We will not refuse to cover the treatment of a condition you had before you enrolled in this Plan solely because you had the condition before you enrolled.

Coverage under this plan qualifies as minimum essential coverage. Please visit the Internal Revenue Service (IRS) website at www.irs.gov/uac/Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision for more information on the individual requirement for MEC.

Our health coverage meets the minimum value standard of 60% established by the ACA. This means that we provide benefits to cover at least 60% of the total allowed costs of essential health benefits. The 60% standard is an actuarial value; your specific out-of-pocket costs are determined as explained in this brochure.

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

• Information on the FEHB Program and plans available to you;
• A health plan comparison tool;
• A list of agencies that participate in Employee Express;
• A link to Employee Express; and
• Information on and links to other electronic enrollment systems.

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

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

We do not determine who is eligible for coverage and, in most cases, cannot change your enrollment status without information from your employing or retirement office. For information on your premium deductions, you must also contact your employing or retirement office.

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

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

If you have a Self Only enrollment, you may change to a Self Plus One or Self and Family enrollment if you marry, give birth, or add a child to your family. You may change your enrollment 31 days before to 60 days after that event. The Self Plus One or Self and Family enrollment begins on the first day of the pay period in which the child is born or becomes an eligible family member. When you change to Self Plus One or Self and Family because you marry, the change is effective on the first day of the pay period that begins after your employing office receives your enrollment form. Benefits will not be available to your spouse until you are married. A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee’s FEHB enrollment.

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

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

Your employment or retirement office will not notify you when a family member is no longer eligible to receive benefits, nor will we. Please tell us immediately of changes in family member status including your marriage, divorce, annulment, or when your child reaches age 26.  

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

If your enrollment continues after you are no longer eligible for coverage (i.e., you have separated from Federal service) and premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not paid. You may be billed for services received directly from your provider. You may be prosecuted for fraud for knowingly using health insurance benefits for which you have not paid premiums. It is your responsibility to know when you or a family member are no longer eligible to use your health insurance coverage.

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

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

• Your enrollment ends, unless you cancel your enrollment, or
• You 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).

If you are divorced from a Federal employee or annuitant, you may not continue to get benefits under your former spouse’s enrollment. This is the case even when the court has ordered your former spouse to provide health coverage for you. However, you may be eligible for your own FEHB coverage under either the spouse equity law or Temporary Continuation of Coverage (TCC). If you are recently divorced or are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get additional information about your coverage choices. You can also visit OPM’s website,              www.opm.gov/healthcare-insurance/healthcare/plan-information/guides. A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee’s FEHB enrollment.

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

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

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

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

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

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

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

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 800-821-6136 or write to us at GEHA, P. O. Box 21542, Eagan, MN 55121. You may also request replacement cards through our website: www.geha.com/my-elevate.

You get care from “Plan providers” and “Plan facilities.” You will only pay copayments, deductibles, and/or coinsurance if you use our network providers. You can also get care from non-Plan providers but it will cost you more.

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

We provide benefits for the services of plan 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.

Plan providers are physicians and other healthcare professionals in our service area that are contracted to provide covered services to our members when acting within the scope of their license or certification under applicable state law. Plan providers are credentialed according to national standards. A listing of plan providers can be found on our website at www.geha.com/my-elevate.

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

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

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

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

Plan facilities are hospitals and other facilities in our service area that are contracted to provide covered services to our members. The plan facilities list is also on our web site at www.geha.com/find-care. You should also contact that provider to verify that they participate with the Plan.

Covered facilities include:

• Freestanding ambulatory facility:
  • A facility which is licensed by the state as an ambulatory surgery center or has Medicare certification as an ambulatory surgical center, has permanent facilities and equipment for the primary purpose of performing surgical and/or renal dialysis procedures on an outpatient basis; provides treatment by or under the supervision of doctors and nursing services whenever the patient is in the facility; does not provide inpatient accommodations; and is not, other than incidentally, a facility used as an office or clinic for the private practice of a doctor or other professional.
  • If the state does not license Ambulatory Surgical Centers and the facility is not Medicare certified as an ambulatory surgical center, then they must be accredited with AAAHC (Accreditation Association for Ambulatory Health Care), AAAASF (American Association for Accreditation for Ambulatory Surgery Facilities), IMQ (Institute for Medical Quality) or TJC (The Joint Commission).
  • Ambulatory Surgical Facilities in the state of California do not require a license if they are physician owned. To be covered these facilities must be accredited by one of the following: AAAHC (Accreditation Association for Ambulatory Health Care), AAAASF (American Association for Accreditation for Ambulatory Surgery Facilities), IMQ (Institute for Medical Quality) or TJC (The Joint Commission).
• Hospice: A facility which meets all of the following:
  • Primarily provides inpatient hospice care to terminally ill persons;
  • Is certified by Medicare as such, or is licensed or accredited as such, by the jurisdiction it is in;
  • Is supervised by a staff of M.D.’s or D.O.’s, at least one of whom must be on call at all times;
  • Provides 24-hour-a-day nursing services under the direction of an R.N. and has a full-time administrator; and
  • Provides an ongoing quality assurance program.
• Skilled Nursing Facility licensed by the state or certified by Medicare if the state does not license these facilities. See limitations in Section 5(c), Services Provided by a Hospital or Other Facility, and Ambulance Services. 

