• No pre-existing condition limitation

• Minimum essential coverage (MEC)

Please visit the Internal Revenue Service (IRS) website at www.irs.gov/uac/Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision for more information on the individual requirement for MEC.

• Minimum value standard

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

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

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

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

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

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

• Types of coverage available for you and your family

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

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

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

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

• Family Member Coverage

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

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

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

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

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

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

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

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

• Children’s Equity Act

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

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

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

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

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

• When benefits and premiums start

The benefits in this brochure are effective January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be processed according to the 2021 benefits of your prior plan or option. If you have met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option.  However, if your prior plan left the FEHB Program at the end of the year, you are covered under that plan’s 2020 benefits until the effective date of your coverage with your new plan. Annuitants’ coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective date of coverage.

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

• When you retire

When FEHB coverage ends

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

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

Any person covered under the 31 day extension of coverage who is confined in a hospital or other institution for care or treatment on the 31st day of the temporary extension is entitled to continuation of 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 Temporary Continuation of Coverage (TCC).

Upon divorce

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

Temporary Continuation of Coverage (TCC)

If you leave Federal service, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC). The Patient Protection and Affordable Care Act (ACA) did not eliminate TCC or change the TCC rules.  For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if you lose your Federal job, if you are a covered dependent child and you turn 26, regardless of marital status, etc.  Under TCC, you no longer receive a government contribution, but instead pay the entirety of your premium plus an administration service charge.

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

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

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

Finding replacement coverage

This Plan no longer offers its own non-FEHB plan for conversion purposes. If you would like to purchase health insurance through the Affordable Care Act’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 provide you with assistance in finding a non-group contract available inside or outside the Marketplace if:

• Your coverage under TCC or the spouse equity law ends (If you canceled your coverage or did not pay your premium, you cannot convert);
• You decide not to receive coverage under TCC or the spouse equity law; or
• You are not eligible for coverage under TCC or the spouse equity law.

You must contact us in writing within 31 days after you are no longer eligible for coverage. For assistance in finding coverage, please contact us at 800-638-8432.

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

Health Insurance Marketplace

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

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

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 800-638-8432 or write to us at Rural Carrier Benefit Plan, 1630 Duke Street, 2nd Floor, Alexandria, VA 22314-3466.  You may also request replacement cards through our website: www.rcbphealth.com.    

Where you get covered care

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

Covered providers

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

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

Covered facilities

Covered facilities include:

Hospital:

1) An institution that is accredited as a hospital under the hospital accreditation program of the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO); or

2) Any other institution that is operated pursuant to law, under the supervision of a staff of doctors and with 24-hour-a-day nursing service, and that is primarily engaged in providing:

• General inpatient care and treatment of sick and injured persons through medical, diagnostic, and major surgical facilities, all of which facilities must be provided on its premises or under its control; or
• Specialized inpatient medical care and treatment of sick or injured persons through medical and diagnostic facilities (including X-ray and laboratory) on its premises, under its control, or through a written agreement with a hospital (as defined above) or with a specialized provider of those facilities.

In no event shall the term hospital include a convalescent nursing home or institution or part thereof that:

1) Is used principally as a convalescent facility, rest facility, nursing facility, or facility for the aged;

2) Furnishes primarily domiciliary or custodial care, including training in the routines of daily living; or

3) Is operated as a school. 

Residential Treatment Center – Residential treatment centers (RTCs) are accredited by a nationally recognized organization and licensed by the state, district, or territory to provide residential treatment for medical conditions, mental health conditions, and/or substance abuse. RTCs provide 24-hour residential evaluation, treatment and comprehensive specialized services relating to the individual’s medical, physical, mental health, and/or substance abuse therapy needs all under the active participation and direction of a licensed physician who is practicing within the scope of the physician’s license.  RTCs offer programs for persons who need short-term transitional services designed to achieve predicted outcomes focused on fostering improvement or stability in functional, physical and/or mental health, recognizing the individuality, strengths, and needs of the persons served.

Skilled Nursing Facility - An institution or that part of an institution that provides convalescent skilled nursing care 24 hours a day and is certified (or is qualified and could be certified) as a skilled nursing facility under Medicare.

Birthing Center: A licensed facility that is equipped and operated solely to provide prenatal care, to perform uncomplicated spontaneous deliveries, and to provide immediate post-partum care.

Hospice: A public or private agency or organization that:

1) Administers and provides hospice care; and

2) Meets one of the following requirements:

• Is licensed or certified as a hospice by the State in which it is located;
• Is certified (or is qualified and could be certified) to participate as a hospice under Medicare;
• Is accredited as a hospice by the JCAHO; or
• Meets the standards established by the National Hospice Organization.

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 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 specialist based on the above circumstances, you can continue to see your specialist and your In-network benefits 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 800-638-8432. If you are new to the FEHB Program, we will reimburse you for your covered services while you are in the hospital beginning on the effective date of your coverage.

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

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

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

You need prior Plan approval for certain services 

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

You must get prior approval or precertification for certain services. Failure to do so may result in a minimum $500 penalty to be taken from any inpatient or Skilled Nursing facility benefits provided by the Plan.  Please see warning under this Section. In addition, we may deny benefits for services listed in this Section under Other services.

Inpatient hospital admission

Precertification is the process by which we evaluate the medical necessity of your proposed stay and the number of days required to treat your condition prior to your inpatient hospital admission or residential treatment care. Unless we are misled by the information given to us, we will not change our decision on medical necessity.

Warning:

Your in-network physician or hospital will take care of requesting precertification. You should always ask your physician or hospital whether or not they have contacted us for precertification. For out-of-network hospitals and Skilled Nursing Facility admissions, we will reduce our benefits for the out-of-network inpatient hospital, Skilled Nursing Facility stay or residential treatment care by $500 if no one contacts us for precertification. If the stay is not medically necessary, we will only pay for any covered medical services and supplies that are otherwise payable on an outpatient basis.

You do not need precertification in these cases:

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

Other services

Some services require a referral, precertification, or prior approval. For a complete list refer to www.aetna.com/health-care-professionals/precertification/precertification-lists.html.

Please call 800-638-8432 for approval for: 

