• No pre-existing condition limitation

• Minimum essential coverage (MEC)

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

• Minimum value standard

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

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

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

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

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

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

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

• Types of coverage available for you and your family

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

If you have a Self Only enrollment, you may change to a Self Plus One or Self and Family enrollment if you marry, give birth or add a child to your family. You may change your enrollment 31 days before to 60 days after that event.

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

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

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

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

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

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

• Family member coverage

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

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

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

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

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

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

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

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

• 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 2022 benefits of your prior plan or option. If you have met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option. However, if your prior plan left the FEHB Program at the end of the year, you are covered under that plan’s 2021 benefits until the effective date of your coverage with your new plan. Annuitants’ coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective date of coverage.

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

• When you retire

• When FEHB coverage ends

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

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

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

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

• Upon divorce

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

• Temporary Continuation of Coverage (TCC)

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

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

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

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

• Converting to individual coverage

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

Your benefits and rates will differ from those under the FEHB program; however, you will not have to answer questions about your health, a waiting period will not be imposed, and your coverage will not be limited due to pre-existing conditions. When you contact us, we will assist you in obtaining information about health benefits coverage inside or outside the Affordable Care Act's Health Insurance Marketplace in your state.  For assistance in finding coverage, please contact us at 844-440-1900 or visit our website at www.healthpartners.com/fehb.

• Health Insurance Marketplace

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

Identification cards

We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan provider or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation letter (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 844-440-1900  (TTY: 952-883-5127) or write to us at Member Services, P.O. Box 1309, Minneapolis, MN 55440-1309. You may also request replacement cards through our website at www.healthpartners.com/fehb.

Where you get covered care

In Network: You get care from "Plan providers" and "Plan facilities." You will pay copayments, deductibles, and/or coinsurance. You can receive covered services from a participating provider without a referral from your primary care physician or another participating provider in the network.

Out of Network (Standard Option): You may choose to use your out-of-network benefits and receive care from any licensed provider. You may be billed for these services and may need to file a claim for reimbursement.

Plan providers

Plan providers are physicians and other health care professionals that we contract with to provide covered services to our members. We credential Plan providers according to national standards.

We list Plan providers in the HealthPartners Open Access Network provider directory, which we update periodically. For information that is updated weekly, visit www.healthpartners.com/fehb.

This Plan lets you receive care from more than 850,000 providers in the Open Access Network. Referrals are not required and you do not need to choose a primary care clinic. Any time you or a member in your family needs care, you may choose to see any provider in this network.

High Option: With limited exceptions, if you seek care from a provider who does not participate in the Open Access Network, your care is considered out of network and may not be covered.

Standard Option: With limited exceptions, if you seek care from a provider who does not participate in the Open Access Network, your care is considered out of network and the lower out-of-network benefits apply.

Plan facilities

Plan facilities are hospitals and other facilities that we contract with to provide covered services to our members. We list these in the Open Access Network provider directory, which we update periodically. The list is on our website: www.healthpartners.com/fehb.

High Option: With limited exceptions, if you seek care from a facility that does not participate in the Open Access Network, your care is considered out of network and may not be covered.

Standard Option: With limited exceptions, if you seek care from a facility that does not participate in the Open Access Network, your care is considered out of network and the lower out-of network benefits apply.

What you must do to get covered care

High Option: Any time you or a member in your family needs care, you should choose to see any provider in the Open Access Network. With limited exceptions, if you seek care from a provider who does not participate in the Network your care is considered out of network and may not be covered.

Standard Option: Any time you or a member in your family needs care, you should choose to see any provider in the Open Access Network. You may choose to use your out-of-network benefit and receive care from any licensed provider. You may be billed for these services and may need to file a claim for reimbursement.

Primary care

Members are not required to pick a primary clinic. However, we encourage members to work with personal physicians who will get to know them. Primary care providers are providers in the following categories: family and general practice, internal medicine, pediatrics, adolescent medicine, adult medicine and geriatrics. Your primary care physician will provide most of your health care or suggest that you see a specialist. You can see any specialist without a referral.

If you want to change your primary care physician or if your primary care physician leaves the Plan, simply choose another provider from the Open Access Network directory for in-network benefits. For the most up-to-date network provider information, visit www.healthpartners.com/fehb, where information is updated weekly.