• Hospital:
  • An institution, or distinct portion of an institution, that is primarily engaged in providing: (1) general inpatient acute care and treatment of sick and injured persons through medical, diagnostic, and major surgical facilities; or (2) specialized inpatient acute medical care and treatment of sick or injured persons through medical and diagnostic facilities (including X-ray and laboratory); or (3) comprehensive specialized services relating to the individual's specific medical, physical, mental health, and/or substance use disorder therapy needs, and has, for each patient, an individualized written treatment plan, which includes diagnostic assessment of the patient and a description of the treatment to be rendered, and provides for follow-up assessments by, or under, the direction of the supervising doctor.
  • All services must be provided on its premises, under its control, or through a written agreement with a hospital or with a specialized provider of those facilities. 
  • A hospital must be operated pursuant to law, accredited as a hospital under the Hospital Accreditation Program of The Joint Commission (TJC) or meet the states' applicable licensing or certification requirements for a hospital, and is operating under the supervision of a staff of physicians with 24-hour-a-day registered nursing services. 
  • The term hospital does not include a convalescent home, extended care facility, skilled nursing facility, or any institution or part thereof which: a) is used principally as a convalescent facility, nursing facility, or long term care; b) furnishes primarily domiciliary or custodial care, including training in the routines of daily living; or c) is operating as or is licensed as a school or residential treatment facility (except as listed in Section 5(e)).
• Residential Treatment Center (RTCs):
  • An institution that is primarily engaged in providing. (1) 24-hour residential evaluation, treatment, and comprehensive specialized services relating to the individual's specific mental health, and/or substance use disorder therapy needs, all under the active participation and direction of a licensed physician who is practicing within the scope of the physician's license; and (2) specialized programs for persons who need short-term services designed to achieve predicted outcomes focused on fostering improvement or stability in mental health and/or substance use disorder, recognizing the individuality, strengths, and needs of the persons served; and (3) care that meets evidence-based treatment guidelines or criteria as determined by the plan. 
  • The services are provided for a fee from its patients and include both: (1) room and board; and (2) 24-hour-a-day registered nursing services. Additionally, the RTC keeps adequate patient records which include: (1) the individualized treatment plan; and (2) the person's progress; and (3) discharge summary; and (4) follow-up programs. Benefits are available for services performed and billed by RTCs, as described in Section 5(e), Mental Health and Substance Use Disorder Benefits. 
  • RTCs must be: (1) operated pursuant to law; and (2) accredited by a nationally recognized organization, and licensed by the state, district or territory to provide residential treatment for mental health conditions and/or substance use disorder, or (3) credentialed by a network partner. 
  • The term RTC does not include a convalescent home, extended care facility, skilled nursing facility, group home, halfway house, sober home, transitional living center or treatment, or any institution or part thereof which: 1) is used principally as a convalescent facility, nursing facility, or long term care; 2) furnishes primarily domiciliary or custodial care, including training in the routines of daily living; or 3) is operating or licensed as a school. 

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 in-network 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 in-network 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 in-network specialist based on the above circumstances, you can continue to see your specialist and your in-network benefits will continue until the end of your postpartum care, even if it is beyond the 90 days.

We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 800-821-6136. If you are new to the FEHB Program, we will reimburse you for your covered services while you are in the hospital beginning on the effective date of your coverage.

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

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

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

Precertification is the process by which we evaluate the medical necessity of your hospital stay and the number of days required to treat your condition. In most cases, your network physician will make necessary hospital arrangements and supervise your care. If you are using a non-network provider or facility, you are responsible for contacting the Plan at 866-257-0721.

Your plan physician or specialist will make necessary inpatient arrangements and supervise your care. This includes admission for a Hospital, Long Term Acute Care, Residential Treatment Center (RTC), Skilled nursing Facility (SNF) or Rehabilitation Facility stay.

Because you are still responsible for ensuring that we are asked to precertify your care, always ask your physician or hospital whether or not they have contacted the Plan.

If you are using a non-network provider or facility, you are responsible for contacting the Plan at 866-257-0721 to determine coverage and obtain precertification for these types of admissions.

Network Plan physicians must provide or arrange your in-network care and get precertification or preauthorization for certain services and/or procedures, including but not limited to those noted below in Other services that require preauthorization. For out-of-network facilities on the Elevate Option, you are responsible for obtaining precertification for these services. 

Note: Avoid paying providers for services prior to preauthorization. It is important to assure services are authorized and provided by a covered provider or facility.

You must get precertification for certain services prior to admission. Failure to do so will result in the following penalties, unless due to a medical emergency:

• Out-of-network (Elevate Option only): 
  • We will reduce our benefits for the Inpatient Hospital stay, Long Term Acute Care, Residential Treatment Center (RTC), Skilled Nursing (SNF), or Rehabilitation Facility stay by $500 per day for each day that is not precertified prior to admission, limited to a maximum penalty of $5,000 per admission. 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. 
  • Out-of-network facilities must, prior to admission, agree to abide by the terms established by the Plan for the care of the particular member and for the submission and processing of related claims. 

You do not need precertification in these cases:  

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

Note: If you exhaust your Medicare hospital benefits and do not want to use your Medicare lifetime reserve days, then we will become the primary payor and you do need precertification.

Some surgeries and procedures, services and equipment require a precertification or preauthorization such as, but not limited to the following:

• Applied Behavioral Analysis (ABA)
• Arthroplasty, including revisions - hip, shoulder, and elbow
• Bariatric surgery - Morbid obesity surgery
• Certain prescription drugs
• Clinical trials
• Computed tomography (CT) scans
• Congenital anomaly repair
• Dialysis
• Discetomy/fusion
• Durable medical equipment over $1,000
• Electro-convulsive therapy
• Genetic testing
• Growth hormone therapy (GHT)
• Hysterectomy except for diagnosis of cancer
• Implantable cardiac monitoring
• Inpatient admissions
• Intensive outpatient therapy
• Lower extremity angiography
• Lower extremity invasive diagnostic and endovascular procedures 
• Magnetic resonance imaging (MRI)
• Magnetic resonance angiogram (MRA)
• Non-emergency/air ambulance services
• Nuclear medicine studies including nuclear cardiology
• Orthopedic and prosthetic devices over $1,000
• Partial hospitalization
• PET scans
• Psychological and neuropsychological testing exceeding 6 hours/calendar year
• Reconstructive surgery
• Sleep apnea evaluation:
  • Surgery
  • Sleep studies (in-lab) - attended or performed in a healthcare facility (home sleep studies do not require preauthorization) 
• Substance use disorder treatment
• Surgical treatment of gender dysphoria
• Transplants
• Vein ablation

Please note this list is subject to change upon notification to Plan providers. Please call customer service 866-257-0721 to verify if your procedure/services do require preauthorization.

