• No pre-existing condition limitation

• Minimum essential coverage (MEC)

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

• Minimum value standard

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

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

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

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

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

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

• Types of coverage available for you and your family

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

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

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

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

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

• Family Member Coverage

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

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

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

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

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

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

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

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

• Children’s Equity Act

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

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

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

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

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

• When benefits and premiums start

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

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

• When you retire

• When FEHB coverage ends

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

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

Any person covered under the 31-day extension of coverage who is confined in a hospital or other institution for care or treatment on the 31^st 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 60^th day after the end of the 31-day temporary extension.

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

• Upon divorce

If you are divorced  from a Federal employee or annuitant, you may not continue to get benefits under your former spouse’s enrollment. This is the case even when the court has ordered your former spouse to provide health coverage for you. However, you may be eligible for your own FEHB coverage under either the spouse equity law or Temporary Continuation of Coverage (TCC). If you are recently divorced or are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get information about your coverage choices.  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.

You can also visit OPM's website at http://www.opm.gov/healthcare-insurance.  It explains what you have to do to enroll.

• Temporary Continuation of Coverage (TCC)

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

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

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

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

We also want to inform you that the Patient Protection and Affordable Care Act (ACA) did not eliminate TCC or change the TCC rules.

• Converting to individual coverage

You may convert to a non-FEHB individual policy if:

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

You are not eligible for coverage under TCC or the spouse equity law.

If you leave Federal or Tribal service, your employing office will notify you of your right to convert.  You must apply in writing to us 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 apply 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 we will assist you in obtaining information about health benefits coverage inside or outside the Affordable Care Act’s Health Insurance Marketplace in your state. For assistance in finding coverage, please contact us at 1-877-835-9861 or visit our website at www.uhc.com. 

• Health Insurance Marketplace

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

Identification cards

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

If you do not receive your ID card within 30-days after the effective date of your enrollment, or if you need replacement cards, call us at 1-877-835-9861 or write to us at M.D. IPA Federal Employees Health Benefits Program at P.O. Box 30432, Salt Lake City, UT 84130-0432.  You may also print temporary ID Cards or request replacement cards through our member website: www.myuhc.com.

You get care from “Plan providers” and “Plan facilities.”  You will only pay copayments and/or coinsurance and you will not have to file claims.

• Plan providers

Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members.  All of our physicians are credentialed in accordance with the standards set by the National Committee for Quality Assurance (NCQA).  For further information on our credentialing procedures, please contact our Customer Service Department at 1-877-835-9861.

We list Plan providers in our Directory of Health Care Professionals which we update periodically. We do recommend you utilize the electronic version as it is more up to date than a published directory.   The list is available on our Website at www.myuhc.com and www.uhcfeds.com. You can also contact our Customer Service Department at 1-877-835-9861 and they can perform a search for you.

• Plan facilities

Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members.  We list these in the provider directory, which we update periodically.  The list is also on our website.

What you must do to get covered care

It depends on the type of care you need. First, you and each family member must choose a primary care physician (PCP).  This decision is important since your PCP provides or arranges for most of your health care.  Contact customer care at 1-877-835-9861 for questions regarding to accessing care, prior authorization requirements and Behavioral Health services.

To choose a PCP,  check our Directory of Health Care Professionals or register on the member website, www.myuhc.com and follow the instructions to select a PCP.  You may also call the Customer Service Department at 1-877-835-9861 and we will process your selection for you over the phone.  Or, if you wish, you may complete the “Federal Information Form” included in your open season information packet and mail to us at P.O. Box 30778, Salt Lake City, UT 84130-0778 or fax to 1-248-733-6257.

• Primary care

Your primary care physician (PCP) can be an internist, an obstetrician/gynecologist for a woman, a pediatrician for a child, or a general/family practitioner for any member of the family.  Your PCP will provide most of your health care, or give you a referral to see a specialist. As our network can change please be sure to ensure that the specialist is a provider in our network. You can do this by contacting customer service at 1-877-835-9861. 

If you want to change primary care physicians or if your primary care physician leaves the Plan, call us.  We will help you select a new one.  You may change your primary care physician (PCP) by submitting the "Federal Information Form", by mail to P.O. Box 30778, Salt Lake City, UT 84130-0778, by calling 1-877-835-9861, by faxing to 1-248-733-6257, or by submitting the change through the member website, www.myuhc.com. If we receive your request by the twentieth (20th) of the month, your change will become effective on the first day of the following month.  If you change your PCP after the 20th of the month, the change will not be effective until the 1st day of the second month following the date of the change.  For example, if you change your PCP on June 25, it would be effective August 1.

• Specialty care

Your primary care physician will refer you to a specialist for needed care.  When you receive a referral from your primary care physician, you must return to the primary care physician after the consultation, unless your primary care physician authorized a certain number of visits without additional referrals.  The primary care physician must provide or authorize all follow-up care.  Do not go to the specialist for return visits unless your primary care physician gives you a referral.  However, you may see.

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 physician will develop a treatment plan that allows you to see your specialist for a certain number of visits without additional referrals. 
  
  Your primary care physician 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 physician.  If he or she decides 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 physician, 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.

