self Plus One enrollment or $900 per Self and Family enrollment) Non-PPO calendar year deductible;
• $200 PPO and $400 Non-PPO per inpatient hospital confinement copayment;
• $20 office visit copayment to primary care physicians under PPO benefits;
• $30 office visit copayment to specialists under PPO benefits;
• $15 telehealth service copayment under PPO benefits;
• $7 Medicare, $12 non-Medicare retail and $15 Medicare, $20 non-Medicare mail order generic per prescription copayments; and
• the coinsurance you pay for:
  • Medical services and supplies provided by physicians and other health care professionals;
  • Surgical and anesthesia services provided by physicians and other health care professionals;
  • Services provided by a hospital or other facility, and ambulance services;
  • Emergency services/accidents (after 24 hours);
  • Mental health and substance use disorder benefits; and
  • In-network preferred and non-preferred brand name prescription drugs.

The following cannot be counted toward Standard Option out-of-pocket expenses:

• expenses in excess of the Plan allowance or maximum benefit limitations; 
• amounts you pay for non-compliance with the Plan's prior authorization requirements; and 
• the cost difference between a brand name drug and its generic equivalent.

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.

If we overpay you

We will make diligent efforts to recover benefit payments we made in error but in good faith. We may reduce subsequent benefit payments to offset overpayments.

Note:  We will generally first seek recovery from the provider if we paid the provider directly or  from the person (covered family member, guardian, custodial parent, etc.) to whom we sent our payment.

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 family member.  They may not seek more than their governing laws allow.  You may be responsible for certain services and charges.  Contact the government facility directly for more information.

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 items 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). 

Travel benefit/services overseas

For covered services rendered by a hospital or by a doctor outside of the United States, the Plan will pay eligible charges at PPO benefit levels, limited to the Plan's allowance established for the Washington, D.C. Metropolitan area.  The member is responsible for the difference between the Plan's allowance and the provider's charge.  See page 89, Section 7 Filing a claim for covered services.

Services for deaf and hearing impaired

SAMBA has a TTY line for the hearing-impaired: 301-984-4155 (TTY equipment is needed).

Telehealth services

Telehealth or tele-medicine services are available through our Telehealth vendor Teladoc^®.  Through Teladoc^® you can receive quality healthcare anytime, anywhere – at work, in the comfort of your home or while traveling.

As a Teladoc^® member, you will have access to a national network of U.S. board-certified physicians.  With an average of over 20 years of clinical experience, Teladoc^® doctors can diagnose, treat and prescribe medication for your non-emergency conditions such as the flu, strep throat, eye infections, bronchitis, and allergies.

Whenever you need care, a doctor is available within minutes by phone or video, 24 hours a day, 7 days a week.

For more information, visit www.Teladoc.com or call 800-Teladoc (835-2362).

Note: Telehealth services are available in most states, but some states do not allow telehealth or prescriptions per state regulations.  For a current list, visit www.Teladoc.com.

Online Resources

Visit our website at www.SambaPlans.com to view your claim history, order prescription refills and have access to many health resources, such as:

• a Hospital Quality Ratings Guide and Treatment Cost Estimator tool,
• an electronic Health Library to obtain information about a specific disease or medical condition,
• preventive care tips, and
• tools to quit smoking, lose weight and live a healthier life.

Through our relationship with Cigna, you and your covered dependents will have access to the Your Health First (YHF) Program.  This Program will assist with empowering our members to stay healthy.

Your Health First is a chronic condition management program that takes a unique approach to help people who have ongoing conditions such as asthma, diabetes, depression, low back pain, and heart disease better manage their health.  This behavioral-based program provides comprehensive health management tailored to each individual and is delivered through the continuous, personalized support of a dedicated health advocate.

For more information, visit our website at www.SambaPlans.com or call 800-887-9735.