Specialty care

Specialty care providers are providers who are not in the following categories: family and general practice, internal medicine, pediatrics, adolescent medicine, adult medicine and geriatrics.

You have direct access to any specialist in the Open Access Network without a referral.

If you are seeing a specialist when you enroll in our Plan and your current specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.

If you are seeing a specialist and your specialist leaves the Plan, call Member Services at 844-440-1900 for assistance. You may receive services from your current specialist until we can make arrangements for you to see someone else.

If you have a chronic or disabling condition and lose access to your specialist because we:

• terminate our contract with your specialist for other than cause;
• drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB plan; or
• reduce our Service Area and you enroll in another FEHB plan;

you may be able to continue seeing your specialist for up to 120 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 until the end of your postpartum care, even if it is beyond the 120 days.

• Designated providers

If you are hospitalized when your enrollment begins

We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call HealthPartners Member Services immediately at 844-440-1900 (TTY: 952-883-5127). If you are new to the FEHB Program, we will arrange for you to receive care and provide benefits for your covered services while you are in the hospital beginning on the effective date of your coverage.

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

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

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

• Determination of coverage

You need prior Plan approval for certain services

Since your primary care physician arranges most referrals to specialists and inpatient hospitalization, the pre-service claim approval process only applies to care shown under Other services.

You must get prior approval for certain services.

Other services

Your primary care physician has authority to refer you for most services. For certain services, however, your physician must obtain prior approval from us. Before giving approval, we consider if the service is covered, medically necessary and follows generally accepted medical practice.

We call this review and approval process prior authorization. Your physician must obtain prior authorization for services such as:

• Reconstructive surgery
• Promising therapies/new technologies
• Transplants
• Medically necessary dental care, such as orthognathic surgery
• Durable medical equipment and prosthetics
• Home health care
• Skilled nursing care
• Hospice care
• Habilitative therapy
• Bariatric surgery
• Growth hormone therapy (GHT)

The complete list, along with the criteria we use to review authorization requests, is available on
www.healthpartners.com/fehb or by calling HealthPartners Member Services at 844-440-1900 (TTY: 952-883-5127). Your physician is responsible for obtaining prior authorization. 

First your physician, your hospital, you, or your representative, must call us at 952-883-6333 before admission or services requiring prior authorization are rendered.

Next, provide the following information:

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

• Non-urgent care claims

For non-urgent care claims, we will tell the physician and/or hospital the number of approved inpatient days, or the care that we approve for other services that must have prior authorization. We will make our decision within 15 days of receipt of the pre-service claim. If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you of the need for an extension of time before the end of the original 15-day period. Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

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

• Urgent care claims

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

If you fail to provide sufficient information, we will contact you within 24 hours after we receive the claim to let you know what information we need to complete our review of the claim. You will then have up to 48 hours to provide 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 844-440-1900 (TTY: 952-883-5127). You may also call OPM's FEHB 2 at 202-606-3818 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review. We will cooperate with OPM so they can quickly review your claim on appeal. In addition, if you did not indicate that your claim was a claim for urgent care, call us at 844-440-1900 (TTY: 952-883-5127). If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim).

• Concurrent care claims

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

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

The Federal Flexible Spending Account Program – FSAFEDS

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

• Emergency inpatient admission

If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your representative, the physician, or the hospital must phone us within two business days following the day of the emergency admission, even if you have been discharged from the hospital.

• If 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 72 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

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

Example: With High Option, when you see your primary care physician, you pay a copayment of $25 per office visit.

Deductible

A deductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for them. Copayments do not count toward any deductible.

Any amounts paid or reimbursed by a third party, including but not limited to: point of service rebates, manufacturer coupons, debit cards or other forms of direct reimbursement to an enrollee for a product or service, will not apply toward your deductible.

High Option:  There is no calendar year deductible for medical care.  

Standard Option: 
For Network Expenses: The calendar year deductible is $750 for persons enrolled for Self Only coverage, $1,500 for persons enrolled for Self Plus One coverage and $1,500 for families enrolled for Self and Family coverage. 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 $750. Under a Self Plus One enrollment, the deductible is considered satisfied and benefits are payable to you and one other eligible family member when the combined covered expenses applied to the calendar year deductible for your enrollment reach $1,500. Under a Self and Family enrollment, the deductible is considered satisfied and benefits are payable for all family members when the combined covered expenses applied to the calendar year deductible for family members reach $1,500.