If the admission is non-urgent or to a non-network inpatient facility (Elevate Option only), you must get the admission authorized by calling the Plan at 866-257-0721. This must be done at least four business days before the admission. If the admission is an emergency or an urgent admission, you, your provider, your representative, or the hospital must notify us by calling 866-257-0721 within one business day, the same day of admission, or as soon as reasonably possible.   

Provide the following information:

• Enrollee’s name and plan identification number;
• Patient’s name, birth date, and phone number;
• Reason for hospitalization, proposed treatment, or surgery;
• Name and phone number of admitting doctor;
• Name of hospital or facility; and
• Number of days requested for hospital stay.

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

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

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

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

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

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

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

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

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

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM. Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at 800-821-6136. You may also call OPM’s FEHB 3 at 202-606-0737 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review. We will cooperate with OPM so they can quickly review your claim on appeal. In addition, if you did not indicate that your claim was a claim for urgent care, then call us at 800-821-6136. If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim).

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. 

A reduction or termination of care can occur due to lack of medical necessity or the member's failure to demonstrate measurable progress towards the established treatment goals and further medical professional intervention is not expected to result in a significant improvement of the patient's condition. 

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.

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

If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your representative, the physician, or the hospital must phone us within one business day, the same day of admission, or as soon as reasonably possible following the emergency admission, even if you have been discharged from the hospital. If you do not phone the Plan within one business day, the same day of admission, or as soon as reasonably possible, penalties may apply - see Warning Section above for more information.

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

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

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

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

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

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 healthcare provider to give you the care or grant your request for preauthorization for a service, drug, or supply; or
2. Ask you or your provider for more information. You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days. If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due. We will base our decision on the information we already have. We will write to you with our decision.
3. Write to you and maintain our denial.

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.

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

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

If you have questions about the processing of overseas claims, contact us at 877-320-9469 or by email overseas@geha.com.  Covered providers outside the United States will be paid at the in-network level of benefits, subject to the plan deductible, copays and/or coinsurance. We will provide translation and currency conversion for claims for overseas (foreign) services. The conversion rate will be based on the date services were rendered. 

Eligibility and/or medical necessity review is required when procedures are performed or you are admitted to a hospital, outside of the United States. Review includes the procedure/service to be performed, the number of days required to treat your condition, and any other applicable benefit criteria. 

When members living abroad are stateside and seeking medical care, contact us at 800-821-6136, or visit www.geha.com/find-care to locate an in-network provider. If you utilize an out-of-network provider, out-of-network benefits would apply on the Elevate Option. Elevate Plus does not provide benefits for out-of-network providers, except in cases of emergency medical care.

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

Example: Under the Elevate Option, you pay 50% of our allowance for out-of-network office visits and any difference between our allowance and the billed amount. 

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 in-network primary care physician (PCP), under the Elevate Plus Option you pay a copayment of $25 per visit.

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

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

Elevate Plus Option

In-Network: There is no calendar year deductible for services received from an in-network provider.

Out-of-Network:  Elevate Plus does not provide out-of-network benefits. 

Elevate Option

In-Network: Under a Self Only enrollment, the deductible is considered satisfied and benefits are payable for you when your covered expenses applied to the calendar year deductible for your enrollment reach $500. Under the Self Plus One and the Self and Family enrollments, once the calendar year deductible amount of $500 is satisfied for an individual, covered benefits are payable for that individual; the calendar year deductible is met for all family members when the covered expenses accumulated to the calendar year deductible for any combination of family members reaches the Self Plus One or the Self and Family limit of $1,000.

Out-of-Network: Under a Self Only enrollment, the deductible is considered satisfied and benefits are payable for you when your covered expenses applied to the calendar year deductible for your enrollment reach $1,000. Under the Self Plus One and the Self and Family enrollments, once the calendar year deductible amount of $1,000 is satisfied for an individual, covered benefits are payable for that individual; the calendar year deductible is met for all family members when the covered expenses accumulated to the calendar year deductible for any combination of family members reaches the Self Plus One or the Self and Family limit of $2,000.

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

Example: If the billed amount is $100, the provider has an agreement with us to accept $80, and you have not paid any amount toward meeting your Elevate Option 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 ($500 per person under Elevate Option for in-network providers) 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 enrollment options in this Plan during the year, we will credit the amount of covered expenses already applied toward the deductible of your old option to the deductible of your new option.

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

In some instances, a provider may ask you to sign a "waiver" prior to receiving care. This waiver may state that you accept responsibility for the total charge for any care that is not covered by your health plan. If you sign such a waiver, whether or not you are responsible for the total charge depends on the contracts that the Plan has with its providers. If you are asked to sign this type of waiver please be aware that if benefits are denied for the services, you could be legally liable for the related expenses. If you would like more information about waivers, please contact us at 800-821-6136 or write to GEHA, P. O. Box 21542, Eagan, MN 55121.

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

Often, the provider's bill is more than a fee-for-service plan's allowance. Whether or not you have to pay the difference between our allowance and the bill will depend on the provider you use. For more information about out-of-area services, see We have Point of Service (POS) benefits in Section 1.