• Inpatient confinements (except hospice) For example, surgical and non-surgical stays; stays in a skilled nursing or rehabilitation facility; and maternity and newborn stays that exceed the standard length of stay(LOS)
• Observation stays more than 24 hours
• Ambulance – prior approval required for transportation by fixed-wing aircraft (plane)
• Autologous chondrocyte implantation, Carticel
• Certain mental health services, inpatient admissions, Residential treatment center (RTC) admissions, Transcranial magnetic stimulation (TMS) and Applied Behavior Analysis (ABA)
• Chiari malformation decompression surgery
• Cochlear device and/or implantation
• Covered transplant surgeries
• Dialysis visits – when request is initiated by an in-network provider, and dialysis to be performed at an out-of-network facility
• Dorsal column (lumbar) neurostimulators; trial orimplanation
• Electric or motorized wheelchairs and scooters
• Endoscopic nasal balloon dilation procedures
• Gender reassignment surgery, even if outside of the 50 United States
• Gene therapy, gene editing and gene silencing
• Hip surgery to repair impingement syndrome
• Hyperbaric oxygen therapy
• Lower limb prosthetics
• Out-of-network freestanding ambulatory surgical facility services, when referred by an in-network provider
• Orthognathic surgery procedures, bone grafts, osteotomies and surgical management of the temporomandibular joint (TMJ)
• Osseointegrated implant
• Osteochondral allograft/knee
• Power morcellation with uterine myomectomy, with hysterectomy or for removal of uterine fibroids
• Proton beam radiotherapy
• Reconstructive or other procedures that maybe considered cosmetic, such as:
  • Blepharoplasty/canthoplasty
  • Breast reconstruction/breast enlargement
  • Breast reduction/mammoplasty
  • Cervicoplasty
  • Excision of excessive skin due to weight loss
  • Gastroplasty/gastric bypass
  • Lipectomy or excess fat removal
  • Surgery for varicose veins, except stab phlebectomy
• Referral or use of out-of-network physician or provider for non-emergent services, unless the member understands and consents to the use of an out-of-network provider under their out-of-network benefits
• Shoulder arthroplasty
• Spinal procedures, such as:
  • Artificial intervertebral disc surgery
  • Cervical, lumbar and thoracic laminectomy/laminotomy procedures
  • Spinal fusion surgery
• Uvulopalatopharyngoplasty, including laser-assisted procedures
• Ventricular assist devices
• Video Electroencephalographic (EEG)
• BRCA genetic testing
• Cardiac rhythm implantable devices
• Hip and knee arthroplasties
• Pain Management
• Pediatric Congenital Heart Surgery
• Polysomnography (attended sleep studies)
• Radiation oncology
• Radiology imaging such as CT scans, MRIs, MRAs, and nuclear

Note: We only cover medically necessary procedures and services. We encourage you to contact the Plan to confirm coverage for proposed treatment prior to incurring services.

Some prescription drugs require prior authorization. Please call 800-237-2767 for approval for:

• Specialty prescription medications and weight management drugs (see Section 5(f))
• Certain compound medications (see Section5(f))

How to request precertification for an admission or get prior authorization for Other services

First, you, your representative, your physician, or your hospital must call us at 800-638-8432 before admission or services requiring prior approval are rendered.

Next, provide the following information:

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

• Non-urgent care claims

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

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

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

• Urgent care claims

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

If you fail to provide sufficient information, we will contact you within 24 hours after we receive the claim to let you know what information we need to complete our review of the claim.  You will 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 800-638-8432.  You may also call OPM’s FEHB 2 at 202-606-3818 between 8 AM and 5 PM Eastern Time to ask for the simultaneous review.  We will cooperate with OPM so they can quickly review your claim on appeal.  In addition, if you did not indicate that your claim was a claim for urgent care, call us at 800-638-8432. If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim).

• Concurrent care claims

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

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

• Emergency inpatient admission

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

• Maternity care

You do not need precertification of a maternity admission for a routine delivery. However, if your medical condition requires you to stay more than 3 days after admission for a vaginal delivery or 5 days after admission for a cesarean section, then your doctor  or the hospital must contact us for precertification  of additional days. Further, if your baby stays after you are discharged, your doctor or the hospital must contact us for precertification of additional days for your baby.

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

• If your hospital stay needs to be extended

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

• If your treatment needs to be extended

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

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

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

• To reconsider a non-urgent care claim

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

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

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

2. Ask you or your provider for more information.

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

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

3. Write to you and maintain our denial.

• To reconsider an urgent care claim

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

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

• To file an appeal with OPM

The Federal Flexible Spending Account Program - FSAFEDS

• Health Care FSA (HCFSA) – Reimburses you for eligible out-of-pocket health care expenses (such as copayments, deductibles, physician prescribed over-the-counter drugs and medications, vision and dental expenses, and much more) for you and your tax dependents, including adult children (through the end of the calendar year in which they turn 26).

• FSAFEDS offers paperless reimbursement for your HCFSA through a number of FEHB and FEDVIP plans. This means that when you or your provider files claims with your FEHB or FEDVIP plan, FSAFEDS will automatically reimburse your eligible out-of-pocket expenses based on the claim information it receives from your plan.

Copayment

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

Example: When you see your In-network physician you pay a copayment of $20 per day for a primary care provider and $35 per day for a specialist provider. If you see more than one In-network physician on the same day, you pay one copayment for each different physician seen on that day. When you have a stay in an In-network hospital, you pay $200 for the first day of your hospital stay and for an Out-of-network hospital; you pay $400 for the first day of your hospital stay.

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.

Deductible

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

• The calendar year deductible for In-network services is $350 per person and for Out-of-network services it is $800 per person. Under a Self Only enrollment, the deductible is considered satisfied and benefits are payable for you when your covered expenses applied to the calendar year deductible for your enrollment reach $350 for In-network services or $800 for Out-of-network services under High Option. Under a Self Plus One enrollment, the deductible is considered satisfied and benefits are payable for you and one other eligible family member when the combined covered expenses applied to the calendar year deductible for your enrollment reach $700 for In-network services or $1,600 for Out-of-network services under High Option. Under a Self and Family enrollment, the deductible is satisfied for all family members when the combined covered expenses applied to the calendar year deductible for family members reach $700 for In-network services and $1,600 for Out-of-network services.  Any expenses incurred that apply toward deductibles for in-network or out-of-network apply toward both in-network and out-of-network limits.
• We have a separate prescription drug deductible of $200 per person each calendar year that applies to all covered prescription drugs that you purchase at a retail drugstore or pharmacy.  The prescription drug deductible of $200 does not apply to members who have Medicare A and B as primary coverage.
• We also have a separate deductible for dental care of $50 per person each calendar year.

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.

Coinsurance

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

Example: You pay 30% of our allowance for office visits under our Out-of-network benefit.

If your provider routinely waives your cost

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

For example, if your physician ordinarily charges $100 for a service but routinely waives your 30% coinsurance, the actual charge is $70. We will pay $49.00 (70% of the actual charge of $70).

Waivers

In some instances, a provider may ask you to sign a “waiver” prior to receiving care. This waiver may state that you accept responsibility for the total charge for any care that is not covered by your health Plan. If you sign such a waiver, whether or not you are responsible for the total charge depends on the contracts that the Plan has with its providers. If you are asked to sign this type of waiver, please be aware that, if benefits are denied for the services, you could be legally liable for the related expenses. If you would like more information about waivers, please contact us at 800-638-8432.

Differences between our allowance and the bill

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

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

When you live in the Plan’s network area, you should use an In-network provider whenever possible. The following two examples explain how we will handle your bill when you go to an In-network provider and when you go to an Out-of-network provider. When you use an In-network provider, the amount that you pay will usually be much less.

• 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 an In-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, you pay just – 15% of our $100 allowance ($15). Because of the agreement, your In-network physician will not bill you for the $50 difference between our allowance and his/her bill.

Follow these procedures when you use an In-network provider to receive In-network benefits: 

• Verify with us that your home address is correct
• When you make an appointment, verify that the physician or facility is still a network provider
• Present your Rural Carrier Benefit Plan ID card at the time that you receive services to receive In-network benefits
• Generally, you do not pay an in-network provider at the time of service, except for any copayment that you owe. In-network providers must bill us directly. We must reimburse the provider directly.  In-network providers will then bill you for any balance due after our payment to them.
• Out-of-network providers, on the other hand, have no agreement to limit what they will bill you. When you use an Out-of-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 an out-of-network physician who charges $150 and our allowance is again $100. Because you’ve met your deductible, you are responsible for your coinsurance, so you pay 30% of our $100 allowance ($30). Plus, because there is no agreement between the out-of-network physician and us, the physician can bill you for the $50 difference between our allowance and his/her bill.