For Out-of-Network Expenses: The calendar year deductible is $2,000 for persons enrolled for Self Only coverage $4,000 for persons enrolled for Self Plus One coverage and $4,000 for families enrolled for Self and Family coverage. 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 $2,000. Under a Self Plus One enrollment, the deductible is considered satisfied and benefits are payable to you and one other eligible family member when the combined covered expenses applied to the calendar year deductible for your enrollment reach $4,000. Under a Self and Family enrollment, the deductible is considered satisfied and benefits are payable for all family members when the combined covered expenses applied to the calendar year deductible for family members reach $4,000.

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

If you change options in this Plan during the year, we will credit the amount of covered expenses already applied toward the deductible of your old option to the deductible of your new option.

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

Your catastrophic protection out-of-pocket maximum

Any amounts paid or reimbursed by a third party, including but not limited to: point of service rebates, manufacturer coupons, debit cards or other forms of direct reimbursement to an enrollee for a product or service, will not apply to your catastrophic protection out-of-pocket maximum.

High Option:  If you are enrolled for Self Only coverage, when your copayments and/or coinsurance total $5,500 in a calendar year, you do not have to pay any more for covered services for the remainder of that calendar year.

If you are enrolled for Self Plus One coverage, when you and your dependent's copayments and/or coinsurance total $11,000 in  a calendar year, you and your dependent do not have to pay any more for covered services for the remainder of that calendar year. However, each enrollee will not pay more than $8,550 in a calendar year.

If you are enrolled for Self and Family coverage, when your family’s copayments and/or coinsurance total $11,000 in a calendar year, you and your dependents do not have to pay any more for covered services for the remainder of that calendar year. However, each enrollee will not pay more than $8,550 in a calendar year.

Standard Option:  In Network:  If you are enrolled for Self Only coverage, when your deductible, copayments and/or coinsurance total $6,500 in a calendar year, you do not have to pay any more for covered services for the remainder of that calendar year.

If you are enrolled for Self Plus One coverage, when you and your dependent's, deductible, copayments and/or coinsurance total $13,000 in a calendar year, you and your dependent do not have to pay any more for covered services for the remainder of that calendar year. However, each enrollee will not pay more than $8,550 in a calendar year.

If you are enrolled for Self and Family coverage, when your family’s deductible, copayments and/or coinsurance total $13,000 in a calendar year, you and your dependents do not have to pay any more for covered services for the remainder of that calendar year. However, each enrollee will not pay more than $8,550 in a calendar year.

 Out of Network:  There is no limit on your out-of-pocket expenses.

Carryover

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

Note: If you change options in this Plan due to a qualifying life event (QLE) during the year, we will credit the amount of covered expenses already accumulated toward the catastrophic out-of-pocket limit of your prior option to the catastrophic protection limit of your new option.

Our Behavioral Health Personalized Assistance Line (PAL) staff can match you with the network provider that best meets your behavioral health needs. We can identify providers based on:

• Specialty or subspecialty
• Specific diagnostic, language and cultural competence

And if you have an urgent need, we can link you to same day/next day psychiatric appointments. Call 952-883-5811 or 888-638-8787.

Nurse Navigators

Nurse Navigators are experienced nurses who can help research treatment options, coordinate care and guide you through difficult decisions. Call 844-440-1900.

If you are deaf or hearing impaired, we have special phone lines which you may call for the following services:

Member Services: 952-883-5127

CareLine Service: 952-883-5474

As a Plan member, you have instant access to detailed, secured information and helpful services tailored to you. Depending on your coverage, you may be able to:

• View your personal health record
• See your claims information
• View your benefits
• View your medical and dental provider networks
• Find health and wellness information 
• Order new ID cards
• Make appointments at HealthPartners Clinics 
• Refill a mail order prescription or a prescription at a HealthPartners Clinic
• Determine the retail and mail order costs of specific drugs
• See all the medications on the HealthPartners preferred list of covered drugs
• Estimate your annual cost of medical care

virtuwell™

virtuwell™ is an online clinic that treats everyday illnesses so you- or your kids-can get better.

