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

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

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, give you other plans' brochures, 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, disability leave, pensions, etc 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.

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 employing or retirement office if you want to change from Self Only to Self Plus One or Self and Family. If you have a Self and Family enrollment, you may contact us to add a family member.

Your employing or retirement office will not notify you when a family member is no longer eligible to receive benefits. Please tell us immediately of changes in family member status, including your marriage, divorce, annulment, or when your child reaches age 26.We will send written notice to you 60 days before we proactively disenroll your child on midnight of their 26th birthday unless your child is eligible for continued coverage because they are incapable of self-support due to a physical or mental disability that began before age 26.

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

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

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

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

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

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

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

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

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

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

OPM implements 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.

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 2024 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 2023 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 separate 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.

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

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

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

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

If you are an enrollee, and your divorce or annulment is final, your ex-spouse cannot remain covered as a family member under your Self Plus One or Self and Family enrollment. You must contact us to let us know the date of the divorce or annulment and have us remove your ex-spouse. We may ask for a copy of the divorce decree as proof. In order to change enrollment type, you must contact your employing or retirement office. A change will not automatically be made.

If you were married to an enrollee and your divorce or annulment is final, you may not remain covered as a family member 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, https://www.opm.gov/healthcare-insurance/life-events/memy-family/im-separated-or-im-getting-divorced/#url=Health. We may request that you verify the eligibility of any or all family members listed as covered under the enrollee’s FEHB enrollment.

If you leave Federal service, Tribal employment, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC).  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 or if you are a covered child and you turn 26.

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 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.

If you leave Federal or Tribal service, your employing office will notify you of your right to convert. You must contact us in writing within 31 days after you receive this notice. However, if you are a family member who is losing coverage, the employing or retirement office will not notify you. You must contact us in writing to us 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, wi 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 608-251-3356 or visit our website at www.ghcscw.com

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

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

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 608-260-3170, or fax us at 608-662-4837, or write to us at PO Box 44971, Madison WI 53744-4971. You may also request replacement cards through our website: www.ghcscw.com.

Plan providers are physicians and other healthcare professionals in our service area that we contract with to provide covered services to our members. Services by Plan Providers are covered when acting within the scope of their license or certification under applicable state law. We credential Plan providers according to national standards.

Benefits are provided under this Plan for the services of covered providers, in accordance with 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.

Members must receive care through GHC-SCW In-Plan Providers for services to be covered. Use of Out-Of-Plan Providers will result in the member being financially responsible for full payment of services, unless written approval (Prior Authorization) for such out-of-plan services has been obtained from GHC-SCW's Care Management Department.

We list Plan providers in the provider directory, which we update periodically. The list is also on our website.

This plan recognizes that transgender, non-binary, and other gender diverse members require health care delivered by healthcare providers experienced in gender affirming health. Benefits described in this brochure are available to all members meeting medical necessity guidelines regardless of race, color, national origin, age, disability, religion, sex or gender.

This plan provides Care Coordinators for complex conditions and can be reached 608-257-5294 for assistance.

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

It depends on the type of care you need. First, you and each family member must choose a primary care provider. This decision is important since your primary care provider provides or arranges for most of your health care. If you need assistance, please call the GHC-SCW Member Services Department at 608-828-4853.

Your primary care provider can be a family practitioner, internist or pediatrician. (You may also select physician assistants or nurse practitioners). Your primary care practitioner will provide most of your healthcare or give you a referral to see a specialist.

If you want to change primary care providers or if your primary care provider leaves the Plan, call us at 608-828-4853 or 800-605-4327. We will help you select a new one

Your primary care provider will refer you to a specialist for needed care. When you receive a referral from your primary care provider, you must return to the primary care provider after the consultation, unless your primary care provider authorized a certain number of visits without additional referrals. The primary care provider must provide or authorize all follow-up care. Do not go to the specialist for return visits unless your primary care provider gives you a referral. However, you may see the following in-plan providers without a referral (Non-GHC-SCW providers may require Prior Authorization, contact GHC-SCW for additional information): mental health, substance abuse, vision, dental and chiropractic services.

Here are some other things you should know about specialty care:

• If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care provider will develop a treatment plan that allows you to see your specialist for a certain number of visits without additional referrals.

Your primary care provider will create your treatment plan. The physician may have to get an authorization or approval from us beforehand. If you are seeing a specialist when you enroll in our Plan, talk to your primary care provider. If they decide to refer you to a specialist, ask if you can see your current specialist.

If 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 your primary care provider, who will arrange for you to see another specialist. You may receive services from your current specialist until we can make arrangements for you to see someone else.
• If you have a chronic and 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 program 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 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 until the end of your postpartum care, even if it is beyond the 90 days.

Your Plan primary care provider or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of facility.

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 Care Management Department immediately at 608-257-5294. 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 92^nd day after you become a member of this Plan, whichever happens first.

These provisions apply only to the benefits of the hospitalized person. If your plan terminates participation in the FEHB 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.

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

It is the Member’s responsibility to ensure a Prior Authorization has been obtained when required.  If Prior Authorization is not received prior to the date of service and/or receipt of supplies, your Provider should contact GHC-SCW’s Care Management Department for a determination of Medical Necessity. 

You must get prior approval for certain services. Failure to obtain Prior Authorization when required may result in the Member receiving a reduction in or no Benefit. 

Your primary care provider 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. You must obtain authorization for services such as, but not limited to:

• Transplants
• Inpatient hospital services
• Inpatient and transitional Mental Health services
• Inpatient and transitional Substance Abuse services
• Outpatient surgical/non-surgical services
• The following outpatient diagnostic and therapeutic services: MRI, MRA, CT/CAT and PET
• Inpatient maternity care
• Home Health Agency services
• Skilled Nursing Facility services
• Orthopedic and Prosthetic devices
• Durable Medical Equipment
• End of Life (Hospice) services
• Outpatient Rehabilitative Therapy (physical therapy, occupational therapy, speech therapy, vision therapy)
• All inpatient Mental Health and AODA services
• Surgical Infertility services
• Surgical and/or Non-Surgical treatment of Temporomandibular Joint (TMJ) syndrome. A written prior authorization is required for the initial acquisition of an intraoral splint.
• All Accidental Injury dental procedures
• Oral surgery services
• Specialist care
• Breast reduction mammoplasty
• Plastic surgery
• Bariatric surgery for morbid obesity
• Growth Hormone Therapy (GHT)
• Prescription drugs not included in the GHC-SCW formulary
• Experimental, Investigational or unproven services
• Injectable medications
• Enteral or specialized nutritional support

GHC-SCW will not guarantee payment for services and/or drugs that require prior authorization which were not prior authorized unless emergent in nature.

First, your physician, your hospital, you, or your representative, must call us at 608-257-5294 before admission or services requiring prior authorization are rendered.

Next, provide the following information:

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

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.

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 medication.

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 after 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 800-605-4327.  You may also call FEHB at (202) 606-0737 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review.  We will cooperate with OPM so they can quickly review your claim on appeal.  In addition, if you did not indicate that your claim was a claim for urgent care, call us at 800-605-4327.   If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim). 

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

If you request an extension of an ongoing course of treatment at least 24 hours prior to 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 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. 

You do not need to precertify a maternity admission for a routine delivery with an in-plan facility. However, if your medical condition requires you to stay more than 48 hours after a vaginal delivery or 96 hours after a cesarean section, your practitioner or hospital must contact us for prior authorization of the additional days. Further, if your baby stays after you are discharged, your physician or hospital must contact us for prior authorization of additional days for your baby.

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

If 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 your claim is in reference to a contraceptive, call 608-828-4811.

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

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

In the case of a pre-service claim and  unless we request additional information, we will notify you of our decision within 72 hours after receipt of your reconsideration request.

1.  Pre-certify your hospital stay or, if applicable, arrange for the healthcare 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.

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.