Participating providers agree to limit what they can collect from you. You will still have to pay your deductible and coinsurance. These providers agree to write off the difference between billed charges and the discount amount.

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

EXAMPLE

Network physician

Physician's charge: $150

Our allowance: We set it at $100

We pay: 85% of our allowance: $85

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

+ Difference up to charge? No -$0

Total You Pay: $15

Out-of-network physician

Physician's charge: $150

Our allowance: We set it at $100

We pay: 70% of our allowance: $70

You owe: Coinsurance: 30% of our allowance: $30

+Difference up to charge? Yes - $50

Total You Pay: $80

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

For those benefits where copayments, coinsurance or deductibles apply, we pay 100% of the Plan allowance for the rest of the calendar year after your expenses total to:

• $5,000 for Self Only enrollment or $10,000 for Self Plus One or Self and Family enrollment when you use In-network providers/facilities and CVS Health In-network retail and/or mail service pharmacy, or
• $7,000 for Self Only enrollment or $14,000 for Self Plus One or Self and Family enrollment when you use Out-of-network providers/facilities and CVS Health Out-of-network retail and/or mail service pharmacy combined.  Any expenses incurred that apply toward the catastrophic out-of-pocket maximum for in-network or out-of-network apply toward both in-network and out-of-network limits.
• For Self Plus One and Self and Family enrollments, once any individual family member reaches the Self Only catastrophic protection out-of-pocket maximum during the calendar year, that member’s claims will no longer be subject to cost-sharing amounts for eligible medical expenses for the rest of the year. All other family members will be required to meet the balance of the catastrophic protection out-of-pocket maximum.

Your out-of-pocket maximum does not include the following:  

• Expenses for dental care
• Expenses in excess of our allowances or maximum benefit limits
• Any penalty you pay for failing to get approval for a hospital stay or residential treatment care
• Any amount you pay for failing to get approval for additional days in the hospital after the initial length of a hospital stay is approved
• Expenses you pay for services, supplies and drugs not covered by us
• Expenses covered by specialty drug copay assistance cards for Self Plus One and Self and Family enrollments, once any individual family member reaches the Self Only catastrophic protection out-of-pocket maximum during the calendar year, that member’s claims will no longer be subject to cost-sharing amounts for eligible medical expenses for the rest of the year. All other family members will be required to meet the balance of the catastrophic protection out-of-pocket maximumFor Self Plus One and Self and Family enrollments, once any individual family member reaches the Self Only catastrophic protection out-of-pocket maximum during the calendar year, that member’s claims will no longer be subject to cost-sharing amounts for eligible medical expenses for the rest of the year. All other family members will be required to meet the balance of the catastrophic protection out-of-pocket maximum

Carryover

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

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.

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 claims process (see Section 8). 

Aexcel Designated Providers

A guide to the Aexcel specialist performance designation

Aexcel is our designation for high-performing specialty physicians and physician groups in twelve medical specialty areas:

• Cardiology
• Cardiothoracic surgery
• Gastroenterology
• General Surgery
• Neurology
• Neurosurgery
• Obstetrics and gynecology
• Orthopedics
• Otolaryngology/ENT
• Plastic Surgery
• Urology
• Vascular surgery

Physicians with the Aexcel specialist designation have met added standards for volume, clinical performance, and efficiency. Aetna evaluates these providers using specific standards and, based on the results, gives them the Aexcel specialty designation.

Visit www.rcbphealth.com and select “Locate a Provider”, and look for the blue star next to the provider’s name for an Aexcel designated provider.  If a specialist does not have a blue star, this does not mean the physician does not provide quality services. It could be that Aetna does not have enough information available to evaluate a particular physician or the physician’s specialty is not one of the 12 specialty categories. The Aexcel information is only a guide.  There are many ways to evaluate doctor practices.  You should talk with your primary care physician and the specialist you are considering before making a decision. Please note that ratings have a chance for error. An Aexcel designation is not a guarantee of service quality or treatment outcome.  Therefore, the Aexcel designation should not be the only reason for choosing a specialty doctor.

Institutes of Excellence (IOE)

The Plan has special arrangements with facilities to provide services for tissue and organ transplants only. The transplant network was designed to give you the opportunity to access providers that demonstrate high quality medical care for transplant patients.

Note: If a qualified tissue/organ transplant is medically necessary and performed at one of the Institutes of Excellence (IOE) network facilities, you may be eligible for reimbursement of some related to expenses for travel and lodging for the transplant recipient and one family member or caregiver. We may also assist you and one family member or caregiver with travel and lodging arrangements.  This benefit does not apply to normal in-network facilities but only to the IOE network facilities.

Reimbursement is subject to IRS regulations.

Note: Receipts are required for reimbursement of travel and lodging costs.

You or your physician can coordinate arrangements by calling a case manager in Aetna's Medical Management Department at 800-638-8432. For additional information regarding the Aetna Transplant Network, please call toll-free 800-638-8432.

Informed Health® Line

Informed Health® Line provides eligible members with phone access to registered nurses experienced in providing information on a variety of health topics. Informed Health Line is available 24 hours a day, 7 days a week and can be reached by calling 800-638-8432. We provide TDD service for the hearing and speech-impaired. We also offer foreign language translation for non-English speaking members. Informed Health Line nurses cannot diagnose, prescribe medication or give medical advice.

Members also may e-mail a nurse by clicking on the “Talk to a Nurse” link on the Aetna member website at www.RCBPhealth.com.  Nurses respond to these online member inquiries within 24 hours.

The online Healthwise Knowledgebase is an online education support resource available to members through the Aetna member website. It is a user-friendly decision- support tool that provides clinical information on 6,000 health topics, 600 medical tests and procedures, 500 support groups and 3,000 medications. The tool promotes informed health decision-making and helps members learn about their treatment options.

Informed Health Line nurses also have access to the Healthwise video library and can relay video links to callers upon request or to provide further education/support of the health topic they discussed.

PinnacleCare 

PinnacleCare provides expert medical guidance when you and your covered dependents are faced with a serious or complicated medical condition and might not know where to turn. We are here to help you find the right specialist, get a second opinion, and navigate the medical system. PinnacleCare saves you time and helps you avoid unnecessary medical procedures by making sure you see the right in-network provider, when needed.

Our customized services may include:

• Expert medical opinion/confirmation of your diagnosis
• Research on your diagnosis and treatment options
• Customized report identifying top local, regional, or national specialists to fit your needs
• Facilitated appointments with top specialists or Centers of Excellence
• Gathering, organizing, and forwarding of your key medical records
• Virtual consultation for second medical opinion if the specialist you need is out of your area

PinnacleCare representatives are available to assist you Monday through Friday 8 a.m. - 6 p.m. (EST) at 888-442-7380 or PinnacleCare.com/support. Let us guide you to the best health care possible.

Complex and Chronic Disease Management Program

Accordant Health Management offers programs for the following complex chronic medical conditions:

• Seizure disorders (Epilepsy)
• Rheumatoid Arthritis (RA)
• Multiple Sclerosis (MS)
• Crohn's Disease
• Parkinson's Disease (PD)
• Systemic Lupus Erythematosus (SLE)
• Myasthenia Gravis (MG)
• Sickle Cell Disease (SCD)
• Cystic Fibrosis (CF)
• Hemophilia
• Scleroderma
• Gaucher Disease
• Polymyositis
• Amyotrophic Lateral Sclerosis (ALS-Lou Gehrig's Disease)
• Dermatomyositis
• Chronic Inflammatory Demyelinating Polyradiculoneuropathy (CIDP)
• Ulcerative Colitis
• Human Immunodeficiency Virus (HIV)
• Chronic Kidney Disease (CKD)

For more information on the Accordant Health Management programs, please call toll-free 866-380-6295.