• Quickly and conveniently get care for over 40 common conditions
• get a diagnosis, treatment plan and prescription if needed- all in less than an hour
• you pay nothing. See section 5(a)
• 24/7, with nurse practitioners available

Mobile tools

Download the HealthPartners app or visit the mobile site to find and manage your health plan on-the-go.

Use your smartphone to:

• Access your Member ID card
• Check your plan balances including your deductible
• Search for the closest care locations to you
• Get cost estimates
• View claims and Explanation of Benefits (EOBs)
• …and more

Download the app today in your app store or visit m.healthpartners.com to learn more about HealthPartners mobile offerings, visit www.healthpartners.com/gomobile.

If you have a mobile phone that can get text messages, you can receive a variety of texts from HealthPartners. Either opt in to receive weekly texts or add a phone number in your myHealthPartners account to get text specific to you.

Text one of these commands to 77199:

• DED: For how much is remaining until you meet your deductible
• YUM: For better-for-you eating tips from yumPower
• FAMILY: For ideas to support your family's health
• QUITNOW: For tips to help you quit smoking

Health assessment and wellness courses

There’s no greater reward than living a healthy life. In case you need extra incentive, we've got one for you. When you complete your health assessment and register and complete an eligible online health improvement program, you are entitled to receive a contribution of $250 into your HealthPartners Wellness Account debit card to be used for most qualified medical expenses, prescriptions and IRS 213(d) vision expenses. For those with Self Plus One or Self and Family coverage, each adult employee or covered spouse, is eligible for the $250 contribution to the HealthPartners Wellness Account. We will send the policyholder two debit cards to access the account. Please keep your card for future use even if you use all of your health account dollars; you may be eligible for wellness incentives in subsequent benefit years. We do not send new cards to continuing participants until the card expires. The account funds must be used by December 31, 2022 or the account will be forfeited.

After completing the online health assessment, you may access online wellness courses to set personalized goals designed to improve your health through increased exercise, healthier nutrition habits, managing your weight, reduced stress, better emotional health, or goals that focus on managing a specific condition. You must complete the health assessment and complete an eligible online health improvement program no later than December 31, 2021 in order to receive these incentives.

Getting rewarded is simple.

• Log into your myHealthPartners account at www.healthpartners.com/fehb. If you don't have a username and password, click on “sign up for myHealthPartners”.

• Take your health assessment.

• Register for an eligible online health improvement program

• Complete the eligible online health improvement program.

• Don’t forget, this includes your covered spouse!

• One set of two debit cards will be sent to access the funds in your HealthPartners Wellness Account.

Medicare Premium Reimbursement for High Option members enrolled in both Medicare Parts A and B

High option members enrolled in both Medicare Part A and Part B are eligible to be reimbursed up to $1,200 per calendar year for their Medicare Part B premium payments. Eligible members must notify HealthPartners of their Medicare enrollment status. For more information on how to get reimbursement for your paid Medicare Part B premiums, please call 844-440-1900 or visit healthpartners.com/fehb/medicare.

Flexible benefits option

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

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

Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process. However, if at the time we make a decision regarding alternative benefits, we also decide that regular contract benefits are not payable, then you may dispute our regular contract benefits decision under the OPM disputed claim process (see Section 8).

Eyewear discount

You may be eligible for an eyewear discount at Plan optical centers, including HealthPartners Eye Care Centers and EyeMed retailers such as Target, LensCrafters, etc.  For more information on the program visit www.healthpartners.com/fehb or call member services at 844-440-1900.

Healthy discounts program

HealthPartners retail savings program gives you discounts on tools and services from reputable organizations to help you be as healthy as you can be. Complete information and list of partner organizations can be found online at www.healthpartners.com/fehb or call member services at 844-440-1900

Medical and hospital benefits

In most cases, providers and facilities file claims for you. Providers 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, contact us at 844-440-1900 (TTY: 952-883-5127), or at our website at www.healthpartners.com/fehb. 