• Hospital Care

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

• If you are hospitalized when your enrollment begins

We pay for covered services from the effective date of your enrollment.  However, if you are in the hospital when your enrollment in our Plan begins, call our Customer Service Department immediately at 1-877-835-9861. 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 coverage. 

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

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

These provisions apply only to the benefits of the hospitalized person.  If your plan terminates participation in the FEHB Program in whole or 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 day of enrollment.

You need preauthorization from your Plan for certain services

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

You must get preauthorization for certain services.  Failure to do so may result in your claim being denied.

• Inpatient hospital admission

• Other Services

Your primary care physician (PCP) has authority to refer you for most services.  For certain services, however, your physician must obtain approval from us.  All care must be arranged with Plan providers except for emergencies.  Before giving approval, we consider if the service is covered, medically necessary, and follows generally accepted medical practice.  Precertification is also required for members when Medicare is primary.

We call this review and approval process precertification.  Your physician must obtain precertification for some services, such as, but not limited to the following services:

• ABA (Applied Behavioral Analysis)
• Air Ambulance 
• Angiomas/hemangioma (with pictures)
• Blepharoplastic (with pictures/visual fields)
• Bariatric surgery
• Breast implant removal, breast reconstruction for non-cancer diagnoses, breast reduction
• Capsule endoscopy
• Clinical trials, experimental services/new technologies, and virtual procedures
• Cochlear Implants
• Colonoscopy screening (virtual)
• Congenital anomaly repair
• Computed Tomography (CT) scans
• Coronary artery bypass graft
• Dental procedures in a facility, general anesthesia for dental procedures, dental services considered medical (not dental), except for fracture care and removal of cysts and tumors
• Dialysis
• Discectomy/fusion
• Durable medical equipment  and cochlear implants
• Electro-convulsive therapy (ECT)
• Genetic testing for hereditary breast and/or ovarian cancer syndrome (HBOC)
• Growth hormone therapy (GHT) and continuous hormone replacement therapy
• Gynecomastia surgery
• Home care
• Hysterectomy
• Implanted Spinal cord stimulators for pain management
• Infertility treatment services
• Inpatient hospitalization 
• Intensive Outpatient treatment
• Joint replacement (hip, knee, ankle, shoulder)
• Laminectomy/fusion
• Certain mental health and substance abuse services (including partial hospitalization)
• Morbid obesity surgery
• Magnetic resonance angiogram (MRA),
• Magnetic resonance imaging (MRI) (brain, chest, heart, musculoskeletal)
• Occupational therapy after the 8th visit
• Orthopedic and prosthetic devices
• Partial day hospitalization
• PET Scans (non-cancer diagnosis)
• Physical therapy after the eighth (8th) visit
• Psychological, neurophysiological and extended developmental testing
• Pulmonary rehabilitation
• Radiation therapy
• Reconstructive surgery
• Rhinoplasty/septo-rhinoplasty
• Sclerotherapy
• Sleep apnea - surgery & appliance (with sleep studies); sleep studies (polysomnograms)- attended
• Speech therapy after the 8th visit
• Substance Misuse services
• Temporomandibular disorder and/or related myofascial pain dysfunction(MDP) treatments
• Transplants
• Uvulopalatopharyngoplasty
• Vagus nerve stimulator
• Vein ablation 
• Ventricular assist device
• Virtual colonoscopy screening

This list is subject to change upon notification to Plan providers.  In addition, your admitting physician and facility must also preauthorize any elective inpatient stays.  We suggest that you call the number on your ID card to verify if your services require preauthorization.  

It is your PCP’s or specialist’s responsibility to obtain precertification/prior authorization for the procedures listed above before performing them.  If the PCP or specialist does not do this, you will not be liable for the cost of covered services.

We will decide whether or not to precertify a procedure within two working days of the receipt of the information we need to make a decision.

If you are not satisfied with our decision, you, or your PCP or specialist on your behalf, may appeal the decision.

How to request preauthorization for an admission or get preauthorization for other services

First, your physician, your hospital, you, or your representative, must call us at 1-877-835-9861 before admission or services requiring preauthorization are rendered. Please note that members with Medicare as primary are also required to follow the preauthorization process.

Next, provide the following information:

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

• Non-urgent care claims

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

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

• Urgent care claims

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

If you fail to provide sufficient information, we will contact you within 24 hours after we receive the claim to let you know what information we need to complete our review of the claim. You will then have up to 48 hours to provide the required information.  We will make our decision on the claim within 48 hours of (1) the time we received the additional information or (2) to 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 1-877-835-9861.  You may also call OPM’s FEHB 3 at (202) 606-0737 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review.  We will cooperate with OPM so they can quickly review your claim on appeal.  In addition, if you did not indicate that your claim was a claim for urgent care, call us at 1-877-835-9861.  If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim).

• Concurrent care claims

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

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

• The Federal Flexible Spending Account Program - FSAFEDS

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

• Emergency inpatient admission

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

• Maternity care

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

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

• If your treatment needs to be extended

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

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

• To reconsider a non-urgent care claim

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

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

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

2. Ask you or your provider for more information.

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

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

3. Write to you and maintain our denial

• To reconsider an urgent care claim

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

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

• To file an appeal with OPM

Copayments

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

Example: When you see a primary care physician (PCP), you pay a copayment of $25 per office visit, and when you are admitted to the hospital, you pay $150 per day for up to 3-days per admission.