• In-network providers agree to limit what they will bill you. Because of that, when you use a network provider, your share of covered charges consists only of your deductible and coinsurance or copayment. Here is an example about coinsurance: You see a network physician who charges $150, but our allowance is $100. If you have met your deductible, you are only responsible for your coinsurance. That is, with the Elevate Option, you pay just – 25% of our $100 allowance ($25). Because of the agreement, your network physician will not bill you for the $50 difference between our allowance and the bill.
• Out-of-network providers, on the other hand, have no agreement to limit what they will bill you. When you use a non-network 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-network physician who charges $150 and our allowance is again $100. Because you've met your deductible, you are responsible for your coinsurance, so with the Elevate Option you pay 50% of our $100 allowance ($50). Plus, because there is no agreement between the non-network physician and us, the physician can bill you for the $50 difference between our allowance and the bill. Elevate Plus does not provide benefits for out-of-network providers, so you would pay 100% of the provider's billed charges. 

The following example illustrates how much you have to pay out-of-pocket, under the Elevate Option, for services from an in-network physician vs. an out-of-network physician. This is an example of a service for which the physician charges $150 and our allowance is $100. It shows the amount you pay if you have met your calendar year deductible.

EXAMPLE
In-network physician
Physician’s charge: $150
Our allowance: We set it at: $100
We pay: 75% of our allowance: $75
You owe: Coinsurance: 25% of our allowance: $25
+Difference up to charge?: No: $0
TOTAL YOU PAY: $25

Out-of-network physician
Physician’s charge: $150
Our allowance: We set it at: $100
We pay: 50% of our allowance: $50
You owe: Coinsurance: 50% of our allowance: $50
+Difference up to charge?: Yes: $50
TOTAL YOU PAY: $100

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

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

• For the Elevate Plus Option, the out-of-pocket maximum is $6,000 for Self Only enrollment; $12,000 when enrollment is Self Plus One or Self and Family when you use in-network providers.
• For the Elevate Option, the out-of-pocket maximum is $7,000 for Self Only enrollment; $14,000 when enrollment is Self Plus One or Self and Family if you use in-network providers.
• Only eligible out-of-pocket expenses from in-network providers count toward these limits.
• An individual under Self Plus One and Self and Family enrollment will never have to satisfy more than what is required for the out-of-pocket maximum under a Self only enrollment.

• Elevate Plus does not provide out-of-network benefits. 
• For the Elevate Option, the out-of-pocket maximum is $14,000 for Self Only enrollment; $28,000 when enrollment is Self Plus One or Self and Family if you use out-of-network providers. Only eligible out-of-pocket expenses from out-of-network providers count toward these limits.
• An individual under Self Plus One and Self and Family enrollment will never have to satisfy more than what is required for the out-of-pocket maximum under a Self only enrollment.

Out-of-pocket expenses for in-network and out-of-network benefits are the expenses you pay for covered services.

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

• Expenses you pay for non-covered services;
• Expenses in excess of our allowable amount or maximum benefit limitations;
• Charges incurred by failure to obtain pre-certification when using non-network facilities and other amounts you pay because benefits have been reduced/denied for non-compliance with the plans requirements (see Section 3); and
• Expenses in excess of plan limits for dental;
• The cost for non-approved medication and drugs that we exclude; and
• The difference (Elevate Plus and Elevate Options) between the cost of the generic and brand name medication.

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 enrollment 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.

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.

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 to pay for certain services and charges. Contact the government facility directly for more information.

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

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

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

For specific information on surprise billing, the rights and protections you have, and your responsibilities go to www.geha.com or contact the health plan at 800-821-6136. 

To be eligible to receive full benefits for mental health and substance use disorder treatment, you must call UnitedHealthcare Clinical Services at 866-257-0721.

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

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

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

The GEHA Wellness Pays program provides rewards for participation in activities that promote health maintenance as well as improvements. Up to two people per household are eligible to participate, including the subscriber and one additional member age 18 and over. Each can earn rewards up to an annual total of $500 (maximum $1,000 for the subscriber and additional member).  Rewardable activities include, but may not be limited to, the following: 

1. Health Survey 
2. Annual physical exam 
3. Preventive screenings such as biometric, cervical, colon and mammogram 
4. Telehealth visit with MDLIVE
5. Flu shot 
6. First trimester prenatal care 
7. Participation in digital programs such as online coaching, missions, quizzes, and step goals
8. Participation in targeted health programs Real Appeal and Quit for Life

Members will be issued a rewards account with a reloadable debit card, which can be used for eligible medical expenses. For detailed information about eligibility requirements, how to access the health survey and all available rewards, visit www.geha.com/rewards.

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

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

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

Your family’s healthcare resources, in your hands whether at home or on the go. The online member portal provides instant access to your family’s critical health information – anytime and anywhere. Whether you want to find a physician near you, check the status of a claim or speak directly with a healthcare professional, the portal is a your go-to resource. Key features include:

• Search for physicians or facilities by location or specialty
• Store favorite physicians and facilities
• View and share health plan ID card information
• Utilize MDLIVE for virtual visits as an alternative to seeing a physician onsite
• Check reward program status and activities
• Can be personalized with individual member avatar, notes and reminders
• Complete confidentiality
• Access and update your Personal Health Record
• Check health-related financial account balance
• Locate nearby convenience clinics, urgent care facilities, and ER’s
• Check status of deductible and out-of-pocket spending

For more information, visit www.geha.com/my-elevate.

Rally® helps simplify your healthcare experience by making it easier to understand and make the best use of your benefits. Get started online with the Rally Health Survey, where you’ll receive personalized recommendations for activities and programs. Learn how to work healthy habits into your daily routine — and get rewarded for taking action to improve your health. Plus, search for providers and compare costs to help make more informed decisions. For more information, visit www.geha.com/my-elevate.

Start living a healthier and happier life with help from Real Appeal®, an online weight loss program available at no additional cost as part of your health benefits plan. Real Appeal is proven to help you achieve lifelong results, one small step at a time. By providing access to tools for goal setting and progress tracking, online group sessions led by a coach, a Success Kit delivered to your door, and a community of members to keep you motivated, Real Appeal delivers the support you need to lose weight successfully. For more information, visit www.geha.com/my-elevate.