Healthy Rewards Program

Through our relationship with Cigna/CareAllies, SAMBA members can participate in the Healthy Rewards Program.  This Program provides access to discounts on treatments and items not covered under the Plan.  For example:

• Over 10,000 fitness centers nationwide including Curves, Anytime Fitness, select Gold's Gym, Jazzercise, Snap Fitness and other chain/local centers.
• Alternative medicine network featuring s network of over 32,000 chiropractors, acupuncturists, massage therapists, and registered dieticians.
• Weight Management Programs
• Mind/Body Programs
• Online store featuring discounts on vitamins & supplements, herbal products, dental products, homeopathic remedies, natural products, diet & sports nutrition, yoga & fitness activities, personal body care, books, audio, video & DVDs.

In addition, Healthy Rewards offers Vision and Hearing Care discounts including eye exams, eye wear, Lasik correction and hearing exams and aids, Just Walk 10,000 Steps a Day™ walking program, and weight management through Jenny Craig.

Visit www.SambaPlans.com for more information.

The Health Risk Assessment (HRA) tool is available online at www.SambaPlans.com.  The tool is designed to assess the member's health profile, analyze the responses and suggest how they could achieve or maintain better health.  This is an excellent tool to assist you in achieving your personal health goals.

To encourage you and your covered family members over age 18 to complete an HRA, the Plan will apply a $25 credit toward the individual's calendar year deductible.  This incentive is limited to two individuals per family and allowed only once per calendar year.

Gaps in Care

The Gaps in Care program uses clinical rule-based software, together with integrated medical, pharmacy, behavioral, and lab data to address members' gaps in care.  Gaps in care occur when individuals do not receive or adhere to care that is consistent with medically proven guidelines for prevention or treatment.

The Gaps in Care program provides coaching, integrated with Case Management, to identify any gaps or barrier preventing necessary medical care.  Simple, easy to understand profiles are sent to members to increase their understanding of potential gaps and improve adherence to existing treatment plans.  The program also generates patient reminders for medications and preventative appointments.

Tobacco Cessation Program

We know it isn't easy to quit smoking.  It can take several attempts to quit before you're successful.

The tobacco cessation program offered by the Plan helps you to develop a personal plan to become and remain tobacco-free from all forms of tobacco use, including cigarettes, E-cigarettes, and smokeless tobacco.  Choose from two convenient options – a phone program featuring a dedicated wellness coach or online for a self-paced program – or use both.

Get the support you need and the results you want.  For more information or to enroll, visit www.SambaPlans.com or call 800-887-9735.

Note:  For group and individual counseling for tobacco cessation, see Educational classes and programs in Section 5(a).

Weight Management Program

Lose weight and improve your health through a personalized weight loss program.  This program helps you change your behaviors by developing healthier eating habits and incorporating exercise into your schedule – helping you to feel better, look better and improve your overall health.

As a participant, in addition to helping you develop a customized diet and exercise plan, you will receive:

• One-on-one support and advice from a health coach by phone or online
• A personal phone assessment that helps make sure your participation in the program will be safe and successful,
• Tools developed by medical experts that provide your health coach with more detailed information about your heart health and eating habits, and
• 24/7 access to a secure website with helpful articles, tools, trackers, and more.

For more information or to enroll, visit www.SambaPlans.com or call 800-887-9735.

24-hour nurse line

Through SAMBA's relationship with Cigna/CareAllies, our members have access to 24/7 Nurseline^sm, an easy to use resource with anytime access to the information you need to make smart health decisions

With 24/7 Nurseline^sm you get:

• Health information in language that is easy to understand and use
• Help deciding the best method to treat a minor injury or illness, including over-the-counter or home remedies
• Peace of mind by having a registered nurse available around the clock

Get expert health advice anytime, anywhere by calling 800-887-9735.

Healthy Pregnancies, Healthy Babies^® Program

Through our relationship with Cigna, SAMBA is pleased to offer you and your covered dependents access to the Healthy Pregnancies, Healthy Babies^® Program.  This free program is designed to help you throughout your pregnancy and in the days and weeks following your baby's birth.

When you enroll in Cigna's Healthy Pregnancies, Healthy Babies® Program, you get unlimited support for a healthier pregnancy.

For more information and to enroll, contact Cigna/CareAllies at 800-887-9735 or visit www.SambaPlans.com.