Coinsurance is the percentage of our allowance that you must pay for your care.

Example: In our Plan, you pay 50% of our allowance for durable medical equipment.

Your catastrophic protection out-of-pocket maximum

After your out-of-pocket expenses, including any applicable deductibles, copayments and coinsurance total $5,000 for Self Only, or $10,000 for a Self Plus One and $10,000 for 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 $5,000 applies to each individual, regardless of whether the individual is enrolled in Self Only, Self Plus One, or Self and Family.

Example Scenario:  Your plan has a $5,000 Self Only maximum out-of-pocket limit and a $10,000 Self Plus One or $10,000 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 $5,000 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 $10,000, an aggregate of other eligible family members will continue to contribute toward the out-of-pocket maximum up to the individual maximum of $5,000 or when qualified medical expenses for the family reaches the $10,000 maximum for the calendar year.

However, copayments and coinsurance, if applicable for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay copayments and coinsurance for these services:

• Dental Discount benefits
• Eyeglasses or contact lenses
• Copayments or coinsurance for chiropractic services
• Expenses for services and supplies that exceed the stated maximum dollar or day limit

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.

Carryover

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

When Government facilities bill us

Facilities of the Department of Veterans Affairs, the Department of Defense and the Indian Health Services are entitled to seek reimbursement from us for certain services and supplies they provide to you or a family member.  They may not seek more than their governing laws allow. You may be responsible to pay for certain services and charges.  Contact the government facility directly for more information.

Medical services provided by physicians: Routine preventive care

Nothing

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

Office visit copay: $25 primary care physician ages 18 and older; $0 through age 17; $40 specialist

Services provided by a hospital: Inpatient

$150 per day up to 3-days per admission

Services provided by a hospital:

• Outpatient Non-surgical
• Outpatient Surgical

• $50 per visit
• $200 per visit at hospital; $10 per visit to approved outpatient surgical facility

Emergency benefits: In-area or out-of-area

$35 per urgent care center visit; $175 per emergency room visit

Mental health and substance use treatment

Regular cost-sharing

Prescription drugs:

• Copayments for prescription drugs and Specialty Pharmaceuticals per 30-day supply
• Copayments for maintenance medications purchased from mail order or pharmacy for up to a 90-day supply

• Tier 1 - $7, Tier 2 - $35, Tier 3 - $65, Tier 4 - $100
• Tier 1 - $21, Tier 2 - $105, Tier 3-$195, Tier 4 - $300

Dental care

Accidental Injury, Discount Dental and Non-FEHB PPO Preventive care

Vision care

$40 copayment for an annual eye refraction exam; Hardware - see
Non FEHB Page

Special Features

See Section 5(h) for programs such as our Spine and Joint Program, Quit Power program and other opportunities for cost savings

Deductible

No Deductible

Section 9

Primary Care Physician Visit

Nothing

Section 9

Preventive Care

Nothing

Section 9

Specialist visit

Nothing

Section 9

Virtual Visit

Nothing

Section 9

Urgent Care

Nothing

Section 9

Emergency Room

Nothing

Section 9

Pharmacy (30-day supply)

Tier 1 - $7
Tier 2 - $35
Tier 3 - $65
Tier 4 - $100

Section 9

Periodic Oral Exam

D0120

Prophylaxis - Adult

D1110

Type I - Diagnostic and Preventive Services

Endodontics - Root Canal Therapy

Type III- Major Dental Services

Crown - Porcelain Fused to Predominately Base Metal

D2751

Inlay  - Metallic - One Surface

Complete Orthodontia - Adolescent

UnitedHealthcare® app

At home and on the go our digital resources can help you manage health and finances.

You want to have the resources to make well informed financial and health care decisions. UnitedHealthcare has created tools to help members maximize their benefits.

At UnitedHealthcare, our mission is helping people live healthier lives®. We strive to make health care simpler and easier for you to understand with our suite of integrated consumer tools on myuhc.com®. For members who are on the go, digital resources are available on the UnitedHealthcare® app — wherever and whenever they need to manage your health care.

Download the UnitedHealthcare® app* for access to health plan ID cards, benefits information and help answering questions.

The mobile app is designed to help you manage different aspects of your health, like searching for providers and getting health care cost estimates for specific treatments and procedures.

• Members have access to their health plan ID card, claims information and real-time status on account balances, deductibles and out-of-pocket spending.
• With the UnitedHealthcare® app you can manage the health care for your entire family, 24/7. They can find a physician or facility near them using the GPS location search feature.
• The UnitedHealthcare® app is the go-to resource to help you manage your health care. Anywhere. Anytime.
• Members can find and receive care, access financial accounts, view claims status, estimate costs and pay bills directly from the app.
• Access to Virtual visits with links to AmWell, Doctor on Demand and Teladoc 

Online web portal can assist to Find Care and Costs to help you find and price care, at the same time. Located on myuhc.com, members can:

 Find a quality doctor, clinic, hospital or lab that helps meet their needs.