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

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

Example:  High Option - When you see your primary care provider you pay nothing per office visit and when you go in for a specialist office visit, you pay $10 per visit.

Example:  Standard Option - When you see your primary care provider you pay $20 per office visit and when you go in for a specialist office visit, you pay $40 per visit.

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

Under the High Option there is no deductible.  Under the Standard Option the deductible is $1,000 for Self Only enrollment, $2,000 for Self Plus One and $2,000 for Self and Family enrollment.

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 allowance that you must pay for your care.  Coinsurance does not begin until you have met your calendar year deductible.

Example:  In the High Option plan, you pay 20% of our allowance for Durable Medical Equipment, disposable medical supplies and Orthopedic and Prosthetic devices, and 50% of our allowances for sexual dysfunction drugs.

Example:  In the Standard Option plan, you pay 20% coinsurance after deductible for lab, X-ray and other diagnostic tests.

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

After your out-of-pocket expenses in the High and Standard Options, including any applicable deductibles, copayments and coinsurance total $7,150 for Self Only, or $14,300 for a Self Plus One or Self and Family enrollment in any calendar year, you do not have to pay any more for covered services. The maximum annual limitation on cost sharing listed under Self Only of $7,150 applies to each individual, regardless of whether the individual is enrolled in Self Only, Self Plus One, or Self and Family.

High Option

Example Scenario:  Your plan has a $7,150 Self Only maximum out-of-pocket limit and a $14,300 Self Plus One or Self and Family maximum out-of-pocket limit.   If you or one of your eligible family members has out-of-pocket qualified medical expenses of $7,150 or more for the calendar year, any remaining qualified medical expenses for that individual will be covered fully by your health plan.  With a Self and Family enrollment out-of-pocket maximum of $14,300, a second family member, or an aggregate of other eligible family members, will continue to accrue out-of-pocket qualified medical expenses up to a maximum of $7,150 for the calendar year before their qualified medical expenses will begin to be covered in full. 

Standard Option

Example Scenario:  Your plan has a $7,150 Self Only maximum out-of-pocket limit and a $14,300 Self Plus One or Self and Family maximum out-of-pocket limit.   If you or one of your eligible family members has out-of-pocket qualified medical expenses of $7,150 or more for the calendar year, any remaining qualified medical expenses for that individual will be covered fully by your health plan.  With a Self and Family enrollment out-of-pocket maximum of $14,300, a second family member, or an aggregate of other eligible family members, will continue to accrue out-of-pocket qualified medical expenses up to a maximum of $7,150 for the calendar year before their qualified medical expenses will begin to be covered in full. 

Be sure to keep accurate records and receipts of your copayments and coinsurance to ensure the plan’s calculation of your out-of-pocket maximum is reflected accurately.

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

Note: If you change options in this Plan during the year, we will credit the amount of covered expenses already accumulated toward the catastrophic out-of-pocket limit of your old option to the catastrophic protection limit of your new option.

The No Surprises Act (NSA) is a federal law that provides you with protections against “surprise billing” and “balance billing” for out-of-network emergency services; out-of-network non-emergency services provided with respect to a visit to a participating health care facility; and out-of-network air ambulance services.

A surprise bill is an unexpected bill you receive for

• emergency care – when you have little or no say in the facility or provider from whom you receive care, or for
• non-emergency services furnished by nonparticipating providers with respect to patient visits to participating health care facilities, or for
• air ambulance services furnished by nonparticipating providers of air ambulance services.

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

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

For specific information on surprise billing, the rights and protections you have, and your responsibilities go to www.ghcscw.com or contact the health plan at 608-828-4853.

• HealthCare FSA (HCFSA) – Reimburses you for eligible out-of-pocket healthcare expenses (such as copayments, deductibles, physician prescribed over-the-counter drugs and medications, vision and dental expenses, and much more) for you, 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.

Professional services of physicians

• In a primary care providers office
• During a hospital stay
• In a skilled nursing facility

$20 per office visit in a primary care providers office

Professional services of physicians

• In specialty physician's office
• In an urgent care center
• Office medical consultations with a specialty physician
• Second surgical opinion
• At home

Note: Specialty medical care provided by a non GHC-SCW Practitioner must be prior authorized if the service requested can be provided by a GHC-SCW Specialty Practitioner.

$10 per office visit

$40 per office visit

• Telehealth services are covered when provided by In-Plan providers specifically contracted with GHC-SCW to provide telehealth services.

Nothing 

Nothing

Tests, such as:

• Blood tests
• Urinalysis
• Non-routine pap test
• Pathology
• X-rays
• Non-routine mammogram
• CT/CAT Scan
• MRI
• Ultrasound
• Electrocardiogram and EEG
• Cologuard

Prior authorization is required.

20% coinsurance after deductible

Routine Physical every year.

The following preventive services are covered at the time interval recommended at each of the links below.

• Immunizations such as Pneumococcal, influenza, shingles, tetanus/Tdap, and human papillomavirus (HPV). For a complete list of immunizations go to the Centers for Disease Control (CDC) website at 
  https://www.cdc.gov/vaccines/schedules/
• Screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer screening. For a complete list of screenings go to the U.S. Preventive Services Task Force (USPSTF) website at https://shorturl.at/hovHM.
• Individual counseling on prevention and reducing health risks
• Preventive care benefits for women such as Pap smears, gonorrhea prophylactic medication to protect newborns, annual counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence. For a complete list of preventive care benefits for women go to the Health and Human Services (HHS) website at 
  https://www.healthcare.gov/preventive-care-women/
• To build your personalized list of preventative services go to 
  https://health.gov/myhealthfinder

Nothing

• Routine mammogram - covered:

Note: Mammograms require a Prior Authorization from the GHC-SCW Care Management Department if they are performed outside a facility either owned or operated by GHC-SCW, or contracted with GHC-SCW to provide mammograms.

Nothing

Nothing

• Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule.

Nothing

Nothing

Note: Any procedure, injection, diagnostic service, laboratory, or x-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance, and deductible.

Nothing

Nothing

Medical Nutrition Therapy and Intensive Behavioral Therapy for the prevention of obesity related comorbidities as recommended under the U.S. Preventive Services Task Force (USPSTF) A and B recommendations.

Nothing

Nothing

Not covered:

Physical examinations for services and/or treatments including, but not limited to:

• Supplies requested by a third party for any reason.
• Any testing or procedures such as, but not limited to, echocardiograms, blood tests, ultrasounds, etc. requested by a third party for any reason
• Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel.
• Immunizations, boosters, and medications for travel or work-related exposure.

All Charges

All Charges

• Well-child visits, examinations, and other preventive services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to https://brightfutures.aap.org
• Immunizations such as DTaP/Tdap, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go to the Centers for Disease Control (CDC) website at 
  https://www.cdc.gov/vaccines/schedules/index.html
• You can also find a complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) online at 
  https://shorturl.at/hovHM. 

Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance, and deductible.

Nothing

Nothing

Complete maternity (obstetrical) care, such as:

• Screening for gestational diabetes
• Prenatal and Postpartum care
• Delivery
• Screening and counseling for prenatal and postpartum depression

Nothing for prenatal care or the first postpartum care visit; $10 per office visit for all postpartum care visits thereafter. Nothing for Inpatient professional delivery services.

Nothing for prenatal care or for the first postpartum care visit; $20 per office visit for all postpartum care visits thereafter.
20% coinsurance for Inpatient professional and facility delivery services.

Breastfeeding support, supplies and counseling for each birth

Nothing

Note: Here are some things to keep in mind:

• You do not need to pre-certify your vaginal delivery; see page 20 for other circumstances, such as extended stays for you or your baby.
• You may remain in the hospital up to 48 hours after a vaginal delivery and 96 hours after a cesarean delivery. We will extend your inpatient stay if medically necessary.
• We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment. Surgical benefits, not maternity benefits, apply to circumcision.
• We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury.
• Hospital services are covered under Section 5(c) and Surgical benefits Section 5(b).
• In-network providers who are certified nursing midwives when services are provided at an in-network facility.
• When a newborn requires definitive treatment during or after the mother's confinement, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.

