• 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 you, 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 below. A Self Plus One enrollment covers you and your spouse, or one other eligible family member as described below.

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

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

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

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

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

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

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

• Children's Equity Act

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

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

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

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

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

• When benefits and premiums start

The benefits in this brochure are effective January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be processed according to the 2020 benefits of your prior plan or option. If you have met (or ay 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 2020benefits 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
• 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 additional information about your coverage choices. You can also visit OPM’s Website at www.opm.gov/healthcare-insurance/healthcare/plan-information/.  A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee's FEHB enrollment. 

• Temporary Continuation of Coverage (TCC)

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

• 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 contact us in writing within 31 days after you receive this notice.  However, if you are a family member who is losing coverage, the employing or retirement office will not notify you. You must contact us in writing within 31 days after you are no longer eligible for coverage.

Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, 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 850-383-3311 or visit our website at www.capitalhealth.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.

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 850-383-3311 or write to us at Capital Health Plan, 2140 Centerville Place, Tallahassee, FL 32308. You may also request replacement cards through our website: www.capitalhealth.com.

Where you get covered care

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

Plan providers are physicians and other health care professionals in our service area that we employ or contract with to provide covered services to our members. We credential Plan providers according to national standards. You must select a primary care physician to direct all of your medical care. Capital Health Plan offers you a choice of primary care physicians at many different locations in the greater Tallahassee area.

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

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. This decision is important since your primary care physician provides or arranges for most of your health care.  

Primary care

Your primary care physician can be a family practitioner, internist, or pediatrician.   Your primary care physician will provide most of your health care, or give you a referral to see a specialist.

It is important to understand the difference between a referral and an authorization, and how to obtain each one.

Referral is the process of sending a patient to another practitioner (ex. specialist) for consultation or a health care service that the referring source believes is necessary but is not prepared or qualified to provide. Your primary care physician will refer you to a participating specialist or a health care service provider if he or she cannot personally provide the care you need. Many referrals do not require an authorization number (authorization number is assigned when the authorization has been approved by Capital Health Plan, see Referrals and Authorizations below).

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.

Capital Health Plan's Directory of Physicians and Service Providers lists the primary care physicians and their office locations.   You can make your selections from this list.   This directory is provided to all new members at the time of enrollment, on request by calling CHP's Member Services Department at 850-383-3311, or on our website at www.capitalhealth.com.   This directory is subject to change and is updated on a regular basis.   On occasion, some physicians may not accept new patients.   CHP's Member Services staff gladly will assist you with your selection of a primary care physician.

Specialty care

Your primary care physician will refer you to a specialist for needed care. CHP has eliminated the need for a CHP Authorization number of most but not all local network practitioner office based on specialty covered services.  You will need a referral or written orders for specialty care. CHP endorses and encourages referrals for clinical recommendations from the primary care physicians. Some specialty care offices may have a policy requiring an authorization number before making an appointment or require new patients to be seen by their primary care physician first. Primary care physicians and specialists communicate with each other to coordinate members’ care as needed. CHP authorization numbers still are required for certain medical services including, but not limited to:

• All inpatient services
• Outpatient Hospital based services for Wound Care, Hyperbaric oxygen treatment (HBO), and Observation
• All non-participating practitioners or facilities in or out of Capital Health Plan's service area
• All nonemergency services received outside CHP’s service area, including out of area contracted  practitioners and facilities (ex. Shands)
• All services related to the mouth and/or teeth
• Speech Therapy
• All home health care services except hospice care
• Services that may be investigational or outside the realm of accepted mainstream medical care.
• All procedures or surgery that have Capital Health Plan clinical criteria requires review and an authorization at any location.  See a listing of Capital Health Plan Clinical Criteria on the Medical Policies page:   http://www.www.capitalhealth.com/Providers/clinical-criteria.

If you have any questions regarding the referrals system, please call CHP Member Services at 850-383-3311 or visit  www.capitalhealth.com/providers/Clinical-Criteria.

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 use our criteria when creating your treatment plan (the physician may have to get an authorization or approval beforehand).
• If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide what treatment you need. 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 850-383-3311.  If you are new to the FEHB Program, we will arrange for you to receive care and provide benefits for your covered services while you are in the hospital beginning on the effective date of your coverage.

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

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

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

You need prior Plan approval for certain services

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

Inpatient hospital admission

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.

Precertification is the process by which – prior to your inpatient hospital admission – we evaluate the medical necessity of your proposed stay and the number of days required to treat your condition. 