• Use multiple search options to filter results by location, specialty, quality, cost, services offered and more.
• See provider ratings created by patients.
• Review cost and care options before making an appointment to help control spending and choose the right level of service.
• Access personalized cost and provider information specific to the benefit plan.

 *Download the UnitedHealthcare® app from the App Store® or Google Play

Quit for Life ®

Quit for Life provides our members with resources and support for tobacco cessation.  Included are:

• Portal and mobile app
• Online learning with interactive and personalized content and a community support forum
• Integrated online and telephonic experience
• Live coaching sessions with coaches with degrees in counseling, addiction studies, and related fields
• Nicotine replacement therapy counseling
• 24/7 support for easier access to services 
• Nicotine replacement therapy both prescription medications and over the counter products (with prescription) 
• Get started today.  Go to myuhc.com, visit the "Health Resources" tab on the top right, Choose the "Quit for Life" tile

Maternity Support Program

If you are thinking about having a baby or are expecting, the Maternity Support Program allows UnitedHealthcare® members the opportunity to build a longer-term relationship with a nurse. 

After you enroll, you will be able to work directly with an experienced maternity nurse who is available to answer your questions and help you with things like:

Staying Connected

• Click to call a registered nurse 24/7
• Access personalized pregnancy information and content
• Link to your pregnancy benefits and cost estimator tools

Staying Healthy

• Monitor your pregnancy with a weight tracker
• Set reminders to take vitamins
• Keep track of calendar appointments and user-specified events
• Take health assessments, with the ability to consult a maternity program nurse by phone

Staying More Informed

• Read weekly developments that typically occur throughout your pregnancy
• Search symptoms and concerns that may arise during your pregnancy
• Track your baby’s movements with a kick counter

To get started you can reach us online https://phs.com/maternity or by phone 1-877-201-5328, TTY 711, 24 hours a day 7 days a week. Enroll in the Maternity Support Program by calling or downloading the app (Available for iPhone in Apple Store or Android in Google Play) and completing a Welcome Pregnancy Questionnaire where you can access maternity support. Like the app, it’s provided at no extra cost as part of your benefit plan.

Spine and Joint Program

Our Spine and Joint Program provides access to surgeons and expert facilities that qualify for our Center of Excellence (COE) designation. Facilities, surgeons and teams are independently evaluated and have been vetted by the NCQA-accredited Optum Clinical Sciences Institute and effective management of complex but common procedures.

• Care delivered at facilities with lower risk of readmissions and complications.
• Predictable medical expenses.
• Support from a Centers of Excellence care navigator while a facility patient

 This program helps support our members while ensuring overall better experience and recovery. Members can experience reduced out of pocket costs when participating in the Spine and Joint Program.

UnitedHealth Premium

Choosing a doctor is one of the most important health decisions you’ll make. The UnitedHealth Premium^® program can help you find doctors who are right for you and your family. You can find quality, cost-efficient care. Studies show that people who actively engage in their health care decisions have fewer Hospitalizations, fewer emergency visits, higher utilization of preventive care and overall lower medical costs.

The program evaluates physicians in various specialties using evidence-based medicine and national standardized measures to help you locate quality and cost-efficient providers. It’s easy to find a UnitedHealth Premium Care Physician. Just go to myuhc.com^® and click on Find a Doctor.  Choose smart. Look for blue hearts.

• Premium Care Physician meets UnitedHealth Premium program quality & cost-efficient care criteria.
• Quality Care Physician meets UnitedHealth Premium program quality care criteria, but does not meet the program’s cost-efficient care criteria or is not evaluated for cost-efficient care. Physician is not eligible for a Premium designation.
• Not Evaluated for Premium Care physician’s specialty is not evaluated and/or does not have enough claims data for program evaluation or the physician’s program evaluation is in process.

Real Appeal 

Real Appeal^® provides tools and support to help members lose weight and prevent weight-related health conditions. Real Appeal is provided at no additional cost to eligible members as part of your medical benefit plan.

 The program can help motivate members to improve their health and reduce risk of developing costly, chronic conditions like cardiovascular disease and diabetes. The program combines clinically proven science with engaging content that teaches members how to eat healthier and be active, without turning their lives upside down, to help them achieve and maintain their weight-loss goals.

Real Appeal includes:

A Success Kit - After attending their first group coaching session, members receive a Success Kit with tools to help them kick-start their weight loss. The kit includes:

 Nutrition guide with recipes

• Portion plate
• Electronic food scale
• Digital weight scale
• Fitness guide
• 12 fitness DVDs
• Resistance bands
• After 8 weeks of the program members receive a blender before the class on healthy smoothie options.

A personalized Transformation Coach - Coaches guide members through the program step-by-step, customizing it to help fit their needs, personal preferences, goals and medical history.

 24/7 online support and mobile app - Staying accountable to goals may be easier than ever.

• Customizable food, activity, weight and goal trackers.
• Unlimited access to digital content.
• Success group support, which lets employees chat with others who are doing the Real Appeal program.
• Online TV shows that is fun, engaging and helps members learn new ways to be healthier

Why Real Appeal works - Real Appeal is guided by a Clinical Advisory Board of obesity, nutrition and behavior change experts that create customized content to help keep members engaged throughout their weight-loss journey. Members will learn steps to help with long-term transformation, which may translate to a happier, healthier member.