Personal Medication Coach (PMC)

Through our relationship with Express Scripts, SAMBA offers our eligible members the Personal Medication Coach (PMC) program.  Through convenient phone consultations with a registered pharmacist, you can receive a full review of your current medications (including over-the-counter medications and supplements), ask the pharmacist any medication-related questions, discuss any side effects you may be experiencing or potentially harmful drug interactions, and determine if lower-cost medication alternatives are available (if requested).  The pharmacist will also collaborate with your prescriber to discuss potential areas of concern and opportunities to optimize your therapy.

How to claim benefits

To obtain claim forms, claims filing advice or answers about our benefits, contact us at 800-638-6589 or 301-984-1440 (for TTY, use 301-984-4155), or at our website at
www.SambaPlans.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.

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
• The charge for each service or supply

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

In addition:

• If another health plan is your primary payor, you must send a copy of the explanation of benefits (EOB) form you received from your primary payor (such as the Medicare Summary Notice (MSN)) with your claim.
• Bills for home nursing care must show that the nurse is a registered or licensed practical nurse.
• If your claim is for the rental or purchase of durable medical equipment; private duty nursing; and 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 (including quantity and dosage) or supply, prescribing provider's name, date, and charge.
• 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.

Deadline for filing your claim

Send us all 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. You are responsible to make certain that your claims are filed within the timely filing deadline.  Once we pay benefits, there is a three-year limitation on the reissuance of uncashed checks.

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 telephone customer assistance), and help with filing claims and appeals (including external reviews) in the applicable non-English language.  The English versions of your EOBs and related correspondence will include information in the non-English language about how to access language services in that non-English language.

Any notice of an adverse benefit determination or correspondence from us confirming an adverse benefit determination will include information sufficient to identify the claim involved (including the date of service, the 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).

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: SAMBA, 11301 Old Georgetown Road, Rockville, MD  20852-2800; 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 members), if you would like to receive our decision via email.  Please note that by giving us your email, we may be able to provide our decision more quickly.

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

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

a) Pay the claim or
b) Write to you and maintain our denial or
c) Ask you or your provider for more information.

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

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

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; and
• Your daytime phone number and the best time to call.
• Your email address, if you would like to receive OPM's decision via email.  Please note that by providing your email address, you may receive OPM's decision more quickly. 

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

Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review request.  However, for urgent care claims, a 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 file a lawsuit, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or supplies or from the year in which you were denied precertification or prior approval. This is the only deadline that can 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

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.SambaPlans.com.

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

When we are the secondary payor, we will determine our allowance.  After the primary plan pays, we will pay what is left of our allowance or up to our regular benefit, whichever is less.  We will not pay more than our allowance.  The combined payments from both plans may not equal the entire amount billed by the provider.  In certain circumstances, when there is no adverse effect on you (that is, you do not pay any more), we may also take advantage of any provider discount arrangements your primary plan may have and pay only the difference between the primary plan’s payment and the amount the provider has agreed to accept as payment in full from the primary plan.

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

• 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

Our reimbursement and subrogation rights are both a condition of, and a limitation on, the benefit payments that you are eligible to receive from us.  By accepting Plan benefits, you agree to the terms of this provision.

If you receive (or are entitled to receive) a monetary recovery from any source as the result of an injury or illness, we have the right to be reimbursed out of that recovery for any and all of our benefits paid to diagnose and treat that illness or injury to the full extent of the benefits paid or provided.  The Plan's right of reimbursement extends to all benefit payments for related treatment incurred up to and including the date of settlement or judgment, regardless of the date that those expenses were submitted to the Plan for payment.  This reimbursement right extends to any monetary recovery that your representatives (for example, heirs, estate) receive (or are entitled to receive) from any source as a result of an accidental injury or illness.  This is known as our reimbursement right.

We may also, at our option, pursue recovery as successor to the rights of the enrollee or any covered family member who suffered an illness or injury, which includes the right to file suit and make claims in your name, and to obtain reimbursement directly from the responsible party, liability insurer, first party insurer, or benefit program. This is known as our subrogation right.

Examples of situations to which our reimbursement and subrogation rights apply include, but are not limited to, when you become ill or are injured due to (1) an accident on the premises owned by a third party, (2) a motor vehicle accident, (3) a slip and fall, (4) an accident at work, (5) medical malpractice, or (6) a defective product.