When you must file a claim – such as for services you received outside the Plan's Network– submit it on the CMS -1500 or a claim form that includes the information shown below. Bills and receipts should be itemized and show:  

• Covered member’s name, date of birth, address, phone number and ID number
• Name and address of the provider or facility that provided the service or supply
• Dates you received the services or supplies
• Diagnosis
• Type of each service or supply
• The charge for each service or supply
• A copy of the explanation of benefits, payments, or denial from any primary payor – such as the Medicare Summary Notice (MSN)
• Receipts, if you paid for your services

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

Submit your claims to:
HealthPartners Claims
P.O. Box 1289
Minneapolis, MN 55440-1289

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

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

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

Notice Requirements

If you live in a county where at least 10 percent of the population is literate only in a non-English language (as determined by the Secretary of Health and Human Services), we will provide language assistance in that 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.

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: Member Services, P.O. Box 1309, Minneapolis, MN 55440-1309; and

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

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

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

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

2

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

a) Pay the claim or  

b) Write to you and maintain our denial or

c) Ask you or your provider for more information

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

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

3

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

You must write to OPM within:

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

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

Send OPM the following information:

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

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

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

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

4

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

If you do not agree with OPM’s decision, your only recourse is to 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 the NAIC website at www.NAIC.org.

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. For example, we will generally only make up the difference between the primary payor’s benefits payment and 100% of the Plan allowance, subject to our applicable coinsurance or copayment amounts, except when Medicare is the primary payor (see page 82). Thus, it is possible that the combined payments from both plans may not equal the entire amount billed by the provider.

Note: When we pay secondary to primary coverage you have from a prepaid plan (HMO), we base our benefits on your out-of-pocket liability under the prepaid plan (generally, the prepaid plan’s copayments), subject to our coinsurance or copayment amounts.
In certain circumstances when we are secondary and there is no adverse effect
on you (that is, you do not pay any more), we may also take advantage of any provider discount arrangements your primary plan may have and only make up the difference between the primary plan’s payment and the amount the provider has agreed to accept as payment in full from the primary plan.

Note: Any visit limitations that apply to your care under this Plan are still in effect when we are the secondary payor. Remember: Even if you do not file a claim with your other plan, you must still tell us that you have double coverage, and you must also send us documents about your other coverage if we ask for them.

• TRICARE and CHAMPVA

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

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

• Workers' Compensation

We do not cover services that:

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

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

• Medicaid

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

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

When other Government agencies are responsible for your care

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

When others are responsible for injuries

Our 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.

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. Our right of reimbursement extends to any payment received by settlement, judgment, or otherwise.

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" 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.

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

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

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; or is a drug trial that is exempt from the requirement of an investigational new drug application. 

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

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

When you have Medicare

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

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

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

All physicians and other providers are required by law to file claims directly to Medicare for members with Medicare Part B, when Medicare is primary. This is true whether or not they accept Medicare. When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care.

Claims process when you have the Original Medicare Plan – You will probably not need to file a claim form when you have both our Plan and the Original Medicare Plan. When we are the primary payor, we process the claim first. When Original Medicare is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. To find out if you need to do something to file your claim, call us at 844-440-1900.

To be eligible for full cost-share waiving, members must be enrolled in both Parts A and B of Original Medicare. For members enrolled in High and Standard Option and also enrolled in the Original Medicare Plan (Part A and B) as your primary payor – we will waive your out-of-pocket costs (applicable deductibles, copays and coinsurance) at in-network providers as follows:

• Inpatient hospital benefits: We waive applicable deductibles, copays and coinsurance.
• Medical and surgery benefits and mental health/substance use disorder care: We waive applicable deductibles, copays and coinsurance.
• Office visits: We waive the applicable deductibles, copays and coinsurance at In-Network Providers.
• Physical, speech and occupational therapy benefits: Applicable deductibles, copays and coinsurance is waived.
• Benefit limits and maximums still apply.
• There is no change to your prescription drug coverage. We do not waive deductibles, copays, or coinsurance.
• We do not waive cost-sharing on hearing aids through TruHearing.

You can find more information about how our Plan coordinates benefits with Medicare by calling our FEHB Member Services team at 844-440-1900 or visit healthpartners.com/fehb/medicare.

Cost sharing may not apply if the Original Medicare Plan is your primary payor

– For Medicare covered services we will coordinate benefits to potentially reduce your out-of-pocket costs as follows: 

When Medicare Part A is primary –

• You may experience a reduction in cost sharing for our in-network:

− Annual hospital copayments for Medicare covered services;

− Hospital coinsurance for Medicare covered services. 