Aetna In Touch Care Program

Aetna In Touch Care (ITC) program offers you:

• Ongoing, one-on-one phone calls with a nurse who serves as a trusted resource for you and your family
• Digital support that provides a variety of resources to help you better manage your health
• Customized health action plans based on your needs and preferences

To start using the digital support of Aetna ITC, log in to the Aetna member website. First-time users will need to register, and then go to your health dashboard. 

We’re committed to giving you all the support you deserve. That’s why we offer both digital and nurse support, and you can move easily between the two.

You’ll benefit from many digital health and wellness related programs and resources: 

• Personal health record–organize and store your health history and information, plus get health alerts and notifications.
• Health assessment – get a custom, step-by-step plan based on questions about your health and habits.
• Health Decision Support – learn about your health care and treatment options. 
• Online coaching programs – find dynamic health coaching programs that give you personalized support.
• Aetna Health Dashboard–view your health information, and find entry points to health and wellness programs and resources. 

Aetna ITC Program also includes a Social Work Program designed to improve the quality of life by taking steps to help you locate the right resources.

Social workers can help connect you with community resources that can provide services to them in times of need. Some examples include:

• Local food pantries
• Utility or rental assistance programs
• Home-delivered meal services
• Support groups
• Counseling services

Social workers can refer you to Federal and state programs, such as:

• Social Security
• Medicare
• Medicaid

Our social workers are licensed and degreed professionals who work in a variety of settings, including government and non-profit organizations, hospitals, schools and clinics. Social workers also help treat mental, emotional, and behavioral issues in clinical settings.

Compassionate Care Program:

The Compassionate Care Program is designed to improve the quality of life through health condition management and to reduce costs for you and your family with advanced illness, including those facing imminent end-of-life decisions. It provides tools and information to encourage advance planning for the kind of issues often associated with an advanced illness, such as living wills, advance directives, and tips on how to begin conversations about these issues with loved ones. This program is designed to provide quality of life improvement through health condition management and to reduce costs for you and your family at the end of life through timely member and caregiver education. It encourages better use of community-based services and resources, systemic palliative care integration and enhanced hospice utilization and retention. This program is a voluntary program provided to you and your dependents at no additional cost.

If you would like to contact the Plan for more information about the ITC Program, please call 800-638-8432. We are available to assist you Monday-Friday from 6:00 a.m. to 5 p.m.  Mountain Time (MST)

Transform Care Programs

The Transform Care Programs for diabetes and hypertension help you stay medication adherent, control your blood glucose and your blood pressure. Participation is voluntary. These programs provide eligible members with a connected glucometer and a digital blood pressure cuff. Digital apps are provided for easier monitoring of your condition. The readings are shared with a health coach that you can interact with through messaging and phone calls. Eligible participants are identified based on their medical history. All eligible members are offered two Minute Clinic visits and unlimited coaching. For questions regarding this program, call 866-623-1441

Lab Savings program

The Lab Savings program gives you the option of having covered outpatient laboratory testing paid at 100%, if your covered provider sends your lab work to Quest Diagnostics or LabCorp for processing.

The Lab Savings program is an optional program. If you or your provider chooses not to use Lab Card, you will not be penalized. You will simply receive the regular Plan benefit for lab tests (see page 28).

The Lab Savings program covers most outpatient laboratory testing covered by the Plan provided that the tests are ordered by a covered provider and processed by Quest Diagnostics or LabCorp. Outpatient lab work covered by the Lab Savings Program includes: blood tests (e.g., cholesterol, CBC, thyroid), urine testing (e.g., urinalysis), cytology and pathology (e.g., pap smear, biopsy) and cultures (e.g., throat culture).

The Lab Savings program does not cover: lab tests ordered during a hospital stay, lab work needed on an emergency (STAT) basis and time sensitive lab tests such as fertility testing, bone marrow studies and spinal fluid tests. Lab Savings program also does not cover X-rays, imaging tests (e.g., CT scans, MRI scans, PET scans), mammography, dental work or lab testing processed by another lab testing company.

If you have one or more of the following chronic conditions, you have the opportunity to discuss one-on-one with a CVS Health pharmacist any questions or concerns about the medication(s) you are taking. Please call toll-free 866-624-1481.

• Diabetes
• Congestive Heart Failure (CHF)
• Coronary Artery Disease (CAD)
• Hypertension (high blood pressure)
• Dyslipidemia (high cholesterol)
• Asthma
• Chronic obstructive pulmonary disease (COPD)
• Depression
• Osteoporosis
• Breast cancer

Aetna member website

Aetna member website - Secure Member Portal

Access the Aetna member website by visiting www.RCBPhealth.com, then click on “Aetna member website” under “Member Resources”. This provides you secure access to a broad range of your personal health information after you register.

The Aetna member website provides tools to become an optimal health care consumer. Services such as the following are available:

• Interactive Personal Health Record — The Plan will build your health record with information from your claims. You also can add other personal health information such as blood pressure, weight, vital statistics, immunization records, and more.
• Claims information — You can view and organize your claims the way you want: sort by date range, health care provider etc.
• Explanation of Benefits (EOBs) — You can access and print your EOBs.
• Decision support tools — You can check the average cost of medical procedures or view hospital quality information before you receive care.
• Health information — You can obtain health information and news that is relevant to you.
• Interactive health tools — You can assess, understand, and manage conditions and health risks. Easy to use content helps members navigate common, but sometimes complex conditions.
• KidsHealth Library — You can access an online resource that educates families and helps them make informed decisions about children's health. KidsHealth is an engaging way to encourage preventive behaviors and motivate kids and teens to become more involved in their health.

Aetna Health App

After registration/log-in you can use the Aetna Health app to:

• Find doctors and facilities using location and see maps for directions
• Locate urgent care - walk in clinics, urgent care, emergency room
• View claims and claim details
• View benefits and balances
• Track out-of-pocket dollars
• View ID card information
• Store ID card offline
• Get cost estimates before you receive care
• View your Health History
• Share your opinion (feedback)

The app can be downloaded for free onto your mobile device.

How to Access:

• Android: Go to Play Store and search for Aetna Health.
• iPhone: Go to App Store and search for Aetna Health.
• Text”Aetna” to 90156 to receive a link to download the Aetna Health app (message and data rates may apply)

Supported Devices:

• Android

• iPhone®

Wellness Incentive

Members (over 18 years of age) who participate in the plans Wellness Incentive programs can earn up to $250 in rewards per calendar year.  

Complete the Health Risk Assessment (HRA) and $100 will be deposited in a Wellness Incentive Fund Account to reimburse you for certain unreimbursed medical expenses (“Eligible Medical Expenses”).  The questions help you uncover your health risks so you’re better able to manage them before they get out of control.  Plus, once you take your HRA you receive a personalized health summary to help you better understand your health risks.  

Complete a biometric screening through Quest Diagnostics by December 1st of the calendar year and $100 will be deposited in a Wellness Incentive Fund Account to reimburse you for certain unreimbursed medical expenses (“Eligible Medical Expenses”).  You can obtain the biometric screening at a Quest Diagnostics Patient Service Center (PSC) or you can obtain the screening from your physician by having your physician complete a Biometric Screening Physician Results Form and fax it back to Quest by December 1st of the calendar year.  To register for your screening call 855-623-9355 or to print a copy of the Biometric Screening Physician Results Form to take to your physician, visit  My.QuestforHealth.com  and enter the registration key: RCBP.   