Other services

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

Prior authorization requirements and guidelines are revised and updated annually, or more frequently as new evidence becomes available that suggests needed revisions, see below: 

• Admissions (non-emergent) to all facilities, including:
  • Hospitals
  • Rehabilitation Facilities
  • Skilled Nursing Facilities
• Bariatric Surgeries (Surgery for Clinically Severe Obesity)
• Behavioral Health services including: 
  • Inpatient admissions, non-emergent
  • Partial hospitalization services
  • Residential treatment (Ex. Eating Disorder and Substance Abuse Facilities)
• Non-routine outpatient services including Applied Behavioral Analysis (ABA) and Transcranial Magnetic Stimulation
• Breast Reduction and Reconstruction Surgeries
• Cardiac Rehabilitation
• Clinical Trials (only routine patient costs for items and services are covered)
• Cochlear Implants
• Computed Tomographic Colonography (Virtual Colonoscopy or CT Colonoscopy)
• Continuous Glucose Monitoring Systems 
• Continuous Passive Motion Device
• Cosmetic/Reconstructive Surgery including: 
  • Abdominoplasty
  • Blepharoplasty / Ptosis repair
  • Destruction of Vascular Cutaneous Lesions
  • Mastectomy for Gynecomastia
  • Orthognathic Surgery
  • Panniculectomy/Removal of Excess Tissue 
  • Ptosis repair
  • Reduction Mammoplasty (Breast Reduction)
  • Removal of Breast Implants
  • Repair of Congenital Chest Wall Deformities
  • Rhinoplasty
  • Scar revision
  • Septoplasty
• Dental and Oral Surgery Services
• Enzyme Replacement Therapy
• Experimental Items and Services
• Formulas and Enteral Nutrition 
• Functional Neuromuscular Stimulation
• Gender Reassignment Surgeries (limited to those surgeries that can be performed by a general surgeon such as mastectomies, hysterectomies, oophorectomies and gonadectomies.) 
• Genetic Testing
• Gynecomastia Surgery 
• Hearing Devices - Implantable
• Hip Arthroplasty/Hip Replacement
• Home Health Care services
• Hospice Services – Inpatient
• Hospital Admissions (Non-emergent)
• Hyperbaric Oxygen (HBO) Therapy
• Implantable Neurostimulators
• Infertility Services
• Inpatient Non-emergent Admissions to all Facilities
• Insulin Infusion Pumps and SuppliesInvestigational Items and Services
• Knee Arthroplasty/Knee Replacement
• Left Atrial Appendage Closure Device (WATCHMAN™)
• Negative Pressure Wound Therapy Pump
• New Technologies that have not been assessed and incorporated into Capital Health Plan benefits
• Non-Emergent Medical Transportation 
• Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Disorders
• Osteogenesis Stimulators
• Outpatient Diagnostic Imaging Services including:
  • Magnetic Resonance Imaging (MRI) of the cervical spine (neck)Magnetic Resonance Imaging (MRI) of the lumbar spine (back)
• Outpatient Pulmonary Rehabilitation
• Outpatient Speech/Language Therapy 
  • Physical and/or Occupational Therapy services require prior authorization if services are expected to exceed the member’s benefit limit. 
• Out-of-Network / Non-contracted provider referrals 
• Prosthetic Devices
• Proton Beam Therapy
• Pulmonary Rehabilitation
• Quantitative Elecrtoencephalography (QEEG)
• Radiation Oncology
• Respiratory Assist Devices (CPAP, APAP, BiPAP)
• Seat Lift Mechanisms
• Selected Medical Benefit drugs and biologicals: See CHP's website https://www.capitalhealth.com/Physicians-Providers/Medication-Center.
• Shoulder Arthroplasty/Shoulder Replacement
• Speech Generating Devices
• Spinal Cord Stimulation
• Spine Surgeries including: 
  • Cervical (Neck)
  • Lumbar (Back)
  • Kyphoplasty
  • Vertebroplasty
• Subcutaneous Implantable Cardioverter-Defibrillator (ICD)
• Thoracic Outlet Syndrome Surgery
• Transcranial Magnetic Stimulation
• Transplant Services
• Tumor treatment field therapy
• Wearable and Non-Wearable Cardioverter-Defibrillators (WCD)
• Weight Control Services (including services provided at the Tallahassee Memorial Hospital Bariatric Center)
• Wheelchairs – Powered or customized wheelchairs only
• Wound Treatment Centers

The following are just a few of the services that have clinical criteria and require a review and a prior authorization:

• Genetic Testing
• Back (lumbar) and neck (cervical) surgery also known as spinal surgery, and MRI's
• Transcranial Magnetic Stimulation
• Implantable Hearing Devices
• Certain Durable Medical Equipment (DME), such as: External Insulin Infusion Pumps & Supplies, Continuous Glucose Monitoring, and Power Wheelchairs

Questions about Capital Health Plan’s prior authorization process?

Call Member Services at (850) 383-3311. For TTY/TDD – Telecommunication Device for the Deaf (for speech or hearing impaired) service, call (850) 383-3534 or 711. Outside the area? Call us toll-free at 1-877-247-6512.