Specialty Pharmacy

Appropriate use of specialty medications can be important to maintaining or improving your health and your quality of life. Our specialty program provides the resources and personalized, condition-specific support you need to help you better manage your condition. These specialty medications are used to treat complex long-term conditions that require additional care and support. It may be injected, inhaled or taken by mount.  In addition, they may require additional education and support for best management have unique storage or shipping requirements and may not be available at retail pharmacies.

The OptumRx^® Specialty Services and BriovaRx Infusion Services, offers support to help you manage these conditions. Take advantage of personalized support - at no charge to you - from knowledgeable pharmacies and nurses who specialize in your condition.  In addition, you will receive:

• Access to your medications at the lowest cost
• Pharmacists available 24/7
• Support through clinical and adherence programs
• Any medication-related supplies at no additional cost
• Proactive refill reminders
• Timely delivery and shipping in confidential, temperature-sensitive packaging
• Contact 877-835-9861 or contact Briova directly at 1-855-4BRIOVA (1-855-427-4682).

Flexible Benefits Option

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

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

Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process.

To be a qualifying clinical trial, a trial must meet all of the following criteria:

• Be sponsored and provided by a cancer center that has been designated by the National Cancer Institute (NCI) as a Clinical Cancer Center or Comprehensive Cancer Center or be sponsored by any of the following:
  • ­ National Institutes of Health (NIH). (Includes National Cancer Institute (NCI).)
  • ­ Centers for Disease Control and Prevention (CDC).
  • ­ Agency for Healthcare Research and Quality (AHRQ).
  • ­ Centers for Medicare and Medicaid Services (CMS).
  • ­ Department of Defense (DOD).
  • ­ Veterans Administration (VA).
• The clinical trial must have a written protocol that describes a scientifically sound study and have been approved by all relevant institutional review boards (IRBs) before participants are enrolled in the trial. We may, at any time, request documentation about the trial to confirm that the clinical trial meets current standards for scientific merit and has the relevant IRB approvals. Benefits are not available for preventive clinical trials.
• The subject or purpose of the trial must be the evaluation of an item or service that meets the definition of a Covered Health Service and is not otherwise excluded under the Policy.

Fitness Program for Medicare Advantage Members:

Renew Active is a fitness benefit which is included in the Medicare Advantage plan which provides:

• A free gym membership to participating facilities
  • To view participating facilities, please visit www.uhcrenewactive.com  
• Access to an extensive network of gyms and fitness locations near members
• A personalized fitness plan 
• Access to a wide variety of fitness classes 
• An online brain health program, exclusively from AARP® Staying Sharp
• Connecting with others at local health and wellness events, and through the Fitbit® Community for Renew Active

House Calls for Medicare Advantage Members

With the UnitedHealthcare^® HouseCalls program, you get an annual in-home preventive care visit from one of our health care practitioners at no extra cost.

 What does HouseCalls include?

• One 45 to 60-minute at-home visit from a health care practitioner, each year.
• A head-to-toe exam, health screenings and plenty of time to talk about your health questions.
• A custom care plan made just for you.
• Help connecting you with additional care you may need.

Health Navigators for Medicare Advantage Members

Health Navigators work with individuals to assist in guiding them through the complexities of the healthcare system due to a complex health event such as diabetes, congestive heart failure, or multiple chronic conditions.  Health Navigators work with individuals to assist in coordinating care with multiple providers and/or facilities and find additional clinical and community programs which may be available. 

Meal Delivery Program for Medicare Advantage Members

As a member, you can receive up to 84 home delivered meals immediately following an inpatient hospitalization when referred by your UnitedHealthcare® case manager.
• Meals are delivered to your door in a climate-controlled cooler in "Fresh-Lock” packaging in shipments of 14 meals or greater
• Meals can be refrigerated for up to 14 days or frozen for up to three months
• Meals are available to support 9 different health conditions
• Meals are provided through our national provider Mom’s Meals®

Real Appeal for Medicare Advantage Members 

Real Appeal is a weight loss program that can help members feel and look better. The program provides everything they need to lose weight and keep it off. This program is a pilot for select members residing in Wisconsin.

The online program includes:

• Personalized diabetes prevention coaching
• 24/7 online support and mobile app
• Customizable food, activity, weight and goal trackers 
• Success group support, which lets members chat with others who are doing the Real Appeal program
• The weekly Real Appeal All-Star Show featuring healthy tips from celebrities, athletes and health experts

Success Kit includes:

• Program, nutrition, and fitness guides
• Tools to help cook healthier, tasty meals
• Delivered right to their front door after attending their first group coaching session

Quit for Life for Medicare Advantage Members

Quit For Life has helped 3.5 million members quit smoking or using tobacco. It provides the tools and one-on-one support to help you quit your way. And for UnitedHealthcare members, it’s offered at $0 out of pocket.  With a 95% satisfaction rate, Quit for Life provides:

• Tools and support to help members quit cigarettes, e-cigarettes, vaping and tobacco
• A personal, one-on-one Quit Coach to help you create a customized quit plan
• The Quit for Life mobile app, which offers 24/7 urge management support
• Text2Quit text messages for daily tips and encouragement 
• Quit medications – Such as nicotine gum or patches – for no charge, based on eligibility

Medical and hospital benefits

In most cases, providers and facilities file claims for you.  Providers must file on the form CMS-1500, Health Insurance Claim Form.  Your facility will file on the UB-94 form.  For claims questions and assistance, call us 877-835-9861.