All Charges

All Charges

Not Covered:

• Birthing Centers
• Costs related to home births

All Charges

All Charges

Nothing

A range of voluntary family planning services, limited to:

• Surgically implanted contraceptives
• Injectable contraceptive drugs (such as Depo Provera)
• Intrauterine devices (IUDs)
• Diaphragms
• Tubal ligation

Note: We cover oral contraceptives under the prescription drug benefit.

Nothing

Voluntary sterilization (See Surgical Procedures Section 5 (b)

Nothing

Nothing

Genetic testing is covered when it is medically necessary for treating an illness or when medically necessary to develop a member's individual health maintenence or screening program.

Nothing

Nothing

Not covered:

• Reversal of voluntary surgical sterilization
• Genetic Testing and Counseling

All Charges

All Charges

Note: Infertility- see section 10 for definition 

Diagnosis of infertility Specific to:

• Artificial Insemination (limited to three (3) cycles annually):
  • Intravaginal insemination (IVI)
  • Intracervical insemination (ICI)
  • Intrauterine Insemination (IUI)

• Iatrogenic Infertility
• Fertility drugs (see section 5f)

Note: Drugs for fertility and for embryo support after assisted reproductive technology (ART) procedures are excluded unless the drug is included in the Formulary.

50% coinsurance

50% coinsurance

Not covered:

• Consultation, treatment, or procedures for Assisted Reproductive Technology (ART), except for IVF-related drugs covered on the formulary (limited to three cycles annually). ART includes all fertility treatments in which either eggs or embryos are handled. In general, ART procedures involve surgically removing eggs from a woman’s ovaries, combining them with sperm in the laboratory, and returning them to the woman’s body or donating them to another woman. They do NOT include treatments in which only sperm are handled (i.e., intrauterine—or artificial—insemination) or procedures in which a woman takes medicine only to stimulate egg production without the intention of having eggs retrieved. ART includes, but is not limited to:
• In Vitro fertilization (IVF)
• Embryo transfer, gamete intra-fallopian transfer (GIFT) and zygote intra-fallopian transfer (ZIFT)
• Services and supplies related to ART
• Cost of donor sperm
• Cost of donor egg
• Fertility drugs, except for Clomiphene Citrate, Progesterone, and up to three cycles of covered IVF-related drugs annually

All Charges

All Charges

• Testing and treatment

$10 per office visit

$20 per primary care office visit or $40 per specialty office visit

• Allergy antigen injections
• Allergy serum injections

Nothing

20% coinsurance after deductible

Not covered:

• Provocative food testing
• Sublingual allergy desensitization

All Charges

All Charges

• Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue Transplants on pages 48-52

• Respiratory and inhalation therapy
• Dialysis – hemodialysis and peritoneal dialysis
• Intravenous (IV)/Infusion Therapy - Home IV and antibiotic therapy
• Growth hormone therapy (GHT)

Note: Growth hormone is covered under the prescription drug benefit.

Note: We only cover GHT when we preauthorized the treatment. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment. We will only cover GHT services and related services and supplies that we determine are medically necessary. See Other Services under You need prior Plan approval for certain services on page 18.

• Medical Nutrition Therapy

Note: Medical Nutrition Therapy, Enteral or specialized nutritional support, is for those members with normal or abnormal gastrointestinal absorptive capacity who, due to non-function or disease of the gastrointestinal tract, require alternative formulas or routes of administration to provide sufficient nutrients. The enteral and/or other nutritional support supplies are covered as DME. See page 41.

• Nutritional formula specifically formulated and prescribed to treat phenylketonuria (PKU) or other inborn errors of metabolism.

20% coinsurance after deductible

• Applied Behavior Analysis (ABA) - children with autism spectrum disorder
  • Autism Spectrum Disorder Diagnostic Testing
  • Specialty Office Visit

Note: Autism Spectrum Disorder medical care must first be provided by a GHC-SCW Practitioner. Prior Authorization is required to see a provider outside of GHC-SCW staff model. The coverage required shall provide at least $50,000 for intensive-level services per insured per year, for up to 35 hours of care per week for a maximum duration of 4 years, and at least $25,000 for non-intensive-level services per insured per year.

$10 per visit for diagnosis and treatment

Nothing for Intensive-Level Services and Non-Intensive Services or Evidence Based Therapies

$40 per office visit for diagnosis and treatment

20% coinsurance after deductible for Intensive-Level Services and Non-Intensive Services or Evidence Based Therapies

Not covered:

• Food or nutrition that is not Medical Food
• Regular grocery products that can be mixed in blenders, pre-blenderized food, infant food, and all other foods, nutritional supplements, and formulas available without prescription, other than nutritional formula specifically formulated for the treatment of infants (i.e., up to 12 months of age) with an inborn error of metabolism.
• Gene therapy, which includes the intentional, expected permanent, and specific alteration of the DNA sequence of the cellular genome, for a clinical purpose.

All Charges

All Charges

Rehabilitative and Habilitative Services of each of the following:

60 visits for the services of each of the following:

• Qualified physical therapists
• Occupational therapists

Note: We only cover therapy when a physician:

• orders the care
• identifies the specific professional skills the patent requires and the medical necessity for skilled services; and
• indicates the length of time the services are needed

20% coinsurance after deductible

Not covered:

• Long-term rehabilitative therapy
• Exercise programs except for those named above
• Dry Needling

All Charges

All Charges

Rehabilitative and Habilitative Services of each of the following

60 consecutive days per condition for the services of qualified speech therapists

Nothing

20% coinsurance after deductible

Not covered:

Treatment for tongue thrust

All Charges

All Charges

• For treatment related to illness or injury, including evaluation and diagnostic hearing tests performed by an M.D., D.O., or audiologist

Note: For routine hearing screening performed during a child's preventive care visit, see Section 5(a) Preventive Care, children on page 31.

• External Hearing Aids
• Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants

Prior authorization will be required for external hearing aids and implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants.

Note: For benefits for the devices, see Section 5(a) Orthopedic and prosthetic devices on pages 38-40.

$10 per office visit

$40 per office visit

Not covered

Hearing services that are not shown as covered.

All Charges

All Charges

• Annual routine vision examination to determine the need for corrective eyeglass lenses and the written prescription for corrective eyeglass lenses for Members performed by an In-Network Optometrist (OD).
• Annual eye refraction

Note: See Preventive care, children for eye exams for children on page 31.

$10 per office visit

$40 per office visit

• Vision Therapy for treatment of Strabismus and other like Convergent disorders as medically necessary for the number of visits as determined by the health plan. Prior authorization is required.

Nothing

20% coinsurance after deductible

• One eyeglass lens (frame not covered) or one contact lens to correct the affected eye for impairment directly caused by ocular injury or intraocular surgery (such as for cataracts).

All charges above cost of covered lens

All charges above cost of covered lens

Not covered:

• Eyewear: including lenses, frames, contact lenses, contact lens prescriptions and contact lens services except as shown above
• Eye exercises and orthoptics
• Radial keratotomy and other refractive surgery
• Routine vision examinations performed by providers other than an optometrist (for example, ophthalmologists).

All Charges

All Charges

20% coinsurance after deductible

Not covered:

• Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above
• Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery)

All Charges

All Charges

• Artificial limbs and eyes
• Prosthetic sleeve or sock
• Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy
• Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome
• Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants
• Internal prosthetic devices, such as artificial joints, pacemakers, and surgically implanted breast implant following mastectomy

Note: For information on the professional charges for the surgery to insert an implant, see Section 5(b) Surgical procedures. For information on the hospital and/or ambulatory surgery center benefits, see Section 5(c) Services provided by a hospital or other facility, and ambulance services.