Our reimbursement and subrogation rights extend to all benefits available to you under any law or under any type of insurance or benefit program, including but not limited to:

• Third party liability coverage;
• Personal or business umbrella coverage;
• Uninsured and underinsured motorist coverage;
• Workers’ Compensation benefits;
• Medical reimbursement or payment coverage;
• Homeowners or property insurance;
• Payments directly from the responsible party;
• Funds or accounts established through settlement or judgment to compensate injured parties; and
• No-fault insurance and other insurance that pays without regard to fault, including personal injury protection benefits, regardless of any election made by you to treat those benefits as secondary to us.  When you are entitled to the payment of healthcare expenses under automobile insurance, including no-fault insurance and other insurance that pays without regard to fault, your automobile insurance is the primary payor and we are the secondary payor.

Our reimbursement right applies even if the monetary recovery may not compensate you fully for all of the damages resulting from the injuries or illness.  In other words, we are entitled to be reimbursed for those benefit payments even if you are not “made whole” for all of your damages by the compensation you receive.

Our reimbursement right is not subject to reduction for attorney’s fees under the “common fund” or any other doctrine.  We are entitled to be reimbursed for 100% of the benefits we paid on account of the injuries or illness unless we agree in writing to accept a lesser amount.

We enforce our reimbursement right by asserting a first priority lien against any and all recoveries you receive by court order or out-of-court settlement, insurance or benefit program claims, or otherwise, regardless of whether medical benefits are specifically designated in the recovery and without regard to how it is characterized (for example as “pain and suffering”), designated, or apportioned.  Our subrogation or reimbursement interest shall be paid from the recovery before any of the rights of any other parties are paid.

You agree to cooperate with our enforcement of our reimbursement right by:

• telling us promptly whenever you have filed a claim for compensation resulting from an accidental injury or illness and responding to our questionnaires;
• pursuing recovery of our benefit payments from the third party or available insurance company;
• accepting our lien for the full amount of our benefit payments;
• signing our Reimbursement Agreement when requested to do so;
• agreeing to assign any proceeds or rights to proceeds from third party claims or any insurance to us;
• keeping us advised of the claim’s status;
• agreeing and authorizing us to communicate directly with any relevant insurance carrier regarding the claim related to your injury or illness;
• advising us of any recoveries you obtain, whether by insurance claim, settlement or court order; and
• agreeing that you or your legal representative will hold any funds from settlement or judgment in trust until you have verified our lien amount, and reimbursed us out of any recovery received to the full extent of our reimbursement right.

We also expect you to fully cooperate with us in the event we exercise our subrogation right.

Failure to cooperate with these obligations may result in the temporary suspension of your benefits and/or offsetting of future benefits.

For more information about this process, please call our Third Party Recovery Services unit at 202-683-9140 or 855-661-7973 (toll free). You also can email that unit at info@elgtprs.com.

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 on BENEFEDS.com or by phone 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.

• 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 800-638-6589 or 301-984-1440 (for TTY, use 301-984-4155) or see our website at www.SambaPlans.com.

We waive some costs if the Original Medicare Plan is your primary payor – We will waive some out-of-pocket costs as follows:

• If you are enrolled in Medicare Part A, we will waive the following:
• the per confinement copayment for inpatient hospital confinements
• the coinsurance for inpatient hospital benefits
• If you are enrolled in Medicare Part B, we will waive the deductibles, copayments and coinsurances for:
• Surgery and anesthesia services
• Mental health and substance use disorder benefits
• Medical services and supplies provided by physicians and other health care professionals
• Outpatient services by a hospital and other facilities and ambulance services
• Dental benefits

Note:  We do reduce the copayments and/or coinsurance for prescription drugs for members and dependents enrolled in Medicare Part B as their primary coverage.  Also, all Plan benefit limitations and exclusions still apply.  In cases where we cover a service that is not covered by Medicare, we are the primary payor.  In these cases, we do not waive any out-of-pocket costs.

Please review the following table, it illustrates your cost share if you are enrolled in Medicare Part B.  If you purchase Medicare Part B, your provider is in our network and participates in Medicare, then we waive some costs because Medicare will be the primary payor.