When you must file a claim - such as for services you receive outside the Plan's service area-submit it on the HCFA-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 domestic medical claims to:

M.D. IPA, a UnitedHealthcare Company, P.O. Box 740825, Atlanta, GA 30374-0825.

Submit international medical claims to:

Submit your international claims to: M.D. IPA, a UnitedHealthcare Company, P.O. Box 740817, Atlanta, GA 30374-0817.

Prescription drugs

Usually, there are no claim forms to fill out when you fill a prescription at a Plan pharmacy.  In some cases, however, you may pay out-of-pocket, such as when you are outside the service area in a medical emergency.  If this happens, contact customer service at 877-835-9861 for a prescription drug claim form and send the following information:

• Your receipt
• The drug NDC number
• The pharmacy’s NABP number
• The prescribing physician’s or dentist’s DEA number

Submit your claims to: OptumRx at PO Box 29044, Hot Springs, AR 71903

Other supplies or services

Submit your claims to: M.D. IPA,  a UnitedHealthcare Company, P.O. Box 740825, Atlanta, GA 30374-0825. 

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.

Notice Requirements

If you live in a county where at least 10 percent of the population is literate only in a non-English language (as determined by the Secretary of Health and Human Services), we will provide language assistance in that non-English language.  You can request a copy of your Explanation of Benefits (EOB) statement, related correspondence, oral language services (such as phone customer assistance), and help with filing claims and appeals (including external reviews) in the applicable non-English language.  The English versions of your EOBs and related correspondence will include information in the non-English language about how to access language services in that non-English language.

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

1

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

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

b) Send your request to us at: M.D. IPA, a UnitedHealthcare Company's Federal Employee Health Benefits (FEHB) Program Appeals, P.O. Box 30573, Salt Lake City, UT 84130-0573; and

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

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

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

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

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

a) Pay the claim or  

b) Write to you and maintain our denial or.

c) Ask you or your provider for more information

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

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

3

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

You must write to OPM within:

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

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

Send OPM the following information:

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

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

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

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

4

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

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

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

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

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

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

The order of benefit determination rules determine whether this plan is a primary plan or secondary plan when the person has health care coverage under more than one plan.  When this plan is primary, it determines payment for its benefits first before those of any other Plan without considering any other plan's benefits.  When this plan is secondary, it determines its benefits after those of another plan and may reduce the benefits it pays so that all plan benefits do not exceed 100% of this plan’s total allowable expense. When this plan is secondary, it may reduce its benefits so that the total benefits paid or provided by all Plans are not more than the total allowable expenses. In determining the amount to be paid for any claim, the secondary plan will calculate the benefits it would have paid in the absence of other health care coverage and apply that calculated amount to any allowable expense under its plan that is unpaid by the primary plan. The secondary plan may then reduce its payment by the amount so that, when combined with the amount paid by the primary plan, the total benefits paid or provided by all plans for the claim do not exceed the total allowable expense for that claim.  In addition, the secondary plan shall credit to its plan deductible any amounts it would have credited to its deductible in the absence of other health care coverage.

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

Workers' Compensation

We do not cover services that:

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

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

Medicaid

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

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

When other Government agencies are responsible for your care

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

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.

Clinical Trials

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

If you are a participant in a clinical trial, and the related care is not covered within the clinical trial, this plan will provide coverage for related costs based on the criteria listed below. 

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

Please see the special features page of the brochure for specific requirements for cancer related trials.

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

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

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

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

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

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

When Original Medicare is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. To find out if you need to do something to file your claim, call us at 877-835-9861 or see our member Website at www.myuhc.com.

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

•  All copayment and coinsurance amounts will be applied until you meet your Medicare Part B deductible. Once the Medicare Part B deductible has been met, all copayments and coinsurance are waived.
• We will pay all amounts identified as “patient responsibility” on the Medicare Explanation of Benefits as long as the service rendered is covered by our plan.
• We will pay the Inpatient Medicare deductible.

Medicare cost share

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

Benefit: Deductible
High Option you pay without Medicare: No deductible
High Option you pay with Medicare Part B: No deductible

Benefit: Out-of-Pocket Maximum
High Option you pay without Medicare: $5,000 Self-only; $10,000 Self Plus One or Self and Family
High Option you pay with Medicare Part B: $5,000 Self-only; $10,000 Self Plus One or Self and Family

Benefit: Part B Premium Reimbursement
High Option you pay without Medicare: N/A
High Option you pay with Medicare Part B: N/A

Benefit: Primary Care Physician
High Option you pay without Medicare: $25
High Option you pay with Medicare Part B: Nothing after Medicare Part B deductible has been reached

Benefit: Specialist
High Option you pay without Medicare: $40
High Option you pay with Medicare Part B: Nothing after Medicare Part B deductible has been reached