• Foot orthotics that are custom molded to the Member's foot are covered; limited to one pair of orthotics per 24 months. Prior authorization is required.

Note: GHC-SCW covers therapeutic shoes (depth or custom-molded) along with inserts for members with diabetes mellitus and any of the following complications involving the foot:

• Peripheral neuropathy with evidence of callus formation
• History of pre-ulcerative calluses
• History of previous ulceration
• Foot deformity
• Previous amputation of the foot or part of the foot
• Poor circulation

These criteria are consistent with CMS guidelines.

Coverage limited to one of the following per member per calendar year:

• No more than one pair of custom-molded shoes (including inserts provided with the shoes) and two additional pairs of inserts; or
• No more than one pair of depth shoes and three pairs of inserts (not including the non-customized removable insert provided with such shoes).

Note: GHC-SCW will provide payment for the initial acquisition and medically necessary revision or replacement of prosthetic appliances, which are artificial devices used to replace all or part of an external body part.

20% of the Plan allowance per item (per purchase or rental period) up to a maximum out-of-pocket amount of $2,500 per member per year, combined with Durable medical equipment. You pay nothing thereafter.

20% coinsurance

• Hearing aids for members under age 18. Limited to one aid every 36 months.

20% Coinsurance

• Hearing aids for members age 18 and older. Limited to one aid, per ear, every 36 months.

20% Coinsurance for models specifically designated by GHC-SCW.  If the hearing aid that has been recommended to you by Your Provider is not designated as covered by GHC-SCW, you will pay 20% Coinsurance, but coverage will be limited to $2,500 every three years (total for both ears).

20% Coinsurance for models specifically designated by GHC-SCW.  If the hearing aid that has been recommended to you by Your Provider is not designated as covered by GHC-SCW, you will pay 20% Coinsurance, but coverage will be limited to $2,500 every three years (total for both ears).

Bone anchored hearing aids (BAHA). Member must meet the BAHA criteria and be prior authorized by the GHC-SCW Care Management Department.

20% Coinsurance and all charges above benefit maximum.

20% Coinsurance after deductible

Not covered:

• Orthopedic and corrective shoes, arch supports, foot orthotics except as noted above, shoes or orthotics not custom made and purchased over the counter, heel pads and heel cups
• Lumbosacral supports
• Corsets, trusses, elastic stockings, support hose, and other supportive devices
• Prosthetic replacements unless the item is no longer useful and has exceeded its reasonable lifetime under normal use; or the member's condition has changed so as to make the original equipment inappropriate.
• Prosthetic replacements not meeting covered criteria.

All Charges

All Charges

We cover rental or purchase of durable medical equipment, at our option, including repair and adjustment. Covered items include:

• Oxygen
• Dialysis equipment
• Hospital beds
• Wheelchairs (standard, motorized) (criteria must be met)
• Scooters (criteria must be met)
• Crutches
• Walkers
• Insulin infusion pumps and related supplies when coverage criteria are met and prior authorization is issued
• TENS Unit
• Compression Stockings (limited to 3 pair per calendar year); requires a prescription from a Plan provider
• Disposable supplies (other than disposable diabetic supplies specifically covered below), including Insulin Infusion Pump supplies
• Disposable needles and syringes (other than insulin needles and syringes covered as diabetic disposable supplies below) for the administration of covered medications
• Enteral feeding supplies (see section 5(a) Treatment Therapies)
• Light Boxes

Note: We only cover Enteral feeding supplies when we preauthorize the treatment. If we determine Enteral feedings are not medically necessary, we will not cover the related services or treatments.

Note: Call us at 608-257-5294 as soon as your Plan physician prescribes this equipment. We will arrange with a healthcare provider to rent or sell you the prescribed durable medical equipment at discounted rates. We will tell you more about this service when you call.

20% of the Plan allowance per item (per purchase or rental period) up to a maximum out of pocket expense of $2,500 per member per year, combined with Orthopedic and prosthetic devices. You pay nothing thereafter.

20% Coinsurance

• Diabetic disposable supplies (including insulin syringes, needles, injection pens, glucose test tablets and test tape, Benedict's solution or equivalent, and acetone test tablets)
• Blood Glucose monitors

20% to a maximum of $500 per member per year

20% to a maximum of $500 per member per year

Not covered:

• Equipment, models or devices that have features over and above that which is Medically Necessary. Coverage will be limited to the standard model as determined by GHC-SCW. This includes the upgrade of equipment, models or devices to better or new technology when the existing equipment, models or devices are sufficient and there is no change in the Member's condition nor is the existing equipment, models or devices in need of repair or replacement.
• Any requests for Insulin Infusion Pumps that do not meet criteria.

All Charges

All Charges

• Home healthcare ordered by a Plan physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.), or home health aide.
• Services include oxygen therapy, intravenous therapy and medications.
• Home health visits are limited to 60 visits per calendar year.

Nothing

20% Coinsurance after deductible

Not covered:

• Nursing care requested by, or for the convenience of, the patient or the patient's family
• Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative.

All Charges

All Charges

• Manipulation of the spine and extremities

$20 per office visit

Not covered:

• Chiropractic services for chronic conditions or for maintenance
• Adjunctive procedcures such as ultrasound, electrical muscle stimulation, vibratory therapy and cold pack application.

All Charges

Coverage is provided for:

• Tobacco and nicotine cessation programs, including individual, group, phone counseling, over-the-counter (OTC) and prescription drugs approved by the FDA to quit smoking (vaping) or other nicotine use.

Nothing for individual counseling for up to two quit attempts per year.

Nothing for OTC and prescription drugs approved by the FDA to treat tobacco dependence.

Nothing for individual counseling for up to two quit attempts per year.

Nothing for OTC and prescription drugs approved by the FDA to treat tobacco dependence.

• Diabetes self-management

Nothing

Nothing

• Multicomponent, family centered programs focused on childhood obesity that are part of intensive behavioral interventions (behavior change counseling for healthy diet and physical activity)

Nothing

Coverage may include:

• Nutrition Education
• Weight Management
• Stress Management
• Prenatal Education
• First Aid Training

Note: Contact the GHC-SCW Member Services at 608-828-4853 for program and fee schedules.

Fees apply to some but not all classes and programs.

Fees apply to some but not all classes and programs.

A comprehensive range of services, such as:

• Operative procedures
• Treatment of fractures, including casting
• Normal pre- and post-operative care by the surgeon
• Correction of amblyopia and strabismus
• Endoscopy procedures
• Biopsy procedures
• Removal of tumors and cysts
• Correction of congenital anomalies (see Reconstructive surgery )
• Surgical treatment of severe obesity (bariatric surgery)
  • An individual must weigh 100 pounds or 100% over his or her normal weight according to the current underwriting standards.
  • An individual must be age 18 or over.
  • An individual's health must be endangered, that is, have a BMI of 40 or greater or a BMI between 35-39 with documented high-risk, comorbid medical conditions that have not responded to medical management and are a threat to life.
  • An individual must have tried conservative measures such as, but not limited to: psychological evaluation, behavior modification, diet restrictions/supplements, physician supervised weight loss plans, physical activity programs, prescription drugs such as appetite suppressants.
  • The following are excluded from coverage even if a physician prescribes or administers them: vitamins, nutrients and food supplements.
  • Note: Contact us for specific information regarding Covered and Not covered Bariatric Surgery procedures.
• Insertion of internal prosthetic devices . See 5(a) – Orthopedic and prosthetic devices for device coverage information
  • Note: Generally, we pay for internal prostheses (devices) according to where the procedure is done. For example, we pay Hospital benefits for a pacemaker and Surgery benefits for insertion of the pacemaker.
• Voluntary sterilization (e.g. vasectomy)
• Treatment of burns

20% Coinsurance after
deductible

• We now cover bilateral cochlear implants and cochlear implants (as well as BAHAs) for members of any age when medically necessary.