Quit For Life® program addresses smoking cessation as a holistic issue. Our program reaches each member through personal coaching to define accountability, offer consistent support and motivate those who are willing to change. We provide immediate goals, support medication and practical tools while also coaching members toward long-term behavior change that helps prevent costly health issues. For more information, visit www.geha.com/my-elevate.

BridgeHealth is a value-based healthcare partner that guides members to surgical Centers of Excellence (COEs) nationwide for certain pre-planned surgeries. This program is available to members age 18 and over with GEHA primary coverage*. If your pre-planned surgery is coordinated and approved through BridgeHealth, we will waive any plan deductible, coinsurance, and copayments. Your total out-of-pocket cost will be $0, including any needed travel. Provider approvals outside of BridgeHealth do not apply. 

BridgeHealth Care Coordinators guide plan members through every step of the process: decision support, scheduling, administrative assistance, pre-surgery prep and post-op recovery. At each stage, the member’s care coordinator provides guidance and support: explaining the benefit, identifying top-rated provider options, collecting medical records, arranging a second opinion, obtaining plan approvals, coordinating surgeon review, scheduling the procedure, and handling travel arrangements for plan member and a companion should travel be necessary to ensure high-quality surgical care. Benefits are subject to preauthorization requirements as set forth in Section 3. How You Get Care. For more information, visit www.geha.com/bridge-to-better-health.                                 

*BridgeHealth is only available to members with GEHA primary coverage who live in the continental US, and for members aged 18 and over. Certain surgeries may be available for members under the age of 18, please call the GEHA Clinical Concierge team at 888-216-8246, Ext. 7922 to learn more. Availability of the BridgeHealth benefit is not guaranteed. 

GEHA makes various maternity resources available to you or your covered dependent.  Visit www.geha.com/elevate-maternity-program to order your packet on pregnancy and prenatal care and to learn more about the maternity program.    

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

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

Our Personal Health Record helps you track health conditions, allergies, medications and more. This program is voluntary and confidential. To access this tool, log in through your member dashboard at www.geha.com/my-elevate. 

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

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

In most cases, providers and facilities file claims for you. Your provider must file on the form CMS-1500, Health Insurance Claim Form. Your facility will file on the UB-04 form. Submit claims to the network address on the back of the GEHA ID card, for both in-network and out-of-network claims. 

Note: The Elevate Plus Option does not provide out-of-network benefits except in cases of emergency. 

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

GEHA
P.O. Box 21542
Eagan, MN 55121

When you must file a claim - such as for services you received overseas or when another group health plan is primary - submit it on the CMS-1500 or a claim form that includes the information shown below or visit www.geha.com/Claim. Bills and receipts should be itemized and show:

• Patient’s name, date of birth, address, phone number and relationship to enrollee; 
• Patient’s Plan identification number;
• Name and address of person or company providing the service or supply;
• Dates that services or supplies were furnished;
• Diagnosis;
• Type of each service or supply; itemized bill including valid codes such as ADA, CPT, HCPCS (including NDC numbers for all Drug type charges); and
• The charge for each service or supply
• We will provide translation and currency conversion services for claims for overseas (foreign) services. The conversion rate will be based on the date services were rendered. 

Note: Canceled checks, cash register receipts, or balance due statements are not acceptable substitutes for itemized bills. Many direct to consumer program models do not support claim submissions to insurance carriers. They do not provide enough detailed, itemized, information to meet this claim submission criteria. 

In addition:

• If another health plan is your primary payor, you must send a copy of the Explanation of Benefits (EOB) form you received from any primary payor (such as the Medicare Summary Notice (MSN)) with your claim.
• Bills for home nursing care must show that the nurse is a registered or licensed practical nurse and should include nursing notes.
• If your claim is for rental or purchase of durable medical equipment; private duty nursing; or physical therapy, occupational therapy, or speech therapy, you must provide a written statement from the provider specifying the medical necessity for the service or supply and the length of time needed.
• Claims for prescription drugs and supplies must include receipts that show the prescription number, name of drug or supply, prescribing provider's name, date, and charge. A copy of the provider's script must be included with prescription drugs purchased outside the United States.

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

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

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

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

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

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

If you have questions about the processing of overseas claims, contact us at 877-320-9469 or by email overseas@geha.com. Covered providers outside the United States will be paid at the in-network level of benefits, subject to the plan deductible, copays and/or coinsurance. We will provide translation and currency conversion for claims for overseas (foreign) services. The conversion rate will be based on the date services were rendered. 

Eligibility and/or medical necessity review is required. when procedures are performed or you are admitted to a hospital, outside of the United States. Review includes the procedure/service to be performed, the number of days required to treat your condition, and any other applicable benefit criteria. 

When members living abroad are stateside and seeking medical care, contact us at 800-821-6136, or visit www.geha.com/my-elevate to locate an in-network provider. If you utilize an out-of-network provider, out-of- network benefits would apply on the Elevate Option. The Elevate Plus Option does not provide out-of-network benefits except in cases of emergency. 

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

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

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

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

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

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

b) Send your request to us at: GEHA, P.O. Box 21542, Eagan, MN 55121; and

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

d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and Explanation of Benefits (EOB) forms.

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

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

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

a) Pay the claim or

b) Write to you and maintain our denial or

c) Ask you or your provider for more information. 

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

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

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

You must write to OPM within:

• 90 days after the date of our letter upholding our 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 3, 1900 E Street NW, Washington, DC 20415-3630.

Send OPM the following information:

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

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

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

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

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

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

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

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

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

When you have double coverage, one plan normally pays its benefits in full as the primary payor and the other plan pays a reduced benefit as the secondary payor. We, like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners’ (NAIC) guidelines. For more information on NAIC rules regarding the coordinating of benefits, visit our website at www.geha.com/cob.

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

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

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

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

Please see Section 4, Your Costs For Covered Services, for more information about how we pay claims.