Once your biometric screening is complete, your results will be available at My.QuestforHealth.com and will also be mailed to you to help you better understand your health risks.

Members with the following conditions may be eligible to earn up to $50 for each incentive to be deposited into a Wellness Incentive Account:

• Controlling Blood Pressure for members with high blood pressure.

The Plan will reach out to you if you are identified through claims data as having high blood pressure and will provide you a form for your provider to complete. On the form, your provider must document two (2) controlled blood pressure readings below 140/90 on separate visits during the current calendar year for you to earn the incentive.

If you are unable to meet this goal, you will receive the incentive if one of the following is completed:

Dietary and nutritional counseling (obtain three counseling visits, which includes individual and group behavioral counseling). See Section 5(a).

Telephonic Health Coach Program(Tobacco Cessation, Weight Management, Exercise, Nutrition, Stress Management). 

• Controlling A1c Hemoglobin (HbA1c) levels for members with diabetes

The Plan will reach out to you if you are identified through claims data as having diabetes and ask you to have your provider submit your HbA1c laboratory results. Your HbA1c laboratory results must be less than 8% during the calendar year for you to earn the incentive.

If your HbA1c is greater than or equal to 8%, you will receive the incentive if one of the following is completed: 

Dietary and nutritional counseling (obtain three counseling visits, which include individual and group behavioral counseling). See Section 5(a).

Diabetic Education or Training (see Section 5(a).

Enroll in the Transform Care Programs and check blood glucose using the meter four times per continuous calendar month for four months. Note: You always should follow directions from your health care provider with respect to the frequency of use and glucose testing.

Telephonic Health Coach Program (Tobacco Cessation, Weight Management, Exercise, Nutrition, Stress Management). 

• Prenatal Care for members who are pregnant

If you are pregnant, your provider must submit documentation of a prenatal care visit during the first trimester. The documentation submitted must include a copy of the prenatal care medical record including Obstetric Panel testing, ultrasound, or prenatal exam from your provider for you to earn the incentive.

• Eliminating tobacco use for tobacco users

If you are identified as a tobacco user you can participate in the Plan's Tobacco Cessation Program (see Section 5(a)).  You must complete:

- At least two quit attempts as part of our Tobacco Cessation Program.  The quit attempt must include tobacco cessation counseling sessions of at least 30 minutes each.  

Note: To earn the incentive for the conditions outlined above, documentation needs to be mailed by December 1st of the calendar year to: Aetna, C/O FEHB QM, 4400 NW Loop 410, Suite 101, San Antonio, TX 78229.

Eligible Medical Expenses, as defined by Internal Revenue Code Section 213(d), include your deductible, coinsurance, and copayments (e.g., prescription drug copayments) incurred by you or your covered dependents.

Reimbursement for your deductible and coinsurance will be sent to you if there are funds available. Other expenses, like dental, vision, and prescriptions purchased through the Plan’s retail pharmacy network or mail order program cannot be reimbursed automatically. You will need to submit a copy of your receipt with a completed claim form (Wellness Incentive Claim Form) found on the Aetna member website. 

• Visit RCBPhealth.com
• Select “Official Plan Documents” under “Member Resources”
• Select “Wellness Incentive Claim Form"

If you are enrolled in a Flexible Spending Account (FSA) and wellness incentives have been deposited into your wellness fund, you may not receive reimbursement for the same medical expense from both your wellness fund account and your FSA. If a medical expense is covered under both your wellness fund account and your FSA, you must use the funds in your wellness fund account first. Enrollees may receive reimbursements from their FSAs for medical expenses that are covered by both their wellness fund account and their FSA only after the funds in the wellness fund account have been exhausted. In order to receive reimbursement from your wellness fund account for qualified medical expenses, you must complete and sign a Wellness Incentive Claim Form certifying that you have not received reimbursement for the applicable qualified medical expense and that you will not seek such reimbursement under any other plan or arrangement. If you receive reimbursements from more than one plan or arrangement for the same qualified medical expense, the amount received in excess of the qualified medical expense may be taxable to you as income.

To monitor the availability of funds in your Wellness Incentive Fund Account, visit the Plan's website (www.RCBPhealth.com), and then click on “Aetna member website”. Once you log on to the Aetna member website, look for the "Health and Wellness" icon, click “Discover a Healthier You” and proceed.

After you have completed a wellness activity, the Plan will deposit the amount earned into a Wellness Incentive Fund Account. Please allow at least 4 weeks after completing a wellness activity for incentives earned to be deposited in the Wellness Incentive Fund Account. You will be reimbursed for certain unreimbursed medical expenses such as deductible, coinsurance, copays and other “Eligible Medical Expenses” approved by the IRS. 

If you have any questions or would like more information about the program, please call customer service at 800-638-8432.

Comprehensive Pain Management Program

RCBP has initiated a Comprehensive Pain Management program to combat the spectrum of chronic pain to acute pain for our members. RCBP members suffer a high incidence of pain largely due to the aging population and the repetitive motion demands of their jobs. Three out of four RCBP members have received a diagnosis for a specific musculoskeletal issue over the past three years which is the tip of the spear for the member’s physical suffering and the fiscal burden on RCBP members. 

A Comprehensive Pain Management Program is needed to help our members dealing with chronic pain management to help them increase their mobility, decrease opioid dependency, improve their quality of life and to help ward off secondary anxiety and depression that often accompanies unchecked long-term pain.

RCBP is leveraging multiple vender partners to provide theinfrastructureand process for a successful pain program.  RCBP’s partner, TrestleTree,is collaborating and coordinating with Aetna and CVS Health to help facilitate a multi-pronged identification and engagement strategy into TrestleTree’s behavior change pain management program.  Aetna’s case managers are currently handing-off at-risk members to TrestleTree’s Coaches and CVS Health is providing a daily Rx file feed directly to TrestleTree to identify each member that had an opioid or pain management medication filled the previous day.

Want more information about the Comprehensive Pain Management Program?  Contact TrestleTree directly at 855-553-5109.

We also have an Opioid Support Program through TrestleTree.  See elsewhere in this Section under Telephonic Health Coaching Program.  

Telephonic Health Coach Program

The Telephonic Health Coach program provides you and your covered dependents the opportunity to work one-on-one with a Health Coach to improve your health. A Health Coach is a healthcare professional who partners with you to transform your health goals into action. Your Health Coach will provide guidance, support, and resources to help you overcome obstacles that may be keeping you from realizing optimal health. You can talk to a Health Coach about the following health-related matters: 

• Tobacco Cessation
• Weight Management 
• Exercise 
• Nutrition 
• Stress Management
• Opioid Support Program

How does health coaching work? 

• You talk with your Health Coach over the phone through conveniently scheduled appointments and create a plan that is right for you to meet your health goals. Everything in the program is tailored to you.

• You explore ways to make changes in your behavior that will last.

• You receive written materials from your Health Coach that can help you decide where you want to go with your health and how to get there.

• Appointments can range from 15 minutes to 30 minutes once a month or twice a month. How long and how often you meet with your Health Coach depends on your individual needs.

To enroll in a program, contact a Health Coach at 855-553-5109. Coaches are available Monday through Thursday from 8:00 a.m. – 10:00 p.m. ET and Friday from 8:00 a.m. – 6:00 p.m. ET. You may also enroll online at enroll.trestletree.com (passcode: RCBP).