20% Coinsurance after
deductible

Not covered:

• Reversal of voluntary sterilization
• Routine treatment of conditions of the foot; (see Foot care)

All Charges

• Surgery to correct a functional defect
• Surgery to correct a condition caused by injury or illness if:
  • the condition produced a major effect on the member's appearance and
  • the condition can reasonably be expected to be corrected by such surgery
• Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital anomalies are: protruding ear deformities, cleft lip, cleft palate, birth marks, and webbed fingers and toes.
• All stages of breast reconstruction surgery following a mastectomy/lumpectomy with radiation and chemotherapy resulting in asymmetry, such as:
  • surgery to produce a symmetrical appearance of breasts
  • treatment of any physical complications, such as lymphedema
  • breast prostheses and surgical bras and replacements (see Prosthetic devices)

Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure.

• Gender Affirming Surgery
  • This plan covers medically necessary gender affirmation surgeries.

20% Coinsurance after
deductible

Not covered:

• Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury. This includes any cosmetic services or surgical procedures performed for psychological reasons. 
  
  

All Charges

Oral surgical procedures (including anesthesia and related X-rays when received from a dentist or dental group designated by GHC-SCW), limited to:

• Incision and drainage of cellulitis 
• incision and removal of a foreign body
• surgical procedures to correct accidental injuries to the lips and oral soft tissues
• surgical correction of cleft lip, cleft palate and severe functional malocclusion
• treatment of fractures and dislocations to facial bones
• hard and soft tissue biopsies
• excision of tumors, cysts, and lesions of the jaw, oral mucous membrane, and underlying soft tissue that require pathological examination
• incision of maxillary sinus and salivary glands or ducts
• extraction of impacted teeth
• frenectomy
• apioectomy
• excision of exostoses
• alveolotomy
• removal of retained residual root
• non-dental treatment of TMJ syndrome

Nothing

20% Coinsurance after
deductible

• Dental treatment of temporomandibular (TMJ) syndrome

Note: a physical therapy evaluation is required before an intraoral splint is considered as a treatment option.

20% Coinsurance after
deductible

Not covered:

• Oral implants and transplants
• Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)

All Charges

All Charges

These solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan. Refer to Other Services in Section 3 for prior authorization procedures.

• Autologuous pancreas islet cell transplant (as anadjunt to total or near total pancreatectomy) only for patients with chronic pancreatitis.
• Cornea 
• Heart
• Heart/lung
• Intestinal transplants
  • Isolated small intestine
  • Small intestine with the liver
  • Small intestine with multiple organs, such as the liver, stomach and pancreas
  • Autologous pancreas islet cell transplant
• Kidney
• Kidney-pancreas
• Liver
• Lung: Single, bilateral/lobar
• Pancreas

These tandem blood or marrow stem cell transplants for covered transplants are subject to medical necessity review by the Plan. Refer to Other services in Section 3 for prior authorization procedures.

• Autologous tandem transplants for
  • AL Amyloidosis
  • Multiple myeloma (de novo and treated)
  • Recurrent germ cell tumors (including testicular cancer)

 Blood or marrow stem cell transplants The Plan extends coverage for the diagnoses as indicated below.

Physicians consider many features to determine how diseases will respond to different types of treatment. Some of the features measured are the presence or absence of normal and abnormal chromosomes, the extension of the disease throughout the body, and how fast the tumor cells grow. By analyzing these and other characteristics, physicians can determine which diseases may respond to treatment without transplant and which diseases may respond to transplant. For the diagnoses listed below, the medical necessity limitation is considered satisfied in the patient meets the staging description.

• Allogeneic transplants for
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced Myeloproliferative Disorders (MPDs)
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Hemoglobinopathy
  • Marrow Failure and Related Disorders (i.e.. Fanconi's, Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia)
  • Myelodysplasia/Myelodyplastic syndromes
  • Paroxysmal Nocturnal Hemoglobinuria
  • Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome)
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
  • Sickle cell anemia
  • X-linked lymphoproliferative syndrome
  • Hematopoietic stem cell transplant
• Autologous transplants for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin's lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin's lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Breast Cancer
  • Ependymoblastoma
  • Epithelial ovarian cancer
  • Ewings Sarcoma
  • Multiple myeloma
  • Neuroblastoma
  • Testicular, Mediastinal, Retroperitoneal, and ovarian germ cell tumors
  • Hematopoietic stem cell transplant

Mini-transplants performed in a clinical trial setting (non-myeloablative, reduced intensity conditioning or RIC) for members with a diagnosis listed below are subject to medical necessity review by the Plan.

Refer to Other services in Section 3 for prior authorization procedures.

• Allogeneic transplants for
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Acute myeloid leukemia
  • Advanced Myeloproliferative Disorders (MPDs)
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Hemoglobinopathy
  • Marrow Failure and Related Disorders (i.e.. Fanconi's, PNH, Pure Red Cell Aplasia)
  • Myelodysplasia/Myelodyplastic syndromes
  • Paroxysmal Nocturnal Hemoglobinuria
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
• Autologous transplants for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin's lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin's lymphona with recurrence (relapsed)
  • Amyloidosis  
  • Neuroblastoma  

These blood or marrow stem cell transplants are covered only in a National Cancer Institute or National Institutes of health approved clinical trial or a Plan-designated center of excellence if approved by the Plan's medical director in accordance with the Plan's protocols.

If you are a participant in a clinical trial, the Plan will provide benefits for related routine care that is medically necessary (such as doctor visits, lab tests, X-rays and scans) and hospitalization related to treating the patient's condition) if it is not provided by the clinical trial. Section 9 has additional information on costs related to clinical trials. We encourage you to contact the Plan to discuss specific services if you participate in a clinical trial.

• Autologous transplants for
• Advanced Childhood kidney cancers
• Advanced Ewing sarcoma
• Aggressive non-Hodgkin's lymphomas (Mantel Cell lymphoma, adult T-cell leukemia/lymphoma, peripheral T-cell lymphomas and aggressive Dendritic Cell neoplasms)
• Breast Cancer
• Childhood rhabdomyosarcoma
• Epithelial Ovarian Cancer
• Mantle Cell (Non-Hodgkin lymphoma)

National Transplant Program (NTP)

Note: We cover related medical and hospital expenses of the donor when we cover the recipient. We cover donor testing for the actual solid organ donor or up to four bone marrow/stem cell transplant donors in addition to the testing of family members.

20% Coinsurance after
deductible

Not covered:

• Donor screening tests and donor search expenses, except as shown above
• Implants of artificial organs
• Transplants not listed as covered

All Charges

Professional services provided in

• Hospital (inpatient)
• Hospital outpatient department
• Skilled nursing facility
• Ambulatory surgical center
• Office

20% Coinsurance after
deductible

Room and board, such as

• Ward, semiprivate, or intensive care accommodations
• General nursing care
• Meals and special diets

Note: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate.

Other hospital services and supplies, such as:

• Operating, recovery, maternity, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests and X-rays
• Dressings, splints, casts, and sterile tray services
• Medical supplies and equipment, including oxygen
• Anesthetics, including nurse anesthetist services
• Take-home items
• Medical supplies, appliances, medical equipment, and any other covered items billed by a hospital for use at home

20% Coinsurance after deductible

Not covered:

• Custodial care
• Non-covered facilities, such as nursing homes, schools
• Personal comfort items, such as phone, television, barber services, guest meals and beds
• Private nursing care
• Hospital stays, which are extended for reasons other than Medical Necessity, including, but not limited to lack of transportation, lack of caregiver, inclement weather and other like reasons.
• A continued Hospital stay, if the attending physician has documented that care could effectively be provided in a less acute care setting, for example, Skilled Nursing Facility.

All Charges

• Operating, recovery, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests, X-rays, and pathology services
• Administration of blood, blood plasma, and other biologicals
• Blood and blood plasma, if not donated or replaced
• Pre-surgical testing
• Dressings, casts, and sterile tray services
• Medical supplies, including oxygen
• Anesthetics and anesthesia service

Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We do not cover the dental procedures.