Benefit Description: Deductible
High Option / Standard Option: You pay without Medicare: In-Network: $300 / $350 per person
High Option / Standard Option: You pay without Medicare: Out-of-Network: $300 / $350 per person
High Option / Standard Option: You pay with Medicare Part B: In-Network: $0
High Option / Standard Option: You pay with Medicare Part B: Out-of-Network: $0

Benefit Description: Catastrophic Protection Out-of-Pocket Maximum
High Option / Standard Option: You pay without Medicare: In-Network: $5,000 / $6,000 self only; $10,000 / $12,000 family
High Option / Standard Option: You pay without Medicare: Out-of-Network: $6,000 / $8,500 self only; $14,000 family
High Option / Standard Option: You pay with Medicare Part B: In-Network: $0
High Option / Standard Option: You pay with Medicare Part B: Out-of-Network: $0

Benefit Description: Part B Premium Reimbursement Offered
High Option / Standard Option: You pay without Medicare: In-Network: NA
High Option / Standard Option: You pay without Medicare: Out-of-Network: NA
High Option / Standard Option: You pay with Medicare Part B: In-Network: NA
High Option / Standard Option: You pay with Medicare Part B: Out-of-Network: NA

Benefit Description: Primary Care Physician
High Option / Standard Option: You pay without Medicare: In-Network: $15 / $20
High Option / Standard Option: You pay without Medicare: Out-of-Network: 35% / 45%
High Option / Standard Option: You pay with Medicare Part B: In-Network: $0
High Option / Standard Option: You pay with Medicare Part B: Out-of-Network: $0

Benefit Description: Specialist
High Option / Standard Option: You pay without Medicare: In-Network: $25 / $30
High Option / Standard Option: You pay without Medicare: Out-of-Network: 35% / 45%
High Option / Standard Option: You pay with Medicare Part B: In-Network: $0
High Option / Standard Option: You pay with Medicare Part B: Out-of-Network: $0

Benefit Description: Inpatient Hospital
High Option / Standard Option: You pay without Medicare: In-Network: $200 per admission, plus 15% / 20% for ancillary services
High Option / Standard Option: You pay without Medicare: Out-of-Network: $300 / $400 per admission, plus 35% / 45%
High Option / Standard Option: You pay with Medicare Part B: In-Network: $0
High Option / Standard Option: You pay with Medicare Part B: Out-of-Network: $0

Benefit Description: Outpatient Hospital
High Option / Standard Option: You pay without Medicare: In-Network: 15% / 20%
High Option / Standard Option: You pay without Medicare: Out-of-Network: 35% / 45%
High Option / Standard Option: You pay with Medicare Part B: In-Network: $0
High Option / Standard Option: You pay with Medicare Part B: Out-of-Network: $0

Benefit Description: Incentives offered
High Option / Standard Option: You pay without Medicare: In-Network: NA
High Option / Standard Option: You pay without Medicare: Out-of-Network: NA
High Option / Standard Option: You pay with Medicare Part B: In-Network: NA
High Option / Standard Option: You pay with Medicare Part B: Out-of-Network: NA

You can find more information about how our plan coordinates benefits with Medicare at
www.SambaPlans.com.

• Tell us about your Medicare coverage

• 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.  We will still limit our payment to the amount we would have paid after Original Medicare's payment.  You may be responsible for paying the difference between the billed amount and the amount we paid.

• 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.  However, we will not waive any of our copayments, coinsurance, or deductibles.  If you enroll in a Medicare Advantage plan, tell us.  We will need to know whether you are in the Original Medicare Plan or in a Medicare Advantage plan so we can correctly coordinate benefits with Medicare.

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

• Medicare prescription drug coverage (Part D)

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.

If your physician accepts Medicare assignment, we waive some of your deductibles, copayment 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.

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
• Extra care costs – costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient's routine care
• Research costs – costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes are generally covered by the clinical trials.  This plan does not cover these costs.

Coinsurance

See Section 4, page 22.