Note: Once you have exhausted your Medicare Part A benefits, you must then pay the applicable copayment or coinsurance.

When Medicare Part B is primary –

• You may experience a reduction in cost sharing for our in-network:

− Coinsurance and copayments for inpatient and outpatient services and supplies provided by physicians and other covered health care professionals for Medicare covered services; and

− Coinsurance and/or copayment for outpatient facility services for Medicare covered services. 

Note: We do not waive benefit limitations, such as the 25-visit limit for home nursing visits. In addition, we do not waive any coinsurance or copayments for prescription drugs.

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.

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: $0
High Option You Pay With Medicare Part B: $0
Standard Option You Pay Without Medicare: In Network: $750/Self Only; $1,500/Self Plus One; $1,500/Family; Out of Network: $2,000/Self Only; $4,000/Self Plus One; $4,000/Family
Standard Option You Pay With Medicare: In Network: $750/Self Only; $1,500/Self Plus One; $1,500/Family; Out of Network: $2,000/Self Only; $4,000/Self Plus One; $4,000/Family

Benefit Description: Out-of-Pocket Maximum
High Option You Pay Without Medicare: Self Only: Nothing after $5,500; Self Plus One: Nothing after $11,000, subject to a maximum of $8,550 per enrollee; Self and Family: Nothing after $11,000, subject to a maximum of $8,550 per enrollee
High Option You Pay With Medicare Part B: Self Only: Nothing after $5,500; Self Plus One: Nothing after $11,000, subject to a maximum of $8,550 per enrollee; Self and Family: Nothing after $11,000, subject to a maximum of $8,550 per enrollee
Standard Option You Pay Without Medicare: In Network: Self Only: Nothing after $6,500; Self Plus One: Nothing after $13,000, subject to a maximum of $8,550 per enrollee; Self and Family: Nothing after $13,000, subject to a maximum of $8,550 per enrollee; Out of Network: No maximum
Standard Option You Pay With Medicare: In Network: Self Only: Nothing after $6,500; Self Plus One: Nothing after $13,000, subject to a maximum of $8,550 per enrollee; Self and Family: Nothing after $13,000, subject to a maximum of $8,550 per enrollee; Out of Network: No maximum

Benefit Description: Part B Premium Reimbursement Offered
High Option You Pay Without Medicare: NA
High Option You Pay With Medicare Part B: Up to $1,200
Standard Option You Pay Without Medicare: NA
Standard Option You Pay With Medicare: None

Benefit Description: Primary Care Physician
High Option You Pay Without Medicare: $25
High Option You Pay With Medicare Part B: Nothing for most Medicare covered services and never more than $25
Standard Option You Pay Without Medicare: In Network: You pay $0 for 5 visits, then 20% after deductible; Out of Network: 40% after deductible
Standard Option You Pay With Medicare: In Network: Nothing for most Medicare covered services and never more than 20% after deductible; Out of Network: Nothing for most Medicare covered services and never more than 40% after deductible

Benefit Description: Specialist
High Option You Pay Without Medicare: $25
High Option You Pay With Medicare Part B: Nothing for most Medicare covered services and never more than $25
Standard Option You Pay Without Medicare: In Network: 20% after deductible; Out of Network: 40% after deductible
Standard Option You Pay With Medicare: In Network: Nothing for most Medicare covered services and never more than 20% after deductible; Out of Network: Nothing for most Medicare covered services and never more than 40% after deductible

Benefit Description: Inpatient Hospital
High Option You Pay Without Medicare: $500 annual copayment for inpatient & outpatient combined, then 10% of charges
High Option You Pay With Medicare Part B: Nothing for most Medicare covered services and never more than a $500 annual copayment for inpatient & outpatient combined, then 10% of charges
Standard Option You Pay Without Medicare: In Network: 20% after deductible; Out of Network: 40% after deductible
Standard Option You Pay With Medicare: In Network: Nothing for most Medicare covered services and never more than 20% after deductible; Out of Network: Nothing for most Medicare covered services and never more than 40% after deductible