20% Coinsurance after deductible

Not covered:

• Blood and blood derivatives not replaced by the member

All Charges

Extended care benefit: We provide a comprehensive range of benefits for up to 30 days per inpatient stay. Multiple stays per year may be covered.  Coverage must me certified as Medically Necessary and is recertified as Medically Necessary every seven (7) days.

20% Coinsurance after deductible

Not covered:

• Custodial care

All Charges

All Charges

End-of-life services are available if:

• the terminally ill person is a GHC-SCW member, and
• the care is ordered by a GHC-SCW Practitioner.

Outpatient End-of-Life covered charges include:

• Part-time or intermittent nursing care by an RN or LPN 
• Medical social services under the direction of a GHC-SCW Practitioner, including:
  • Assessment of the terminally ill person's social, emotional and medical needs, and home and family situation
  • Identification of community resources available to the terminally ill person
  • Assistance to the terminally ill person in obtaining the community resources needed to meet his or her assessed needs
  • Psychological and dietary counseling
  • Consultation or care management services by a GHC-SCW Practitioner
  • Physical and occupational therapy
  • Part-time or intermittent home health aid services consisting mainly of caring for the terminally ill person
  • Medical supplies, drugs, and medications prescribed by a GHC-SCW practitioner
  • Charges made by any other covered health care practitioner for the services and supplies listed above only if the provider is not part of or employed by a hospice care agency, and the hospice care agency retains responsibility for the care of the terminally ill person
  • Bereavement counseling
• Inpatient End-of-Life Services include:
  • Charges made by an end-of-life facility for room and board. If a private room is used, any part of the daily room and board charge that is more than the end-of-life facility's most common semi-private room charge is not covered; and
  • Other services and supplies furnished to the terminally ill person for uncontrolled, new onset acute symptom management when, in the determination of the GHC-SCW Medical Director, an inpatient stay is Medically Necessary.

20% Coinsurance after deductible

Not covered:

• Independent nursing, homemaker services

All Charges

GHC-SCW will provide supportive and palliative care for a terminally ill Member, whose life expectancy is six months or less if the illness runs its normal course, for in-home and inpatient care with Prior Authorization. Certification of the terminal illness must be given to GHC-SCW's Care Management Department by the Primary Care Practitioner upon request.

Nothing

20% Coinsurance after deductible

20% Coinsurance after deductible

Not covered:

• ambulance services to home following an inpatient stay

All Charges

All Charges

• Emergency care at a doctor's office
• Emergency care at an urgent care center

$40 per office visit

• Emergency Outpatient Care at the emergency department of a Hospital for an Emergency Condition, inclusive of all necessary and related diagnostic and therapeutic services, is a covered benefit. GHC-SCW reserves the right to determine whether a specific medical situation actually constitutes an Emergency Condition. Prior authorization is not required.
• Co-payments associated with this service are waived if the member is admitted as a hospital inpatient or is placed in observation status for a period of time more than 24 hours.

$100 per visit

Not covered:

• Elective care

All Charges

All Charges

• Emergency care at a doctor's office
• Emergency care at an urgent care center

$40 per office visit

• Emergency Outpatient Care at the emergency department of a Hospital for an Emergency Condition, inclusive of all necessary and related diagnostic and therapeutic services, is a covered benefit. GHC-SCW reserves the right to determine whether a specific medical situation actually constitutes an Emergency Condition. Prior authorization is not required.
• Co-payments associated with this service are waived if the member is admitted as a hospital inpatient or is placed in observation status for a period of time more than 24 hours.

$100 per visit

Not covered:

• Elective care or non-emergency care and follow-up care recommended by non-Plan providers that has not been approved by the Plan or provided by Plan providers
• Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
• Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area

All Charges

Professional ambulance service when medically appropriate.

Nothing

20% coinsurance after deductible

Not covered:

• Ambulance services to home following an in-patient stay.

All Charges

When part of a treatment plan we approve, we cover professional services by licensed professional mental health and substance use disorder treatment practitioners when acting within the scope of their license, such as psychiatrists, psychologists, clinical social workers, licensed professional counselors, or marriage and family therapists.

Diagnosis and treatment of psychiatric conditions, mental illness, or mental disorders. Services include:

• Diagnostic evaluation
• Crisis intervention and stabilization for acute episodes
• Medication evaluation and management (pharmacotherapy)
• Psychological and neuropsychological testing necessary to determine the appropriate psychiatric treatment
• Diagnosis and treatment of substance use disorders including detoxification, treatment and counseling
• Professional charges for intensive outpatient treatment in a provider's office or other professional setting
• Electroconvulsive therapy

Your cost-sharing responsibilities are no greater than for other illness or conditions.

• Treatment and counseling (including individual or group therapy visits)
• Diagnosis and treatment of alcoholism and drug use, including detoxification, treatment and counseling
• Professional charges for intensive outpatient treatment in a provider's office or other professional setting
• Couples Counseling

Nothing

$20 per office visit

• Outpatient diagnostic tests provided and billed by a licensed mental health and substance use disorder treatment practitioner
• Outpatient diagnostic tests provided and billed by a laboratory, hospital or other covered facility
• Inpatient diagnostic tests provided and billed by a hospital or other covered facility

20% Coinsurance after deductible

Inpatient services provided and billed by a hospital or other covered facility

• Room and board, such as semiprivate or intensive accommodations, general nursing care, meals and special diets, and other hospital services.

20% Coinsurance after deductible

Outpatient services provided and billed by a hospital or other covered facility

• Services in approved alternative care settings such as partial hospitalization, full-day hospitalization, facility based intensive outpatient treatment

20% coinsurance after deductible

We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy or through our mail order program:

• Drugs and medications that by Federal law of the United States require a physician’s prescription for their purchase, except those listed as Not covered-
• Insulin
• Diabetic Supplies limited to:
  • Disposable needles and syringes for the administration of covered medications.
• fertility drugs - 
  • in vitro fertilization (IVF)-related drugs – limited to three cycles annually (See below)

  Covered under prescription drug benefit

  • Clomiphene citrate and Progesterone
• Injectable Drugs: Coverage of prescription drugs administered by intravenous or intramuscular injection in a clinic or office setting are covered only when coverage criteria are met and when prior authorization is issued, unless required for immediate treatment of an acute medical problem. Prescription drugs administered subcutaneously are considered outpatient prescription drugs, regardless if self-administered or administered by a health care provider.
• Drugs used for weight reduction.

Note: Specialty drugs - see Section 10 for definition

Note: When a covered drug is available as both a brand-name and equivalent generic product, only the generic will be on the Formulary. Prior Authorization for the branded product may be granted based on criteria established by GHC-SCW. Member responsibility for brand-name drugs that have a generic equivalent will be the highest-tier copay assigned to the plan (Tier 4).

Note:  Compound prescriptions are covered, so long as: all active ingredients are on the Formulary and are FDA-approved as drugs; the resulting product is well-supported by medical literature as reasonable and generally accepted medical practice; and equivalent or similar products are not available commercially.  Compounds above a cost threshold require Prior Authorization.

Retail - 30 day supply

Tier One - $5

Tier Two - $20

Tier Three - $50

Tier Four - $100

Mail-order

3x for 90-day supply

Tier One - $15

Tier Two - $60

Tier Three - $150

Tier Four - $300

Retail - 30 day supply

Tier One - $5

Tier Two - $20

Tier Three - $50

Tier Four - $100

Mail-order

3x for 90-day supply

Tier One - $15

Tier Two - $60

Tier Three - $150

Tier Four - $300

Contraceptive drugs and devices prescribed by a health care professional and obtained from a Plan pharmacy or through our mail order program.  