Congenital anomaly

A condition existing at or from birth, which is a significant deviation from the common form or norm. For purposes of this Plan, congenital anomalies include protruding ear deformities, cleft lips, cleft palates, birthmarks, webbed fingers or toes, and other conditions that the Carrier may determine to be congenital anomalies. In no event will the term congenital anomaly include conditions relating to teeth or intra-oral structures supporting the teeth except for the Dental prosthetic appliances benefit and Orthodontic treatment covered under Section 5(g); Dental benefits.

Convenient care clinic

A small healthcare clinic, usually located in a high-traffic retail outlet with a limited pharmacy, that treats uncomplicated minor illnesses and provides preventative healthcare services on a walk-in basis.  Examples of a convenient care clinic include MinuteClinic in CVS pharmacy locations and Take Care Clinic ^sm in Walgreens pharmacy locations.  Convenient care clinics are different from Urgent care centers (see page 106) that primarily provide treatment to patients who have an illness or injury that requires immediate care but is not serious enough to warrant a visit to the emergency room.

Copayment

See Section 4, page 21.

Cost-sharing

See Section 4, page 21.

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:

1. personal care such as help in: walking; getting in and out of bed; bathing; eating by spoon, tube or gastrostomy; exercising; dressing;
2. homemaking, such as preparing meals or specials diets;
3. moving the patient;
4. acting as companion or sitter;
5. supervising medication that can usually be self administered; or
6. 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.

Deductible

See Section 4, page 21.

Equipment and supplies that:

1. Are prescribed by your attending physician (i.e., the physician who is treating your illness or injury);
2. Are medically necessary;
3. Are primarily and customarily used only for a medical purpose;
4. Are generally useful only to a person with an illness or injury;
5. Are designed for prolonged use; and
6. Serve a specific therapeutic purpose in the treatment of an illness or injury.

Experimental or investigational services

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.

Genetic counseling

Genetic counseling is a process of communication between patients and trained professionals intended to provide patients who have a genetic disease, or risk of such a disease, with information about their condition and its effect on their family. This allows patients and their families to make informed reproductive and other medical decisions.

Genetic screening

The diagnosis, prognosis, management, and prevention of genetic disease for those patients who have no current evidence or manifestation of a genetic disease and those who have not been determined to have an inheritable risk of genetic disease.

Genetic testing

The diagnosis and management of genetic disease for those patients with current signs and symptoms, and for those who have been determined to have an inheritable risk of genetic disease.

Hospice is a coordinated program of maintenance and supportive care for the terminally ill provided by a medically supervised team under the direction of a Plan-approved independent hospice administration.

Infertility

Infertility is the condition of an individual who is unable to conceive or produce conception during a period of 1 year if the female is age 35 or younger or during a period of 6 months if the female is over the age of 35.  For women without male partners or exposure to sperm, infertility is the inability to conceive after six cycles of Artificial Insemination or Intrauterine Insemination performed by a qualified specialist using normal quality donor sperm. These 6 cycles (including donor sperm) are not covered by the plan as a diagnosis of infertility is not established until the cycles have been completed.

Intensive outpatient program

A comprehensive outpatient treatment program that includes extended periods of individual or group therapy sessions designed to assist members with mental health and/or substance use disorder conditions. It is an intermediate setting between traditional outpatient therapy and partial hospitalization. Program sessions may occur more than one day per week.

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

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

Mental conditions/substance use disorder

Conditions and diseases listed in the most recent edition of the International Classification of Diseases (ICD) as psychosis, neurotic disorders, or personality disorders; other nonpsychotic mental disorders listed in the ICD; or disorders listed in the ICD requiring treatment for use of, or dependence upon, substances such as alcohol, narcotics, or hallucinogens.

Observation services

Hospital observation care has a well-defined set of specific, clinically appropriate services that are billed hourly.  Although you may stay overnight in a hospital room and receive meals and other hospital services, some services and overnight stays – including “observation services” – are actually outpatient care.  Observation care includes care provided to members who require a significant period of treatment or monitoring before a physician can decide whether to admit them to the hospital on an inpatient basis or discharge them to home.  The provider may need 6 to 24 hours or more to make that decision.

If you are in the hospital more than a few hours, always ask your physician or the hospital staff if your stay is considered inpatient or outpatient. 