Note: See Section 5(a), Educational classes and programs for more information.

Health Risk Assessment

Make a difference in your health in just a few minutes by completing a simple Health Risk Assessment (HRA). It asks questions about your health history and habits.  It can:

• Help you learn more about your health risks, so you can take steps to lower them

• Provide strategies to improve your health and well-being

• Give you personalized health results to share with your doctor

To schedule an appointment to complete your telephonic HRA, contact a Health Coach at 855-553-5109. Coaches are available Monday through Thursday from 8:00 a.m. – 10:00 p.m. ET and Friday from 8:00 a.m. – 6:00 p.m. ET. You can also schedule an appointment online at http://enroll.trestletree.com (passcode: RCBP).

Telehealth

AbleTo Support Program

AbleTo is a web-based video conferencing personalized 8-week treatment support designed to address the unique emotional and behavioral health needs of individuals learning to live with conditions like heart disease, type 2 diabetes, chronic pain or life events like losing a loved one or having a baby. Members work with the same therapist and coach each week to set reasonable goals toward healthier lifestyle changes.

There are several ways we identify members that may benefit from the AbleTo support such as:

• Your nurses or clinicians may refer you to AbleTo as they work directly with you and can refer you if it’s determined that you can benefit from AbleTo
• If identified, an Engagement Specialist from AbleTo will contact you to introduce the treatment

If you feel you would benefit from this program, would like more information, or enroll in this program please call 866-287-1802 or visit their website at www.AbleTo.com/enroll.

Value Added Programs and Services

The Plan may offer a number of programs and services to members to maximize optimal health, reduce out of pocket costs, and assist with special conditions and needs as they become available during the year. Visit www.rcbphealth.com for a current list of programs, program criteria, and contact information.

Digital (online) Coaching Program

Digital coaching programs — These include nine base programs for weight management, smoking cessation, stress management, nutrition, physical activity, cholesterol management, blood pressure, depression management, and sleep improvement. Programs are prioritized based on a member’s health risk assessment to help create a personalized plan for successful behavior change. Members can engage and participate through personalized messaging with tools and resources to help track their progress and stay on the path to wellness.

This provides you secure access to a broad range of your personal health information after you register.

Access the Plan's website tool from your Aetna member website at www.rcbphealth.com. Select “Discover a Healthier You” under the Stay Healthy icon, then "Dashboard" and finally "Digital Coach”.

How to claim benefits

To obtain claim forms or other claims filing advice or answers about our benefits, contact us at 800-638-8432 or at our website at www.rcbphealth.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. For claims questions and assistance, call us at 800-638-8432.

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. Send your claims to:

Rural Carrier Benefit Plan
P O Box 14079
Lexington, KY 40512-4079

Bills and receipts should be itemized and show:

• Name of patient, date of birth and relationship to enrollee;
• Plan identification number of the enrollee;
• Name, address and tax identification number of the person or firm providing the services or supplies;
• Dates that services or supplies were furnished;
• Diagnosis;
• Valid medical or ADA dental code if it exists or a description of each service or supply; and 
• The charge for each service or supply.

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

In addition:

• Generally, you need to complete only one claim form each calendar year. You should also complete a new claim form if the claim is for an accidental injury, your mailing address changes, or if your other insurance/Medicare coverage changes.
• 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. See Section 9 for Medicare claims.
• Claims for rental or purchase of durable medical equipment must include the price of the equipment, a prescription and a written statement from the provid specifying the medical necessity, including the diagnosis, and the estimated length of time needed.
• Claims for dental care must include a copy of the itemized bill from the dentist (including the information above) and the dentist's Federal Tax ID number. The Plan does not have a separate dental claim form.   

Please see Section 5(f), Prescription drug benefits for instructions on how to file a claim for prescription drugs that you buy at a non-participating (out-of-network) retail pharmacy.

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.

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

Overseas claims

Follow the same procedures when submitting claims for overseas (foreign) services as you would when submitting claims for stateside services.  Claims for overseas services should include an English translation.  We will use the U.S. dollar exchange rate applicable on the date service was incurred if you do not supply us with a currency exchange rate along with a paid receipt.

Overseas providers (those outside the 50 United States) will be paid at the In-Network level of benefits for covered services. Overseas hospitals and physicians are under no obligation to file claims for you. You may be required to pay for the services at the time you receive them and then submit a claim to us for reimbursement.

Notice requirements

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

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

1

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

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

b) Send your request to us at: Rural Carrier Benefit Plan, P O Box 14079, Lexington, KY 40512-4079; 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.

c) Ask you or your provider for more information.

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

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

3

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

You must write to OPM within:

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

Write to OPM at: United States Office of Personnel Management, Healthcare and Insurance, Federal Employee Insurance Operations, FEHB 2 1900 E Street, NW, Washington, DC 20415-3620.

Send OPM the following information:

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

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

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

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

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

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

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

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

When you have other health coverage

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

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

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

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

Note: The $200 deductible for prescriptions purchased at a network retail pharmacy does not apply when you have Medicare Parts A and B as primary coverage.

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

• TRICARE and CHAMPVA

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

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

• Workers' Compensation

We do not cover services that:

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

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

• Medicaid

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

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

When others are responsible for injuries

Our right to pursue and receive subrogation and reimbursement recoveries is a condition of, and a limitation on, the nature of benefits or benefit payments and on the provision of benefits under our coverage. By accepting Plan benefits, you agree to the terms of this provision.

If you have received benefits or benefit payments as a result of an injury or illness, and you or your representatives, heirs, administrators, successors, or assignees receive payment from any party that may be liable, a third party’s insurance policies, your own insurance policies, or a workers’ compensation program or policy, you must reimburse us out of that payment. The Plan's right of reimbursement extends to all benefit payments for related treatment incurred up to and including the date of settlement or judgement, regardless of the date that those expenses were submitted to the Plan for payment

We are entitled to reimbursement to the extent of the benefits we have paid or provided in connection with your injury or illness. However, we will cover the cost of treatment that exceeds the amount of the payment you received.

Reimbursement to us out of the payment shall take first priority (before any of the rights of any other parties are honored) and is not impacted by how the judgment, settlement, or other recovery is characterized, designated, or apportioned. Our right of reimbursement is not subject to reduction based on attorney fees or costs under the “common fund” or any other doctrine and is fully enforceable regardless of whether you are “made whole” or fully compensated for the full amount of damages claimed.

We may, at our option, choose to exercise our right of subrogation and pursue a recovery from any liable party as successor to your rights.

If you do pursue a claim or case related to your injury or illness, you must promptly notify us and cooperate with our reimbursement or subrogation efforts.

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

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

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

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

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

You further agree to cooperate fully with us in the event we exercise our subrogation right.

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

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

Clinical trials

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

If you are a participant in a clinical trial, this 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 trial. This Plan does not cover these costs.

When you have Medicare

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

• What is Medicare?