Contraceptive drugs and devices as listed in the ACA/HRSA site.  Contraceptive coverage is available at no cost to FEHB members. The contraceptive benefit includes at least one option in all methods of contraception (as well as the screening, education, counseling, and follow-up care).  Any contraceptive that is not already available without cost sharing on the formulary can be accessed through the contraceptive exceptions process described below. 

• To initiate an exception request, a Plan physician (or member or member’s representative) may submit via facsimile or telephone information about the member’s diagnosis, other therapies tried, and medial necessity rationale to the Plan. GHC-SCW Pharmacy Administration may be contacted via telephone at 608-828-4811 for questions about the exceptions process.

The "morning after pill" is considered preventive service under contraceptives, with no cost to the member if prescribed by a physician and purchased at a network pharmacy. The "morning after pill" should be addressed under the pharmacy benefit as an over-the counter (OTC) emergency contraceptive drug.

Nothing

Nothing

Medications to promote better health as recommended by ACA.

The following drugs and supplements are covered without cost-share, even if over-the-counter, are prescribed by a health care professional and filled at a network pharmacy.

• Aspirin (81 mg) for men age 45-79 and women age 55-79 and women of childbearing age
• Folic acid supplements for women of childbearing age 400 & 800 mcg
• Liquid iron supplements for children age 6 months - 1year
• Fluoride tablets, solution ( not toothpaste, rinses) for children age 0-6
• Statins (low to moderate dose) for adults ages 40-75 who are prescribed statin use by their physician for prevention of cardiovascular disease

Note:  To receive this benefit a prescription from a doctor must be presented to pharmacy.

Nothing

Nothing

Not covered:

• Drugs not on the Formulary, unless prior authorized
• Drugs and supplies for cosmetic purposes
• Drugs to enhance athletic performance
• Fertility drugs, except for Clomiphene Citrate, Progesterone, and up to three cycles of covered IVF-related drugs annually
• Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies.  If a member uses a non-authorized pharmacy, reimbursement for that prescription will be limited to the amount the plan would be responsible for if the member had used an authorized pharmacy.
• Vitamins, nutrients and food supplements not listed as a covered benefit even if a physician prescribes or administers them
• Nonprescription medications unless specifically indicated elsewhere
• Gene therapy, which includes the intentional, expected permanent, and specific alteration of the DNA sequence of the cellular genome, for a clinical purpose
• Vitamin D supplements (prescription strength) (400 & 1000 units) for members 65 or older
• Any brand-name drug that has an available "authorized generic".  An authorized generic is a generic product marketed under the equivalent brand-name drug's FDA New Drug Application.

Note: Over-the-counter and prescriptions drugs approved by the FDA to treat tobacco and nicotine dependence are covered under the Tobacco cessation and nicotine cessation benefit. (See page 43)

All Charges

All Charges

We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The need for these services must result from an accidental injury.

To be eligible for coverage, the accident and treatment must occur while the member is enrolled under the GHC-SCW Plan. Care must be initiated within 90 days of the accident and must be completed within 12 months of the accident.

NOTE: Damage to teeth caused by chewing or biting does not constitute an accidental injury.

Nothing up to $1,500 per accident

All charges above $1,500 per accident.

20% Coinsurance after deductible

Nothing if prior authorized and performed at a Plan participating hospital or facility.

20% Coinsurance after deductible if prior authorized and performed at a Plan participating hospital or facility.

• Prophylaxis or cleaning (one in any six month period)
• Topical applications of fluroide through age fifteen (15) - one every six months

Nothing if you use a GHC-SCW Plan dentist.

All charges for services provided by a non-plan dentist.

Nothing if you use a GHC-SCW Plan dentist.

All charges for services provided by a non-plan dentist.

Not covered:

• all other dental services, including but not limited to x-rays, fillings, extractions, crowns, orthodontics, etc.

All Charges

All Charges

Telehealth services are covered when provided by In-Plan providers specifically contracted with GHC-SCW to provide telehealth services.  See Section 5(a).

In most cases, providers and facilities file claims for you. 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, contact us at 608-828-4853 or at our website at
www.ghcscw.com.

When you must file a claim – such as for services you received outside the Plan’s service area – 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: GHC-SCW Claims Dept., PO Box 44971, Madison WI 53744-4971

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.

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

If you live in a county where at least 10% 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 healthcare provider, and the claim amount, if applicable), and a statement describing the availability, upon request, of the diagnosis and procedure codes

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: GHC-SCW Member Services Dept., PO Box 44971, Madison WI 53744-4971; 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 OPM's decision via e-mail. Please note that by providing your email address, you may receive OPM's 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 our claim and any new rationale for our claim decision. We will provide you with this information sufficiently in advance of the date that we are required to provide you with our reconsideration decision to allow you a reasonable opportunity to respond to us before that date. However, our failure to provide you with new evidence or rationale in sufficient time to allow you to timely respond shall not invalidate our decision on reconsideration. You may respond to that new evidence or rationale at the OPM review stage described in step 4.

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

a)     Pay the claim or

b)     Write to you and maintain our denial or

c)     Ask you or your provider for more information.

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

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

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

You must write to OPM within:

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

Write to OPM at: United States Office of Personnel Management, Healthcare and Insurance, Federal Employee Insurance Operations,  FEHB 3, 1900 E Street, NW, Washington DC 20415-3630.

Send OPM the following information:

• A statement about why you believe our decision was wrong, based on specific benefit provisions of 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 healthcare professional with knowledge of your medical condition may act as your authorized representative without your express consent.

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

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

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

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

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

Note: If you have a serious or life threatening condition (one that may cause permanent loss of bodily function or death if not treated as soon as possible), and you did not indicate that your claims was a claim for urgent care, then call us at (800) 605-4327. We will expedite our review (if we have not yet responded to your claim); or we will inform OPM so they can quickly review your claim on appeal. You may call FEHB 3 at 202-606-0737 between 8 a.m. and 5 p.m. Eastern Time.

Please remember that we do not make decisions about plan eligibility issues.  For example, we do not determine whether you or a family member are covered under this plan.  You must raise eligibility issues with your Agency personnel/payroll office if you are an employee, your retirement system if you are an annuitant or the Office of Workers' Compensation Programs if you are receiving Workers' Compensation benefits.

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

When you have double coverage, one plan normally pays its benefits in full as the primary payor and the other plan pays a reduced benefit as the secondary payor. We, like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners’ (NAIC) guidelines.  For more information visit our website at www.ghcscw.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 processes the benefit, we will pay what is left of our allowance, up to our regular benefit.  We will not pay more than our allowance. 

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

Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these programs, eliminating your FEHB premium. (OPM does not contribute to any applicable plan premiums.) For information on suspending your FEHB enrollment, contact your retirement or employing 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.

Every job-related injury or illness should be reported as soon as possible to your supervisor. Injury also means any illness or disease that is caused or aggravated by the employment as well as damage to medical braces, artificial limbs and other prosthetic devices. If you are a federal or postal employee, ask your supervisor to authorize medical treatment by use of form CA-16 before you obtain treatment. If your medical treatment is accepted by the Dept. of Labor Office of Workers’ Compensation (OWCP), the provider will be compensated by OWCP. If your treatment is determined not job-related, we will process your benefit according to the terms of this plan, including use of in-network providers. Take form CA-16 and form OWCP-1500/HCFA-1500 to your provider, or send it to your provider as soon as possible after treatment, to avoid complications about whether your treatment is covered by this plan or by OWCP.

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.

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 or employing office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under the state program.

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

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

Some FEHB plans already cover some dental and vision services. When you are covered by more than one vision/dental plan, coverage provided under your FEHB plan remains as your primary coverage. FEDVIP coverage pays secondary to that coverage. When you enroll in a dental and/or vision plan by phone (1-877-888-3337) (TTY 1-877-889-5680), you will be asked to provide information on the FEHB plan so that your plans can coordinate benefits. Providing your FEHB information may reduce your out-of-pocket cost.

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is either Federally funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration; 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- This plan does not cover these costs.