Partial Hospitalization

A time-limited, ambulatory, active treatment program used to treat mental illness and substance use disorder. The patient continues to reside at home, but commutes to a treatment center that offers intensive clinical services that are coordinated and structured in a stable therapeutic environment. Provides at least 20 hours of scheduled programs extended over a minimum of five days per week in a licensed or JCAHO accredited facility.

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 allowance as follows:

• PPO providers:  For services rendered by a covered provider who participates in the Plan's PPO network, our allowance is based on a  negotiated rate agreed to under the providers' network agreement.

Note: You will not be responsible for any amount above the providers' negotiated rate; PPO providers accept the Plan's allowance as payment in full.

• Non-PPO providers:  When you receive care from a Non-PPO provider, our allowance is determined as follows:

For all dialysis and urine drug screening/testing, our allowance is 200% of the Medicare allowance for these services.

For all other services, we determine our allowance based on the following rules in order.

• Rule One

When a Non-PPO provider has agreed to discount their charges, our allowance is the amount that the provider has negotiated and agreed to accept for the services or supplies.  You are not responsible for the difference between the allowance and the provider’s billed charges.

If the provider has not agreed to discount their charges, we will access Rule Two.

• Rule Two

An amount equal to 200% of the current Medicare rate for professional and facility expenses. You may be responsible for the difference between the allowance and the provider’s billed charges.

If there is no Medicare rate for the service(s) billed, we will access Rule Three.

• Rule Three

We will utilize outside sources, such as Fair Health, Inc., to determine the allowance for certain services and supplies in a specific geographic area. You may be responsible for the difference between the allowance and the provider’s billed charges

For certain services, exceptions may exist to the use of the out-of-network fee schedule to determine the Plan's Non-PPO allowance.  For claims governed by OBRA '90 and '93, the Plan allowance will be based on Medicare allowable amounts as is required by law.  For claims where the Plan is the secondary payor to Medicare, the Plan allowance is the Medicare allowable charge.

For covered services rendered by a hospital or by a doctor outside the United States, our allowance is based on the Plan’s allowance established for the Washington, D.C. Metropolitan area.

Note: We will not consider any fee charged above the Plan's allowance.  The member is responsible for the difference between the Plan’s allowance and the provider’s charge.

• Other Participating Providers:  When you use certain Non-PPO providers that have agreed to discount their charges, our Plan allowance is the amount that the provider has negotiated and agreed to accept for the services and/or supplies.  Benefits will be paid at the Non-PPO benefit levels.  You are not responsible for the difference between the Plan's allowance/negotiated amount and the provider's billed charges.

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

Pre-service claims

Those claims (1) that require precertification, prior approval, or a referral and (2) where failure to obtain precertification, prior approval, or referral results in a reduction of benefits.

Primary Care Physician

For purposes of the office visit copayment, primary care physicians are individual doctors (M.D. or D.O.) whose medical practice is limited to family practice, general practice, internal medicine, pediatrics, adolescent medicine, obstetrics/gynecology, or geriatrics. Also considered primary care physicians for the purpose of this benefit are psychiatrists, licensed clinical psychologists, licensed clinical social workers, licensed professional counselors, or licensed marriage and family therapists. Doctors listed in provider directories and/or advertisements under any other medical specialty or sub-specialty area (such as internal medicine doctors also listed under endocrinology, or pediatric sub-specialties such as pediatric cardiology) are considered specialists, not primary care physicians.

Reimbursement

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

Subrogation

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

Urgent care center

An ambulatory care center, outside of a hospital emergency department, that provides treatment for medical conditions that are not life-threatening, but need quick attention, on a walk-in basis.  Urgent care centers are different from convenient care clinics, see page 101.

Urgent care claims

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

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

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

If you believe your claim qualifies as an urgent care claim, please  contact our Customer Service Department at 800-638-6589 or 301-984-1440 (For TTY, use 301-984-4155).  You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care.