This plan always pays secondary to:

• Any medical payment, PIP or No-Fault coverage under any automobile policy available to you.
• Any plan or program which is required by law.

You should review your automobile insurance policy to ensure that uncoordinated medical benefits have been chosen so that the automobile insurance policy is the primary payer.

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

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

We do not cover services that:

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

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

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.

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

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

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

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

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

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

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

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

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

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

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.

Note: Requires preauthorization.

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

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

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

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

Claims process when you have the Original Medicare Plan – You will probably not need to file a claim form when you have both our Plan and the Original Medicare Plan.

When we are the primary payor, we process the claim first.

When Original Medicare is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. To find out if you need to do something to file your claim, call us at 800-821-6136 or see our website at www.geha.com.

For members enrolled in the Elevate Option, we do NOT waive deductibles, coinsurance, or copayments for Medicare members. 

For members enrolled in Elevate Plus Option we waive some costs if the Original Medicare Plan is your primary payor as follows:

• Inpatient hospital benefits: If you are enrolled in Medicare Part A, we waive the copayment or the deductible and coinsurance.
• Outpatient facility benefits: If you are enrolled in Medicare Part B, we waive the copayment or the deductible and coinsurance.
• Medical and surgery benefits and mental health/substance use disorder care: If you are enrolled in Medicare Part B, we waive the copayment or the deductible and coinsurance.
• Office visit providers and MinuteClinic (where available): If you are enrolled in Medicare Part B, we waive the copayment or the deductible and coinsurance  for office visits.
• If you obtain services from a non-Medicare provider, we will limit our payment to the copayment or coinsurance amount we would have paid after Original Medicare’s payment based on our Plan allowable and the type of service you receive.

Please review the following that illustrates your cost share if you are enrolled in Medicare Part B and the Elevate Plus Option. If you purchase Medicare Part B, then we waive some costs because Medicare will be the primary payor.

Elevate Plus Option    

Benefit Description: Deductible
You Pay without Medicare: In-Network: $0
You Pay without Medicare: Out-of-Network: N/A
You Pay with Medicare Part B: In Network: $0
You Pay with Medicare Part B: Out-of-Network: $0

Benefit Description: Catastrophic Protection Out-of-Pocket Maximum
You Pay without Medicare: In-Network: $6,000 self only/$12,000 family
You Pay without Medicare: Out-of-Network: N/A
You Pay with Medicare Part B: In Network: $6,000 self only/$12,000 family
You Pay with Medicare Part B: Out-of-Network: N/A

Benefit Description: Part B Premium Reimbursement Offered
You Pay without Medicare: In-Network: N/A
You Pay without Medicare: Out-of-Network: N/A
You Pay with Medicare Part B: In Network: N/A
You Pay with Medicare Part B: Out-of-Network: N/A

Benefit Description: Primary Care Physician
You Pay without Medicare: In-Network:  $25
You Pay without Medicare: Out-of-Network: N/A
You Pay with Medicare Part B: In Network: $0
You Pay with Medicare Part B: Out-of-Network: $0

Benefit Description: Specialist
You Pay without Medicare: In-Network: $40
You Pay without Medicare: Out-of-Network: N/A
You Pay with Medicare Part B: In Network: $0
You Pay with Medicare Part B: Out-of-Network: $0

Benefit Description: Inpatient Hospital
You Pay without Medicare: In-Network: $250/day, up to a maximum of $1,000/admission
You Pay without Medicare: Out-of-Network: N/A
You Pay with Medicare Part B: In Network: $0
You Pay with Medicare Part B: Out-of-Network: $0

Benefit Description: Outpatient Hospital
You Pay without Medicare: In-Network: $250 per day per facility
You Pay without Medicare: Out-of-Network: N/A
You Pay with Medicare Part B: In Network: $0
You Pay with Medicare Part B: Out-of-Network: $0

Benefit Description: Incentives Offered
You Pay without Medicare: In-Network: N/A
You Pay without Medicare: Out-of-Network: N/A
You Pay with Medicare Part B: In Network: N/A
You Pay with Medicare Part B: Out-of-Network: N/A

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

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

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

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 healthcare choices (like HMOs and regional PPOs) in some areas of the country. To learn more about Medicare Advantage plans, contact Medicare at 1-800-MEDICARE, (1-800-633-4227), (TTY: 877-486-2048) or at www.medicare.gov.

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

This Plan and another plan’s Medicare Advantage plan: You may enroll in another plan’s Medicare Advantage plan and also remain enrolled in our FEHB plan. We will still provide benefits when your Medicare Advantage plan is primary, even out of the Medicare Advantage plan’s network and/or service area (if you use our Plan providers). However, if you do go outside the Medicare Advantage plan's network and/or service area, 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 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.

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

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.

For the Elevate Plus option, if your physician accepts Medicare assignment, we waive some of your deductibles, copayments and coinsurance for covered charges.

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

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

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

The process of making decisions about future healthcare options in the event of a medical crisis. This might involve the appointment of a substitute decision maker or the completion of an advance care directive or similar document. 

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

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

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

See Section 4, Your Costs for Covered Services. 

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

See Section 4, Your Costs for Covered Services.  

See Section 4, Your Costs for Covered Services.  

We do not provide benefits for custodial care, regardless of who recommends the care or where it is provided. The Carrier or its delegated medical professionals determine which services are custodial care. 

Custodial care includes treatment, supplies or services, that are provided to a patient mainly to help with activities of daily living. These activities include but are not limited to:

• Service, supplies, and treatment that are designed mainly to train or assist the patient in personal hygiene or other activities of daily living rather than provide therapeutic treatment; or 
• Personal care such as help ambulating getting in and out of bed, eating by spoon, tube or gastrostomy, exercise, and dressing;
• Homemaking, such as preparing meals or special diets;
• Acting as companion or sitter;
• Supervising medication that can usually be self-administered; 
• Physical, emotional, or behavioral treatment or services that can be provided by non-licensed caregivers with minimal instruction, including but not limited to recording temperature, pulse, and respirations, or administration and monitoring of feeding systems; and
• Services or treatment where further medical professional intervention is not expected to result in significant improvement in the member's condition. The member's condition is no longer demonstrating measurable progress towards established treatment goals that have been documented in the patient's treatment record. 