Benefit Description: Outpatient Surgery - Hospital
High Option You Pay Without Medicare: $500 annual copayment for inpatient & outpatient combined, then 10% of charges
High Option You Pay With Medicare Part B: Nothing for most Medicare covered services and never more than a $500 annual copayment for inpatient & outpatient combined, then 10% of charges
Standard Option You Pay Without Medicare: In Network: 20% after deductible; Out of Network: 40% after deductible
Standard Option You Pay With Medicare: In Network: Nothing for most Medicare covered services and never more than 20% after deductible; Out of Network: Nothing for most Medicare covered services and never more than 40% after deductible

Benefit Description: Incentives Offered
High Option You Pay Without Medicare: N/A
High Option You Pay With Medicare Part B: Health assessment and wellness courses. For more information see page (Applies to printed brochure only)
Standard Option You Pay Without Medicare:
Standard Option You Pay With Medicare: Health assessment and wellness courses. For more information see page (Applies to printed brochure only)

You can find more information about how our plan coordinates benefits with Medicare by visiting www.healthpartners.com/fehb.

• Tell us about your Medicare coverage

• Medicare prescription drug coverage (Part B)

This health plan does not coordinate its prescription drug benefits with Medicare Part B.

• 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 or call us at 844-440-1900 (TTY: 952-883-5127) or see our website at www.healthpartners.com/fehb.

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

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

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

• Medicare prescription drug coverage (Part D)

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

Biosimilar Drug

A prescription drug, approved by the Food and Drug Administration (FDA), that the FDA has determined is biosimilar to and interchangeable with a biological brand name drug. Biosimilar drugs are not considered generic drugs and are not covered under the generic drug benefit.

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 review by the Food and Drug Administration; or is a drug trial that is exempt from the requirement of an investigational new drug application.

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

Coinsurance

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

Copayment

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

Cost-sharing

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

Deductible

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

Experimental or investigational service

As determined by us, a drug, device, medical, behavioral health or dental treatment is investigative if reliable evidence does not permit conclusions concerning its safety, effectiveness, or positive effect on health outcomes and will be considered investigative unless all of the following categories of reliable evidence are met:

• There is final approval from the appropriate government regulatory agency, if required. This includes whether a drug or device can be lawfully marketed for its proposed use by the United States Food and Drug Administration (FDA); and
• The drug or device or medical, behavioral health or dental treatment or procedure is not the subject of ongoing Phase I, II or III clinical trials; and
• The drug, device or medical, behavioral health or dental treatment or procedure is not under study and further studies are not needed (such as post-marketing clinical trial requirements) to determine maximum tolerated dose, toxicity, safety, effect on health outcomes or efficacy as compared to existing standard means of treatment or diagnosis; and
• There is conclusive evidence in major peer-reviewed medical journals demonstrating the safety, effectiveness and positive effect on health outcomes (the beneficial effects outweigh any harmful effects) of the service or treatment when compared to standard established service or treatment.  Each article must be of well-designed investigations, using generally acceptable scientific standards that have been produced by nonaffiliated, authoritative sources with measurable results.  Case reports do not satisfy this criterion.  This also includes consideration of whether a drug is included in one of the standard reference compendia or “Major Peer Reviewed Medical Literature” (defined below) for use in the determination of a medically necessary accepted indication of drugs and biologicals used off-label as appropriate for its proposed use.

Major Peer Reviewed Medical Literature. This means articles from major peer reviewed medical journals that have recognized the drug or combination of drugs' safety and effectiveness for treatment of the indication for which it has been prescribed. Each article shall meet the uniform requirements for manuscripts submitted to biomedical journals established by the International Committee of Medical Journal Editors or be published in a journal specified by the United States Secretary of Health and Human Services pursuant to United States Code, title 42, section 1395x, paragraph (t), clause (2), item (B), as amended, as acceptable peer review medical literature. Each article must use generally acceptable scientific standards and must not use case reports to satisfy this criterion.