Benefit: Inpatient hospital
High Option you pay without Medicare: $150 per day up to 3 days per admission ($450)
High Option you pay with Medicare Part B: Nothing

Benefit: Outpatient hospital
High Option you pay without Medicare: $100 free-standing facility; $200 hospital-based facility
High Option you pay with Medicare Part B: Nothing

Benefit: Incentives offered
High Option you pay without Medicare: Nothing
High Option you pay with Medicare Part B: Nothing

• Tell us about your Medicare coverage

• Medicare Part B Premium Reimbursement

We offer a plan designed to help members with their Medicare Part B premium. This plan is called, UnitedHealthcare Retiree Advantage (UHCA). If you have Medicare Parts A and B and enroll in the UHCA, you will be reimbursed $144.60 of your Medicare Part B monthly premium. This will be sent from Centers for Medicare & Medicaid Services (CMS) directly to your Social Security. If you do not receive  Social Security please advise us at enrollment so that we may make arrangements for your reimbursement.  To learn more about UHCA and how to enroll, call us at 1-844-481-8821, 8 a.m. to 8 p.m., local time Monday thru Friday,  For TTY for the deaf, hard of hearing, or speech impaired, call 711. We will send you additional information and an application for enrollment.

• Medicare Advantage (Part C)

If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage plan. These are private health care choices (like HMOs and regional PPOs) in some areas of the country. To learn more about Medicare Advantage plans, contact Medicare at 1-800-MEDICARE (800-633-4227), (TTY:800-486-2048) or at www.medicare.gov  or UnitedHealthcare Retiree Services at 844-481-8821..

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

This Plan and our Medicare Advantage plan: You may enroll in our Medicare Advantage plan and also remain enrolled in this FEHB plan. For more information on our Medicare Advantage plan, please contact 844-481-8821. 

You may enroll in the UnitedHealthcare Retiree Advantage Plan if:

• You are enrolled in the UnitedHealthcare FEHBP active plan and have both Medicare Part A and Part B
• You are retired and live in our geographic service area which is described on page 14.
• You are a United States citizen or are lawfully present in the United States
• You do NOT have End-Stage Renal Disease (ESRD), with limited exceptions
• You complete an application for enrollment in the UnitedHealthcare Retiree Advantage Plan (UHCA).
• DO NOT suspend or term your FEHB plan benefits to enroll in this program 

Reimbursements will begin on the first of the month following approval of your UHCA application. As part of this process CMS will verify your Medicare Part B enrollment. During a calendar year, you may enroll in UHCA only once. If the FEHB subscriber and or dependent enrolls in the UHCA, each family member will have to complete an application by calling into our Retiree Services team (1-844-481-8821).  Members who are not eligible for Medicare Part A and B will remain on the FEHB plan.  If, for any reason, you do not meet the enrollment requirements, you will no longer be eligible to participate in the UHCA plan. Your contributions will end and your regular FEHB benefits will resume. You may be required to repay any reimbursements paid to you in error.

We offer a plan designed:

• To help members with their Medicare Part B premium costs
• To provide access to our national network of providers, (in-network or out-of-network) at the same cost share
• To cover eligible medical benefits with little to no out of pocket costs
• To provide coverage with a catastrophic benefit for prescriptions

The UHCA provides monthly reimbursement of $144.60 of your Medicare Part B monthly premium.  If you do not receive  Social Security please advise us at enrollment so that we may make arrangements for your reimbursement. In addition, we cover benefits, including office visit copayments at ($0), urgent care and emergency care at ($0), plus additional coverage for hearing aids discounts and wellness programs like Silver Sneakers.   See chart following:

Benefit Description: Deductible
Member Cost without Medicare: No plan deductible
Member Cost with Medicare Part B: No plan deductible
UnitedHealthcare Retiree Advantage Health Plan: No plan deductible

Benefit Description: Out of Pocket Maximum
Member Cost without Medicare: $5,000 Self Only; $10,000 Self Plus One; and $10,000 Self and Family
Member Cost with Medicare Part B: $5,000 Self Only; $10,000 Self Plus One; and $10,000 Self and Family
UnitedHealthcare Retiree Advantage Health Plan: You pay nothing for Medicare-covered service from any provider

Benefit Description: Primary Care Physician
Member Cost without Medicare: $25
Member Cost with Medicare Part B: $0 after Medicare Part B deductible has been reached
UnitedHealthcare Retiree Advantage Health Plan: $0

Benefit Description: Specialist
Member Cost without Medicare: $40
Member Cost with Medicare Part B: $0 after Medicare Part B deductible has been reached
UnitedHealthcare Retiree Advantage Health Plan: $0

Benefit Description: Virtual Visits
Member Cost without Medicare: $5
Member Cost with Medicare Part B: $0 after Medicare Part B deductible has been reached
UnitedHealthcare Retiree Advantage Health Plan: $0

Benefit Description: Urgent Care
Member Cost without Medicare: $35
Member Cost with Medicare Part B: $0 after Medicare Part B deductible has been reached
UnitedHealthcare Retiree Advantage Health Plan: $0