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

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

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

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

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

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

When Original Medicare is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges.  To find out if you need to do something to file your claim, call us at 608-828-4853 or see our website at www.ghcscw.com.

We do not waive any costs if the Original Medicare Plan is your primary payor. 

Please review the following examples which 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
You pay without Medicare: High: Nothing; Standard: $1,000 Self Only/$2,000 Self Plus One and Self and Family
You pay with Medicare Part B: High and Standard: Nothing

Benefit Description: Out-of-Pocket-Maximum
You pay without Medicare: High and Standard: $7,150 Self Only/$14,300 Self Plus One and Self and Family
You pay with Medicare Part B: High and Standard: $7,150 Self Only/$14,300 Self Plus One and Self and Family

Benefit Description: Part B Premium Reimbursement Offered
You pay without Medicare:  N/A
You pay with Medicare Part B: N/A

Benefit Description: Primary Care Provider
You pay without Medicare: High: Nothing; Standard: $20 copayment
You pay with Medicare Part B: High and Standard: Nothing

Benefit Description: Specialist
You pay without Medicare: High: $10 copayment; Standard: $40 copayment
You pay with Medicare Part B: High and Standard: Nothing

Benefit Description: Inpatient Hospital 
You pay without Medicare: High: Nothing; Standard: 20% coinsurance after deductible
You pay with Medicare Part B: High and Standard: Nothing

Benefit Description: Outpatient Hospital
You pay without Medicare: High: Nothing; Standard: 20% coinsurance after deductible
You pay with Medicare Part B:High and Standard: Nothing

Benefit Description: Incentives Offered
You pay without Medicare: N/A
You pay with Medicare Part B: N/A

If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage plan. These are private healthcare choices (like HMOs and regional PPOs) in some areas of the country.

To learn more about Medicare Advantage plans, contact Medicare at 800-MEDICARE (1-800-633-4227), (TTY 1-877-486-2048) or at www.medicare.gov.

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

This Plan and our Medicare Advantage plan:

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 or employing 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.

• You have FEHB coverage on your own or through your spouse who is also an active employee

• You have FEHB coverage through your spouse who is an annuitant

• It is within the first 30 months of eligibility for or entitlement to Medicare due to ESRD (30-month coordination period)

• It is beyond the 30-month coordination period and you or a family member are still entitled to Medicare due to ESRD

• This Plan was the primary payor before eligibility due to ESRD (for 30-month coordination period)

• Medicare was the primary payor before eligibility due to ESRD

• Medicare based on age and disability

• Medicare based on ESRD (for the 30-month coordination period)

• Medicare based on ESRD (after the 30-month coordination period)

An authorization by you (the enrollee or covered family member) that is approved by us (the
Carrier), for us to issue payment of benefits directly to the provider.

• We reserve the right to pay you directly for all covered services. Benefits payable under the
  contract are not assignable by you to any person without express written approval from us, and in
  the absence of such approval, any assignment shall be void.
• Your specific written consent for a designated authorized representative to act on your behalf to
  request reconsideration of a claim decision (or, for an urgent care claim, for a representative to
  act on your behalf without designation) does not constitute an Assignment.
• OPM’s contract with us, based on federal statute and regulation, gives you a right to seek
  judicial review of OPM's final action on the denial of a health benefits claim but it does not
  provide you with authority to assign your right to file such a lawsuit to any other person or entity.
  Any agreement you enter into with another person or entity (such as a provider, or other
  individual or entity) authorizing that person or entity to bring a lawsuit against OPM, whether or
  not acting on your behalf, does not constitute an Assignment, is not a valid authorization under
  this contract, and is void.

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.

• 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.   

Refer to section 4 page 22.

Refer to section 4 page 22.

Refer to section 4 page 22.

Custodial care means care that is primarily for the purpose of meeting personal needs and which could be provided by persons without professional skill or training. For example, custodial care includes help in walking, getting in or out of bed, bathing, dressing, eating, preparing special diets, and taking medication. Custodial care that lasts 90 days or more is known as Long Term Care.

Refer to section 4 page 22.

Means a health service, treatment, or supply used for an illness or injury which, at the time it is used, meets one or more of the following criteria:

(a)   is subject to final approval by an appropriate governmental agency for the purpose it is being used for, such as, but not limited to the Food and Drug Administration (FDA),

(b)   is not commonly accepted medical practice in the American medical community

(c)   is the subject of a written investigational or research protocol,

(d)   requires a written investigational or research protocol,

(e)   requires a written informed consent by a treating facility that makes reference to it being Experimental, Investigational, educational, for a research study, or posing an uncertain outcome, or having an unusual risk,

(f) is the subject of an ongoing FDA Phase I, II, III clinical trial.

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

The inability to conceive or carry a pregnancy to term as documented by 1) twelve (12) months of trying to conceive through egg-sperm contact if member is age 34 or younger; 2) six (6) months of trying to conceive if member is age 35 or older; or 3) diagnosis of infertility by a Provider that is supported by other medical history or diagnostic testing.

Medical necessity means a service, treatment, procedure, equipment, drug, device or supply provided by a Hospital, Practitioner or other health care provider that is required to identify or treat a member's illness, disease or injury and which is, as determined by the GHC-SCW Medical Director:

1. consistent with the symptom(s) or diagnosis and treatment of the Member's illness, disease or injury;
2. appropriate under the standards of acceptable medical practice to treat that illness, disease or injury;
3. not solely for the convenience of the Member, Practitioner, Hospital or other health care provider; and
4. the most appropriate service, treatment, procedure, equipment, drug, device or supply which can be safely provided to the Member and accomplishes the desired end result in the most economical manner. This means if there is more than one medically established standard treatment approach available nationally, and these approaches are relatively equivalent in terms of proven medical outcomes, GHC-SCW will make the determination on the selected approach to be covered.

Plan allowance is the amount we use to determine our payment and your coinsurance for covered services.

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

Specialty drugs means drugs manufactured through advanced technologies including biotechnology methods involving live organisms or derived functional components (bioprocessing) approved and regulated by the FDA's Center for Drug Evaluation and Research (CDER) intended for the prevention, treatment or cure of disease/condition in human beings.

Specialty drugs are those drugs designated as 'Specialty' by the GHC-SCW Technology Assessment Committee (TAC). Please refer to www.ghcscw.com or contact GHC-SCW Member Services at 608-828-4853 or 800-650-4327, ext. 4504, for a current listing of Specialty Drugs.

An unexpected bill you receive for:

• emergency care – when you have little or no say in the facility or provider from whom you receive care, or for
• non-emergency services furnished by nonparticipating providers with respect to patient visits to participating health care facilities, or for
• air ambulance services furnished by nonparticipating providers of air ambulance services.

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 608-828-4853. You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care.

Us and We refer to Group Health Cooperative of South Central Wisconsin (GHC-SCW).

Office visit copay:

$0 Primary Care

$10 Specialist Care

28

Nothing

54

Nothing

55

$75 per visit, waived if admitted

59

$75 per visit, waived if admitted

59

Regular cost-sharing

61

Tier 1: $5, Tier 2: $20, Tier 3:$50, Tier 4: $100

65

Mail order is available - you will pay 3x retail copay

64

You pay nothing if you use a GHC-SCW plan dentist. 

69

 $10 office visit

38

$7,150 for Self Only; $14,300 for Self Plus One and Self and Family

22

$20 Primary Care

$40 Specialist Care

28

20% Coinsurance after deductible*

54

20% Coinsurance after deductible*

55

$100 per visit; waived if admitted

59

$100 per visit, waived if admitted

59

Regular cost-sharing

62

Tier 1: $5, Tier 2: $20, Tier 3: $50, Tier 4: $100

65

Mail order is available - you will pay 3x the retail copay.

64

Nothing if you use a GHC-SCW Plan dentist.

69

 $40 per office visit

38

$7,150 for Self Only; $14,300 for Self Plus One and Self and Family

22