This plan defines medically necessary care as care that is appropriate for the condition, including those related to mental health. It includes the kind and level of service. It includes the number of treatments. It also includes where you get the service and how long it continues. Medically necessary care must:

• Be the service that other providers would usually order
• Help you get better, or stay as well as you are
• Help stop the condition from getting worse
• Help prevent and find health problems

Plan allowance

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

• For covered services delivered by Plan providers, or Plan referral providers, our allowance is the provider’s discounted charge for a given medical/surgical service, procedure or item, which Plan providers have agreed to accept as payment in full.
• For covered services delivered by non-Plan providers, our allowance is the provider’s charge for a given medical/surgical service, procedure or item, according to the usual and customary charge amount. A contracted rate may apply if such arrangement is available to HealthPartners.
• For the usual and customary charge for covered services delivered by non-network providers, our payment is calculated using one of the following options to be determined at HealthPartners’ discretion: 1) a percentage of the Medicare fee schedule; 2) a comparable schedule if the service is not on the Medicare fee schedule; or 3) a commercially reasonable rate for such service.
• The usual and customary charge is the maximum amount allowed we consider in the calculation and payment of charges incurred for certain covered services. You must pay for any charges above the usual and customary charge, and they do not apply to the catastrophic protection out-of-pocket maximum.

Urgent care claims

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

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

Medical services provided by physicians:

• Diagnostic and treatment services provided in the office, urgent care and convenience clinic and by evisit and telephone

$10 per convenience clinic visit; $25 per office visit; $45 per urgent care visit; nothing for virtuwell evisits 

26

virtuwell

Nothing

26

Services provided by a hospital:

• Inpatient and Outpatient

$500 annual copayment for inpatient & outpatient combined, then 10% of charges

51

Emergency benefits:

• In-area and out-of-area

$150 per emergency room visit; $45 per office or urgent care center visit

55

Mental health and substance use disorder treatment

Regular cost sharing

57

Prescription drugs:

• Retail pharmacy (generally a 30-day supply)

$5 for low cost generic preferred drugs; $25 for high cost generic preferred drugs; $55 for brand-name preferred drugs; $90 for non-preferred drugs; 20% for specialty drugs

60

• Mail order service (generally a 90-day supply)

$10 for low cost generic preferred drugs; $50 for high cost generic preferred drugs; $110 for brand-name preferred drugs; $180 for non-preferred drugs

64

Dental care:

• Accidental injury

20% of charges, if Plan dentist provides care

30% of charges when provided by Out of Network dentist if the injuries require immediate treatment.

65

Vision care

Nothing for preventive care

37

Protection against catastrophic costs

(out-of-pocket maximum)

Self Only: Nothing after $5,500; Self Plus One: Nothing after $11,000, subject to a maximum of $8,550 per enrollee; Self and Family: Nothing after $11,000, subject to a maximum of $8,550 per enrollee

20

Special features:

CareLine® service, Nurse Navigator, Behavioral Health Personalized Assistance Line, special phone lines for deaf and hearing impaired, personalized member page on website, health improvement programs

66

Medical services provided by physicians:

• Diagnostic and treatment services provided in the office, urgent care and convenience clinic and by evisit and telephone

In Network: $0 for 5 visits, then 20% after deductible
Out of Network: 40% after deductible

26

virtuwell

Nothing

26

Services provided by a hospital

• Inpatient and Outpatient

In Network: 20% after deductible
Out of Network: 40% after deductible

51

Emergency outpatient hospital benefits

• In-area and out-of-area

20% after in-network deductible

55

Mental health and substance use disorder treatment

Regular cost sharing

57

Prescription drugs:

• Retail pharmacy (generally a 30-day supply)

60

• Mail order service (generally a 90-day supply)

In Network copayments: $10 for low cost generic preferred drugs; $50 for high cost generic preferred drugs; $120 for brand name preferred drugs after deductible; $300 for non-preferred drugs after deductible. Out of Network: all charges.

64

Dental care:

• Accidental injury

In Network: 20% after deductible. Out of Network: 30% after deductible.

65

Vision care

Nothing for preventive care

37

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

In Network: Self Only: Nothing after $6,500; Self Plus One: Nothing after $13,000, subject to a maximum of $8,550 per enrollee; Self and Family: Nothing after $13,000, subject to a maximum of $8,550 per enrollee; Out of Network: no maximum

20

Special features:

CareLine® service, Nurse Navigator, Behavioral Health Personalized Assistance Line, special phone lines for deaf and hearing impaired, personalized member page on website, health improvement programs

66