Benefit Description: Emergency
Member Cost without Medicare: $175
Member Cost with Medicare Part B: $0 after Medicare Part B deductible has been reached
UnitedHealthcare Retiree Advantage Health Plan: $0

Benefit Description: Inpatient Hospital
Member Cost without Medicare: $150 per day, up to $450 per admission
Member Cost with Medicare Part B: $0
UnitedHealthcare Retiree Advantage Health Plan: $0

Benefit Description: Outpatient Hospital
Member Cost without Medicare: Surgical-$100 copay per visit at free-standing facility/$200 copay at hospital
Member Cost with Medicare Part B: Nothing
UnitedHealthcare Retiree Advantage Health Plan: $0

Benefit Description: Rx (30-day supply)
Member Cost without Medicare: Tier 1 - $7; Tier 2 - $35; Tier 3 - $65; Tier 4 - $100
Member Cost with Medicare Part B: Tier 1 - $7; Tier 2 - $35; Tier 3 - $65; Tier 4 - $100
UnitedHealthcare Retiree Advantage Health Plan: Tier 1 - $7; Tier 2 - $35; Tier 3 - $65; Tier 4 - $100

Benefit Description: Rx - Mail Order (90-day supply)
Member Cost without Medicare: 3 x retail copay
Member Cost with Medicare Part B: 3 x retail copay
UnitedHealthcare Retiree Advantage Health Plan: 2 x retail copay

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

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

• Medicare prescription drug coverage (Part D)

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

Clinical Trials Cost Categories

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is either Federally funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration; 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 cancer, whether the patient is in a clinical trial or is receiving standard therapy
• Extra care costs – costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient’s routine care
• Research costs – costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes. These costs are generally covered by the clinical trials. This plan does not cover these costs.  

Coinsurance

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

Copayment

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

Cost-sharing

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

Custodial Care

Medical or non-medical services:

• Which are furnished mainly to assist you in the activities of daily living (feeding, dressing, bathing, transferring and ambulating)
• For which professional skills or training is not required
• Which are not likely to result in the improvement of your condition or in your recovery

Custodial care that lasts 90 days or more is sometimes known as long term care.

Deductible 

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

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

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

Infertility

Medical necessity

Health care services provided for the purpose of preventing, evaluating, diagnosing or treating a Sickness, Injury, Mental Illness, Substance Use Disorder disease or its symptoms, that are all of the following as determined by us or our designee, within our discretion.

• In accordance with Generally Accepted Standards of Medical Practice.
• Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for your Sickness, Injury, Mental Illness, Substance Use Disorder, disease or its symptoms.
• Not mainly for your convenience or that of your doctor or other health care provider
• Not more costly than an alternate drug, service(s) or supply that is at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of your Sickness, Injury, disease or symptoms.

Generally Accepted Standards of Medical Practice are standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, relying primarily on controlled clinical trials, or if not available, observational studies from more than one institution that suggest a causal relationship between the service or treatment and health outcomes. The fact that a  Physician may prescribe, authorize or direct a service does not of itself make it Medically Necessary or covered by this Plan.

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

Unproven Service(s)

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

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

We have a process by which we compile and review clinical evidence with respect to certain health services.  From time to time, we issue medical and drug policies that describe the clinical evidence available with respect to specific health care services.  These medical and drug policies are subject to change without prior notice.  You can view these policies at www.myuhc.com .

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

Urgent care claims

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

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

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

If you believe your claim qualifies as an urgent care claim, please contact our Customer Service Department at 877-835-9861. You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care

Medical services provided by physicians: 

Routine preventive care  

Nothing 

29

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

Office visit copay:

$25 primary care physician ages 18 and older;

$0 under age 18;

$40 specialist

28

Services provided by a hospital:

Inpatient 

$150 per day for up to 3 days per admission

50

Services provided by a hospital:

Outpatient Surgical

$200 per visit at hospital facility;

$100 per visit at approved free-standing surgical center

51

Services provided by a hospital:

Outpatient Non-Surgical

$50 per visit

51

Emergency benefits:

• In-area or out-of-area

$35 per urgent care center visit

$175 per emergency room visit

53

Mental health and substance use disorder treatment

Regular cost-sharing

55

Prescription drugs:

Plan Retail Pharmacy and Specialty Pharmaceuticals

Up to a 30-day supply:

Tier 1 - $7 

Tier 2 - $35 

Tier 3 - $65 

Tier 4 - $100

60

Prescription drugs:

Plan mail order

Up to a 90-day fill 

Tier 1: $21

Tier 2: $105

Tier 3: $195

Tier 4: $300

60

Dental care

Adjunct dental services, accidental injury and discount dental benefits

62 & 63

Vision care

$40 copayment for eye refraction exam adults

$0  Annual routine eye examination children 17 and under

35

Wellness and other Special features:

Real Appeal Weight Loss Program,  Rally, Quit for Life Smoking Cessation program, Healthy Pregnancy Program, Educational Resources,  Spine and Joint Program, Health Risk assessments, UnitedHealthcare® app

67

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

Note: Some costs do not count toward this protection

Nothing after: $5,000 for Self Only, $10,000 Self Plus One or $10,000 for Self and Family enrollment per year

23