Medicare is a health insurance program for:

• People 65 years of age or older
• Some people with disabilities under 65 years of age
• People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant)

Medicare has four parts:

• Part A (Hospital Insurance). Most people do not have to pay for Part A. If you or your spouse worked for at least 10 years in Medicare-covered employment, you should be able to qualify for premium-free Part A insurance. (If you were a Federal employee at any time both before and during January 1983, you will receive credit for your Federal employment before January 1983.) Otherwise, if you are age 65 or older, you may be able to buy it. Contact 800-MEDICARE 800-633-4227, TTY: 877-486-2048 for more information.
• Part B (Medical Insurance). Most people pay monthly for Part B. Generally, Part B premiums are withheld from your monthly Social Security check or your retirement check.
• Part C (Medicare Advantage). You can enroll in a Medicare Advantage Plan to get your Medicare benefits. Please review the information on coordinating benefits with Medicare Advantage Plans on the next page.
• Part D (Medicare prescription drug coverage). There is a monthly premium for Part D coverage.  Before enrolling in Medicare Part D, please review the important disclosure notice from us about the FEHB prescription drug coverage and Medicare.  The notice is on the first inside page of this brochure. For people with limited income and resources, extra help in paying for a Medicare prescription drug plan is available. For more information about this extra help, visit the Social Security Administration online at www.socialsecurity.gov, or call them at 800-772-1213, TTY: 800-325-0778.

• Should I enroll in Medicare?

The decision to enroll in Medicare is yours. We encourage you to apply for Medicare benefits 3 months before you turn age 65. It’s easy. Just call the Social Security Administration toll-free number 800-772-1213, TTY: 800-325-0778 to set up an appointment to apply. If you do not apply for one or more Parts of Medicare, you can still be covered under the FEHB Program.

If you can get premium-free Part A coverage, we advise you to enroll in it. Most Federal employees and annuitants are entitled to Medicare Part A at age 65 without cost. When you don’t have to pay premiums for Medicare Part A, it makes good sense to obtain the coverage. It can reduce your out-of-pocket expenses as well as costs to the FEHB, which can help keep FEHB premiums down.

Everyone is charged a premium for Medicare Part B coverage. The Social Security Administration can provide you with premium and benefit information. Review the information and decide if it makes sense for you to buy the Medicare Part B coverage. If you do not sign up for Medicare Part B when you are first eligible, you may be charged a Medicare Part B late enrollment penalty of a 10% increase in premium for every 12 months you are not enrolled.  If you did not take Part B at age 65 because you were covered under FEHB as an active employee (or you were covered under your spouse's group health insurance plan and he/she was an active employee), you may sign up for Part B (generally without an increased premium) within 8 months from the time you or your spouse stop working or are no longer covered by the group plan. You also can sign up at any time while you are covered by the group plan.

If you are eligible for Medicare, you may have choices in how you get your health care. Medicare Advantage is the term used to describe the various private health plan choices available to Medicare beneficiaries. The information in the next few pages shows how we coordinate benefits with Medicare, depending on whether you are in the Original Medicare Plan or a private Medicare Advantage plan.

(Please refer to page 98 for information about how we provide benefits when you are age 65 or older and do not have Medicare.)

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

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

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

When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care except you do not need to get a hospital stay approved when Medicare pays first. We do not require preauthorization and concurrent review of mental health and substance misuse disorder treatment when Medicare Part B pays first. However, when Medicare stops paying benefits for any reason, you must follow our precertification, preauthorization and concurrent review procedures.

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

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

When Original Medicare is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. To find out if you need to do something to file your claim, call us at 800-638-8432.

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

Benefit Description-Deductible
High Option You pay without Medicare In-Network: $350/$700
High Option You pay without Medicare Out-of-network: $800/$1600
High Option You pay with Medicare In-network: N/A
High Option You pay with Medicare Out-of-network: N/A

Benefit Description - Catastrophic Protection  Out of pocket maximum
High Option You pay without Medicare In-Network: $5,000/$10,000
High Option You pay without Medicare Out-of-network: $7,000/$14,000
High Option You pay with Medicare In-network: $5,000/$10,000
High Option You pay with Medicare Out-of-network: $7,000/$14,000

Benefit Description - Part B premium reimbursement offered
High Option You pay without Medicare In-Network: N/A
High Option You pay without Medicare Out-of-network: N/A
High Option You pay with Medicare In-network: N/A
High Option You pay with Medicare Out-of-network: N/A

Benefit Description - Primary care physician
High Option You pay without Medicare In-Network: $20 copay
High Option You pay without Medicare Out-of-network: 30% of Plan allowance and any difference after deductible
High Option You pay with Medicare In-network: Nothing
High Option You pay with Medicare Out-of-network: Nothing

Benefit Description - Specialist
High Option You pay without Medicare In-Network: $35 Copay
High Option You pay without Medicare Out-of-network: 30% of Plan allowance and any difference after deductible
High Option You pay with Medicare In-network: Nothing
High Option You pay with Medicare Out-of-network: Nothing

Benefit Description - Inpatient Hospital
High Option You pay without Medicare In-Network: $200 copay per admission
High Option You pay without Medicare Out-of-network: $400 copay per admission and any difference after deductible
High Option You pay with Medicare In-network: Nothing
High Option You pay with Medicare Out-of-network: Nothing

Benefit Description - Outpatient Hospital
High Option You pay without Medicare In-Network: 15% of Plan’s allowance after calendar year deductible
High Option You pay without Medicare Out-of-network: 30% of Plan allowance and any difference after calendar year deductible
High Option You pay with Medicare In-network: Nothing
High Option You pay with Medicare Out-of-network: Nothing

Benefit Description - Incentives Offered
High Option You pay without Medicare In-Network: N/A
High Option You pay without Medicare Out-of-network: N/A
High Option You pay with Medicare In-network: N/A
High Option You pay with Medicare Out-of-network: N/A

Note: The $200 deductible for prescriptions purchased at a network retail pharmacy does not apply when you have Medicare Parts A and B as primary coverage.

• Private Contract with your physician

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

• Medicare Advantage (Part C)

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

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

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

• Medicare prescription drug coverage  (Part D)

Does not participate with Medicare,

your deductibles, coinsurance, copayments, and any balance up to 115% of the Medicare approved amount.

Does not participate with Medicare and is not a member of our PPO network,

your out-of-network deductibles, coinsurance, and any balance up to 115% of the Medicare approved amount.

Opts-out of Medicare via private contract,

your deductibles, coinsurance, copayments, and any balance your physician charges.

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

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

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

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

• If your physician accepts Medicare assignment, you pay nothing for covered charges.
• If your physician does not accept Medicare assignment, you pay the difference between the “limiting charge” or the physician’s charge (whichever is less) and our payment combined with Medicare’s payment.

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

Clinical Trials Cost Categories

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

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

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

Coinsurance is the percentage of our allowance that you must pay for your care. You may also be responsible for additional amounts. See page 20.

A copayment is a fixed amount of money you pay when you receive covered services. See page 20.

Treatment or services, no matter who recommends them or where you receive them, which a person without medical skills can provide safely and reasonably. In addition, treatment and services designed mainly to help the patient with daily living activities. These include:

• personal care like help in: walking; getting in and out of bed; bathing; eating (by spoon, gastrostomy or tube); exercising; dressing
• homemaking services, like preparing meals or special diets
• moving the patient
• acting as a companion or sitter
• supervising the taking of medication that can usually be self-administered; or
• treatment or services that anyone can perform with minimal training like recording temperature, pulse and respirations or administering and monitoring a feeding system.

We determine what treatments or services is custodial care.

A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for those services. See page 20.

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

A medical treatment or procedure, or a drug, device or biological product is experimental or investigational if:

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

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

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

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

The inability to conceive after 12 months of unprotected intravaginal sexual relations (or 12 cycles of artificial insemination) for women under age 35, and 6 months of unprotected intravaginal sexual relations (or 6 cycles of artificial insemination) for women age 35 and over.