See Section 4, Your Costs for Covered Services.  

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

Equipment and supplies that:

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

The date the benefits described in this brochure are effective:

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

Experimental or Investigational Service(s) - medical, surgical, diagnostic, psychiatric, mental health, substance use disorders or other healthcare services, technologies, supplies, treatments, procedures, drug therapies, medications or devices that , at the time we make a determination regarding coverage in a particular case are determined to be any of the following:

• Not approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed for the proposed use and not identified in the American Hospital Formulary Service or the United States American Hospital Pharmacopoeia Dispensing Information as appropriate for the proposed use.
• Not recognized, in accordance with generally accepted medical standards, as being safe and effective for your condition.
• Subject to review and approval by any institution review board for the proposed use. (Devices which are FDA approved under the Humanitarian Use Device exemption are not considered to be Experimental or Investigational.)
• The subject of an ongoing clinical trial that meets the definition of a Phase 1, 2 or 3 clinical trial set forth in the FDA regulations, regardless of whether the trial is actually subject to FDA oversight.

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

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

The condition of an individual who is unable to conceive or produce conception.

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

Often referred to as LTCH or LTAC, these facilities provide services for patients who need extended intensive or critical, hospital-level of care beyond that of the traditional short hospital stay. LTCH's specialize in treating patients who have more than one serious condition yet have the potential to improve with time and care and return to their previous health status. Generally, services are focused on respiratory therapy, head trauma treatment, and pain management.

We do not provide benefits for long-term care, regardless of who recommends the care or where it is provided. The Carrier or its delegated medical professionals determine which services are long-term care.

A range of services and support provided to meet personal care needs on a long-term basis. While some medical care may be necessary, most of the care provided is not and does not require a licensed caregiver. This encompasses a spectrum of services provided in a variety of settings for people who do not have full independence because of a medical condition, injury, or chronic and/ or behavioral illness.

Long-term care is often used to provide custodial care as well as instrumental activities of daily living necessary for safety and health.

Long-term care is usually custodial care that has lasted for 90 days or more yet can begin prior to 90 days dependent on the member's response to professional intervention.

Long-term care and long-term acute care are not one and the same. See the definition of long-term acute care for more information about those services.

Inborn errors of metabolism are rare genetic (inherited) disorders in which the body cannot properly turn food into energy. The disorders are usually caused by defects in specific proteins (enzymes) that help break down (metabolize) parts of food. GEHA will cover medical food for a diagnosis of IEM. Medical Food is defined as a food which is recommended by a physician after an evaluation and is intended to provide for the dietary management of a disease or condition that has specific nutritional requirements. GEHA will not cover "grocery" food items that can routinely be obtained online or in stores (e.g. gluten-free breads).

Healthcare services provided for the purpose of preventing, evaluating, diagnosing or treating a sickness, injury, mental illness, substance use disorder or its symptoms, that are all of the following as determined by us or our designee, within our discretion.

• In accordance with Generally Accepted Standards of Medical Practice.
• Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for your sickness, injury, mental illness, substance use disorder, disease or its symptoms.
• Not mainly for your convenience or that of your doctor or other healthcare provider.
• Not more costly than an alternate drug, service(s) or supply that is at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of your sickness, injury, disease or symptoms.
• Is not custodial or long-term care (see the Plan's definition on the previous page)

If no credible scientific evidence is available then standards are based on Physician specialty society recommendations or professional standards of care may be considered. We reserve the right to consult expert opinion in determining whether healthcare services are Medically Necessary.

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

Inpatient Mental Health:

• Acute Care Hospital
• Residential Treatment Center (RTC)  

Intensive Day Treatment:

Intensive day treatment programs are outpatient services that must be rendered on an outpatient basis. Regardless of where services are rendered, the provider and/or the facility, must be licensed to provide intensive day mental health and/or substance use treatment and must meet GEHA's definition of a covered provider in Section 3. GEHA does not cover room and board during intensive day treatment programs. Under the direction of a physician, services must be provided for at least two hours per day and may include group, individual, and family therapy along with psychoeducational services and adjunctive psychiatric medication management.

• Partial Hospitalization Program (PHP): A facility based outpatient treatment program for mental health and/or substance use disorder conditions not requiring 24-hour care.  Twenty or more hours of care per week is usually delivered at a minimum of four hours a day, five days a week. Time frames and frequency will vary based on condition, severity, and individual treatment plan. 
• Intensive Outpatient Program (IOP): A comprehensive, structured outpatient treatment program that includes extended periods of individual or group therapy sessions for mental health and/or substance use disorders conditions. It is an intermediate level of care between traditional outpatient therapy and partial hospitalization, delivered in an outpatient facility or outpatient professional office setting.  Nine or more hours of care per week is usually delivered at a minimum of three hours a day, three days a week.  Time frames and frequency will vary based on condition, severity, and individual treatment plan. 

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

Federal or State policies that bar healthcare providers from charging patients for care that is attributable to certain avoidable complications or errors, such as wrong site surgery.

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

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

Allowable expense (plan allowance) is a healthcare expense, including deductibles, coinsurance and copayments, that is covered at least in part by any plan covering the person. When a plan provides benefits in the form of services, the reasonable cash value of each service will be considered an allowable expense and a benefit paid.