Medical services provided by physicians:

• Diagnostic and treatment services provided in the office

PPO:  $15 copayment per office visit to primary care physicians; $25 copayment per office visit to specialists

Non-PPO: 35%* of the Plan allowance

29

Services provided by a hospital:

• Inpatient 

PPO: $200 copayment per confinement, nothing for room & board and 15% for other hospital services

Non-PPO: $300 copayment per confinement and 35% of the Plan allowance

60

• Outpatient

PPO: 15% of the Plan allowance

Non-PPO: 35%* of the Plan allowance

61

Emergency benefits:

• Accidental injury

Nothing within 24 hours

64

• Medical emergency

Regular benefits apply

65

Mental health and substance use disorder treatment

Regular cost-sharing

66

Prescription drugs

• Retail pharmacy

$10 generic ($5 if Medicare Part B primary), 30% of the Plan allowance ($100 maximum) preferred brand name (25% if Medicare Part B primary)  or 45% of the Plan allowance ($300 maximum) non-preferred brand name; limited to the initial fill (not to exceed a 30-day supply) and one refill

75

• Mail order

$15 generic ($10 if Medicare Part B primary), 30% of the Plan allowance ($200 maximum) preferred brand name (25% if Medicare Part B primary) or 45% of the Plan allowance ($400 maximum) non-preferred brand name

75

Dental care:

PPO: 15%* of the Plan allowance for certain covered services

Non-PPO: 35%* of the Plan allowance for certain covered services

79

Wellness and other special features:

Flexible benefits option; Travel benefit/services overseas; Services for deaf and hearing impaired; Telehealth Services; Online Resources; Your Health First Program; Healthy Rewards Program; Health Risk Assessment; Gaps in Care; Tobacco Cessation Program; Weight Management Program; 24-hour Nurse Line; Healthy Pregnancies, Healthy Babies® Program; Personal Medication Coach (PMC)

81

Protection against catastrophic costs (out-of-pocket maximum):

Some costs do not count toward this protection

PPO: Nothing after $5,000 per person, per calendar year/$10,000 per Self Plus One or Self and Family enrollment, per calendar year

Non-PPO: Nothing after $6,000 per person, per calendar year/$14,000 per Self Plus One or Self and Family enrollment, per calendar year

23

Medical services provided by physicians:

• Diagnostic and treatment services provided in the office

PPO: $20 copayment per office visit to primary care physicians;  $30 copayment per office visit to specialists

Non-PPO:  45%* of the Plan allowance

29

Services provided by a hospital:

• Inpatient

PPO: $200 copayment per confinement, nothing for room & board and 20% for other hospital services
Non-PPO: $400 copayment per confinement and 45% of the Plan allowance

60

• Outpatient

PPO: 20%* of the Plan allowance
Non-PPO: 45%* of the Plan allowance

61

Emergency benefits:

• Accidental injury

Nothing within 24 hours

64

• Medical emergency

Regular benefits apply

65

Mental health and substance use disorder treatment:

Regular cost-sharing

66

Prescription drugs

• Retail pharmacy

$12 generic ($7 if Medicare Part B primary), 35% of the Plan allowance ($150 maximum) preferred brand name (30% if Medicare Part B primary) or 50% of the Plan allowance ($300 maximum) non-preferred brand name; limited to the initial fill (not to exceed a 30-day supply) and one refill

75

• Mail order

$20 generic ($15 if Medicare Part B primary), 35% of the Plan allowance ($300 maximum) preferred brand name (30% if Medicare Part B primary) or 50% of the Plan allowance ($400 maximum) non-preferred brand name

75

Dental care:

We cover surgical and dental treatment of accidental injury to sound natural teeth.  Treatment must be rendered within 24 months of the accident.  Regular benefits apply.

79

Wellness and other special features:

Flexible benefits option; Travel benefit/services overseas; Services for deaf and hearing impaired; Telehealth Services; Online Resources; Your Health First Program; Healthy Rewards Program; Health Risk Assessment; Gaps in Care; Tobacco Cessation Program; Weight Management Program; 24 hour Nurse Line; Healthy Pregnancies, Healthy Babies® Program; Personal Medication Coach (PMC)

81

Protection against catastrophic costs (out-of-pocket maximum):

Some costs do not count toward this protection

PPO: Nothing after $6,000 per person, per calendar year/$12,000 per Self Plus One or Self and Family enrollment, per calendar year

Non-PPO: Nothing after $8,500 per person, per calendar year/$14,000 per Self Plus One or Self and Family enrollment, per calendar year

23