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

• are appropriate to diagnose or treat the patient's condition, illness or injury;
• are consistent with standards of good medical practice in the United States; 
• are not primarily for the personal comfort or convenience of the patient, the family, or the provider; 
• are not a part of or associated with the scholastic or vocational training of the patient; and

• in the case of inpatient care, cannot be provided safely in an outpatient setting. 

The fact that a covered provider prescribes, recommends, or approves a service, supply, drug or equipment does not, by itself, make it a medical necessity.

Mental health conditions/substance use disorder

Conditions and diseases listed in the most recent edition of the International Classification of Diseases (ICD) as mental, behavioral, and neurodevelopmental disorders, to be determined by the Plan.

Observation Care

Observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment, that are provided while a decision is being made regarding whether a patient will require further treatment as a hospital inpatient or whether the patient will be able to be discharged from the hospital. Observation services are commonly ordered for a patient who presents to the emergency room department and who then requires a significant period of treatment or monitoring in order to make a decision regarding their inpatient admission or discharge. Some hospitals will bill for observation room status (hourly) and hospital incidental services.

If you are in the hospital for more than a few hours, always ask your physician or the hospital staff  if your stay is considered inpatient or outpatient. Although you may stay overnight in a hospital room and receive meals and other hospital services, some hospital services-including “observation care”- are actually outpatient care. Since observation services are billed as outpatient care, outpatient facility benefit levels apply and your out-of-pocket expenses may be higher as a result.

This Plan uses National Standardized Criteria Sets and other recognized clinical guidelines in making determinations to evaluate the appropriateness of observation care services. 

Plan allowance

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

In-network Providers – Our Plan allowance is a negotiated amount between the Plan and the provider. We base our coinsurance on this negotiated amount, and the provider has agreed to accept the negotiated amount as full payment for any covered services rendered. This applies to all benefits in Section 5 of this brochure.

Out-of-network Providers – Our Plan allowance is the lesser of: (1) the provider’s billed charge; or (2) the Plan’s out-of-network (OON) fee schedule amount. The Plan’s OON fee schedule amount is equal to the 90th percentile amount for the charges listed in the Prevailing Healthcare Charges System, administered by Fair Health, Inc. The OON fee schedule amounts vary by geographic area in which services are furnished. We base our coinsurance of this OON fee schedule amount. This applies to all benefits in Section 5 of this brochure. For urine testing services, the Out-of-network allowance is the maximum Medicare allowance for such services.

If you receive services from a participating provider, the Plan’s allowance will be the amount that the provider has negotiated and agreed to accept for the services and or supplies. Benefits will be paid at Out-of-network benefit levels, subject to the applicable deductibles, coinsurance and copayments.

For certain services, exceptions may exist to the use of the OON fee schedule to determine the Plan’s allowance for Out-of-network providers, including, but not limited to, the use of Medicare fee schedule amounts. For claims governed by OBRA ’90 and ’93, the Plan allowance will be based on Medicare allowable amounts as is required by law. For claims where the Plan is the secondary payer to Medicare (Medicare COB situations), the Plan allowance is the Medicare allowable charge.

The plan allowance for prescription medications is based on the average wholesale price or an alternative pricing benchmark.

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

Routine preventive services/immunizations

Preventive services:

• We cover preventive services, counseling and screenings recommended under the Affordable Care Act (ACA). For a complete list of ACA preventive care services, visit: www.healthcare.gov/what-are-my-preventive-care-benefits. We cover preventive services, counseling and screenings that that have a recommendation of “A” or “B” from the United States Preventive Services Task Force (USPSTF). For a complete list of preventive care services with an “A” or “B” recommendation by the USPSTF visit www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations/. If our preventive services, counseling and screening benefits are more generous than the ACA or USPSTF “A” or “B” recommendations, we pay under the appropriate benefit without cost sharing when delivered by an in-network provider.

Immunizations:

• We cover routine adult immunizations. See www.cdc.gov/vaccines/schedules/index.html.

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

Urgent care claims

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

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

Urgent care claims 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 800-638-8432. You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care.

Medical servides provided by physicians: Diagnostic and treatment services provided in the office

In-network primary care provider: $20/office visit

In-network specialist provider: $35/office visit

Out-of-network: 30% of our allowance and any difference between our allowance and the billed amount*

29-30

Medical services provided by physicians: Surgery

In-network: 15% of our allowance (No deductible)

Out-of-network: 30% of our allowance and any difference between our allowance and the billed amount

48-52

Medical services provided by physicians: Telehealth

In-network:  Nothing (No deductible) if you contact DialCare for services

Out-of-network: No benefit

31

Services provided by a hospital: Inpatient

In-network: $200 copayment per admission (waived for maternity stay)

Out-of-network: $400 copayment per admission; 30% of covered charges

59-61

Services provided by a hospital: Outpatient

In-network: 15% of our allowance*

Out-of-network: 30% of our allowance* and any difference between our allowance and the billed amount

61

Emergency benefits: Accidental Injury

Nothing for emergency room visit and first physician office visit

64

Emergency Room Benefits: Medical emergency

Emergency room benefits for In-network and Out-of-network services: 15% of the Plan allowance^*

65

Mental health and substance use treatment: Applied Behavioral Analysis (ABA)

In-network: 15% of the Plan allowance (no deductible)

Out-of-network: 30% of the Plan allowance and any difference between our allowance and the billed amount

67

Mental Health and Substance Abuse treatment: Inpatient

In-network: $200 copayment per admission

Out-of-network: $400 copayment per admission; 30% of covered charges.

68

Mental health and substance use treatment: Outpatient

In-network: 15% of the Plan allowance*

Out-of-network: Physician Services--30% of the Plan allowance and any difference between our allowance and the billed amount*

Facility Chargers:--30% of the Plan allowance and any difference between our allowance and the billed amount*

69

Prescription drugs: Network and Non-Network pharmacy

30% of cost*

73-74

Prescription drugs: Mail Order Pharmacy

Up to a 90 day supply: Tier I--$10/generic; Tier II--$50/preferred brand name; Tier III--$80/non-preferred brand name; Tier IV--Specialty drugs $80 for a 30 day supply/$125 for a 90 day supply

74

Prescription drugs: Mail order pharmacy with Medicare Part B

Up to a 90 day supply: Tier I--$10/generic; Tier II--$40/preferred brand name; Tier III--$70/non-preferred brand name: Tier IV--
Specialty drugs $80 for a 30 day supply/$125 for a 90 day supply

74

Dental care:

Any difference between our scheduled allowance and the billed amount

77-78

Special features:

Flexible benefits option; Cancer treatment benefit; Kidney dialysis benefit; 24 hour nurse line; Travel assistance program; Routine eye exam benefit; Healthy maternity program; Complex and Chronic Disease Management Program; Aetna In Touch Care Program; Livongo, a remote diabetes monitoring program; Lab Savings program; Smoking cessation program; Institutes of Excellence (IOE); Genetic testing for prescription drugs; Pharmacy Advisor Program; Wellness Incentive program; Health Risk Assessment; Telephonic Health Coaching program; Telehealth program

79-89

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

In-network: Nothing after $5,000 for Self Only enrollment or $10,000 for Self Plus One or Self and Family enrollment per calendar year including CVS Health In-network retail and/or mail service pharmacy.

Out-of-network: Nothing after $7,000 for Self Only enrollment or $14,000 for Self Plus One or Self and Family per calendar year including CVS Health In-network retail and/or mail service pharmacy.

Note: Benefit maximums apply and some costs do not count toward this protection

25