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

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

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

1. For emergent services, air ambulance, and services performed by out-of-network providers rendered at in-network facilities, the Plan allowance will be the "recognized amount" as defined by federal law. 
2. We consult standard industry guides, such as national databases of prevailing healthcare charges from FAIR Health or another identified data source, that are available for our use in a given state or geographic area. After the data supplier removes outliers from the claim data they collect, they group the remaining data by percentiles. We use the 70th percentile. This means that out of every 100 reports remaining after outliers amount or less.
3. For services or supplies obtained in a state or geographic area where the above data source is unavailable for our use, and also for dialysis centers and outpatient dialysis performed at a hospital our non-network Plan allowance is two times the Medicare participating provider allowance for the service or supply in the geographic area in which it was performed or obtained. This Medicare-based allowance is not used for those services where Medicare sets a fixed national payment amount that does not  vary geographically (such as blood draws). Medicare fee schedule information for physician services may be obtained at www.cms.hhs.gov/PFSlookup.
   
   Note: Labs drawn during the week of dialysis treatments and drugs provided on the day of dialysis are part of the bundled  dialysis payment.
4. Some Plan allowances may be submitted to medical consultants who recommend allowances based on standard industry relative value guidelines. For services or supplies for which Medicare does not provide an allowance amount, we may use the current fee schedule used by the Federal Office of Workers Compensation (OWCP). OWCP fee schedule information may be obtained at www.dol.gov/OWCP/regs/feeschedule/fee.htm. For services or supplies that do not have a value currently established by public healthcare care plans such as Medicare or Medicaid, or for implantable devices and surgical hardware, we may use medical consultants to determine an appropriate allowance. We may also conduct independent studies to determine the usual cost of a service or supply in a geographic area, or to establish allowances for services or supplies provided outside the United States.

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

Plan allowance for prescription drugs is determined using Average Wholesale Price or other industry-standard reference price data. Charges for some Plan allowances are stated in this brochure. These include limited benefits such as manipulative therapy care and routine dental care.

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

To estimate our maximum Plan allowance for a non-network provider before you receive services from them, call us at 800-821-6136. For more information, see Differences between our allowance and the bill in Section 4.

You should also see Important Notice About Surprise Billing - Know Your Rights in Section 4 that describes your protections against surprise billing under the No Surprises Act. 

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

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

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

The process of collecting information and obtaining authorization from the health plan prior to an inpatient admission or other selected ambulatory procedures and services.

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

A sound natural tooth is a whole or properly restored tooth that has no condition that would weaken the tooth or predispose it to injury prior to the accident, such as decay, periodontal disease, or other impairments. For purposes of the Plan, damage to a restoration, such as a prosthetic crown or prosthetic dental appliance (i.e., bridgework), would not be covered as there is no injury to the natural tooth structure.

Specialty medications are biotech or biological drugs that are oral, injectable or infused, or may require special handling. To maximize patient safety, all specialty medications require prior authorization. These drugs are used in the treatment of complex, chronic medical conditions such as hemophilia, multiple sclerosis, hepatitis, cancer, rheumatoid arthritis, pulmonary hypertension, osteoarthritis, and immune deficiency.

Online/virtual doctor visits provided remotely by means of telecommunications technology. 

Unproven services, including medications, that are determined not to be effective for treatment of the medical condition and/or not to have a beneficial effect on health outcomes due to insufficient and inadequate clinical evidence from well-conducted randomized controlled trials or cohort studies in the prevailing published peer-reviewed medical literature.

• Well-conducted randomized controlled trials. (Two or more treatments are compared to each other, and the patient is not allowed to choose which treatment is received.)
• Well-conducted cohort studies from more than one institution. (Patients who receive study treatment are compared to a group of patients who receive standard therapy. The comparison group must be nearly identical to the study treatment group.)

We have a process by which we compile and review clinical evidence with respect to certain health services. From time to time, we issue medical and drug policies that describe the clinical evidence available with respect to specific healthcare services. These medical and drug policies are subject to change without prior notice.

Please note: If you have a life-threatening sickness or condition (one that is likely to cause death within one year of the request for treatment) we may, in our discretion, consider an otherwise unproven service to be a covered health service for that sickness or condition. Prior to such a consideration, we must first establish that there is sufficient evidence to conclude that, albeit unproven, the service has significant potential as an effective treatment for that sickness or condition.

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

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

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

If you believe your claim qualifies as an urgent care claim, please contact our Customer Service Department at 800-821-6136. 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.

Us and We refer to Government Employees Health Association, Inc.

You refers to the enrollee and each covered family member.

In-network: Nothing for preventive care; $25 copay primary care physician; $40 copay specialist

32

In-network: $250 per day up to a maximum of $1,000 per admission

66

In-network: $250 per day per facility

67

In-network: $200 copayment per visit

Out-of-network: $200 copayment per visit

73

Regular cost-sharing

76

In-network benefits ONLY

Network pharmacy 30-day supply:

• Generic: Member pays lesser of $10 or pharmacy’s usual and customary cost
• Preferred Brand: Member pays lesser of $80 or pharmacy’s usual and customary cost
• Non-preferred Brand: 50% of Plan allowance

86

Mail order network 90-day supply:

• Generic: Member pays lesser of $20 or the cost of the drug
• Preferred Brand: Member pays lesser of $200 or the cost of the drug
• Non-preferred Brand: 50% of Plan allowance

86

Accidental Dental coverage only. Services are paid at regular medical Plan benefits.

91

Nothing after $6,000 Self Only ($12,000 Self Plus One or Self and Family) per year for in-network providers.

27

In-network: Nothing for preventive care; $10 copay primary care physician; $25 copay specialist

32

In-network: 25%* of the Plan allowance

66

In-network: 25%* of the Plan allowance

67

In-network: 25%* of the Plan allowance

73

Regular cost-sharing

76

In-network benefits ONLY

Network pharmacy 30-day supply:

• Generic: Member pays lesser of $4 or pharmacy’s usual and customary cost
• Preferred Brand: Member pays 50% of Plan allowance up to a maximum of $500
• Non-preferred Brand: 100% of all charges

86