Prior Authorization

Capital Health Plan requires prior authorization (prospective review of medical necessity, clinical appropriateness, eligibility, and level of benefits) for selected medications, procedures, services and items.  Authorization and denial decisions are made in a timely manner that accommodates the clinical urgency of the situation.  Providers are responsible for obtaining prior authorizations when required. Your physician will submit authorization requests electronically, by phone, or in writing by fax or mail.  If approved, an authorization number is then generated by Capital Health Plan and is available to you via CHPConnect. If the requested service is not authorized, the member and provider are notified in writing with the specific reasons for the denial.  Members are responsible for ensuring a prior authorization is in place prior to receiving these services.  Failure to comply with these prior authorization requirements will result in denial of the claim payment.  Prior authorization requirements are subject to change. For up-to-date information on services requiring a prior authorization, Members should contact the Member Services Department (850-383-3311) or visit our website at  www.capitalhealth.com/Members/items-and-services-requiring-prior-authorizations. 

Referrals and Authorizations

It is important to understand the difference between a referral and an authorization, and how to obtain each one.

Referral is the process of sending a patient to another practitioner (ex. specialist) for consultation or a health care service that the referring source believes is necessary but is not prepared or qualified to provide. Your primary care physician will refer you to a participating specialist or a health care service provider if he or she cannot personally provide the care you need. Many referrals do not require an authorization number.

Authorization, also known as precertification or prior authorization, is a process of reviewing certain medical, surgical or behavioral health services to ensure medical necessity and appropriateness of care prior to services being rendered. The review also includes a determination of whether the service being requested is a covered benefit under your benefit plan. Authorizations are only required for certain services.

First, your primary care physician, your hospital, you, or your representative, must call us at 850-383-3311 before admission or services requiring prior authorization are rendered.

Next, provide the following information:

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

Non-urgent care claims

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

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

Urgent care claims

If you have an urgent care claim (i.e. when waiting for the regular time limit for your medical care or treatment could seriously jeopardize our life, health, or ability to regain maximum function, or in the opinion of a physician with knowledge of our 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 with 72 hours.  If you request that we review your claim as an urgent care claim, we will review the documentation you provide and decide whether or not it is an urgent care claim by applying the judgment of a prudent layperson that possesses an average knowledge of health and medicine. 

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

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

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM.  Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at 850-383-3311.  You may also call OPM’s FEHB 3 at 202-606-0755 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review.  We will cooperate with OPM so they can quickly review your claim on appeal.  In addition, if you did not indicate that your claim was a claim for urgent care, then call us at 850-383-3311. 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

Maternity care

Maternity Care is defined as hospital services provided to a member for normal pregnancy, delivery, miscarriage, or pregnancy complications within the CHP service area only, unless the need for these services was not, and reasonably could not have been, anticipated before leaving the service area.

• 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.

What happens when you do not follow the precertification rules when using non-network facilities

Capital Health Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other providers that contract with us. When you receive services from plan providers, you will not have to submit claim forms or pay bills. You pay only the copayments described in this brochure. When you receive emergency services from non-plan providers, you may have to submit claim forms.

Benefits are available for care from non-plan providers in a medical emergency only if a delay in reaching a plan provider would result in death, disability, or significant jeopardy to your condition. Capital Health Plan members can access out-of-area urgent and emergency care at any affiliated Blue Cross and Blue Shield provider in the country through the BlueCard network and claims automatically will be routed to CHP.

Out-of-Area Services

Capital Health Plan has a variety of relationships with other Blue Cross and Blue Shield Plans and their Licensed Controlled Affiliates (“Licensees”).  Generally, these relationships are called “Inter-Plan Programs.”  These Inter-Plan Arrangements operate based on rules and procedures issued by the Blue Cross Blue Shield Association ("Association"). Whenever a Member obtain Covered Services outside of the Service Area, the claims for these services may be processed through one of these Inter-Plan Programs.

When a Member receives care for Covered Services outside of the Service Area, the Member will receive the care from one or two kinds of providers.  Most providers ("participating providers") contract with the local Blue Cross and/or Blue Shield Plan in that geographic area ("Host Blue").  Some providers ("nonparticipating providers") do not contract with the Host Blue.  Capital Health Plan explains below how Capital Health Plan pays both kinds of providers.  

Capital Health Plan covers only limited healthcare services received outside of the Service Area.  As used in this section “Out-of-Area Covered Healthcare Services” include emergency care, urgent care, or care authorized by Capital Health Plan obtained outside of the Service Area. Any other services will not be covered when processed through any Inter-Plan Programs arrangements. unless authorized by the Member's Primary Care Physician.  

A.       BlueCard® Program

Under the BlueCard® Program, when a Member obtains Out-of-Area Covered Healthcare Services within the geographic area served by a Host Blue, Capital Health Plan will remain responsible for fulfilling our contractual obligations. However the Host Blue is responsible for contracting with and generally handling all interactions with its participating healthcare providers.  The BlueCard® Program enables a Member to obtain Out-of-Area Covered Healthcare Services, as defined above, from a healthcare provider participating with a Host Blue, where available. The participating healthcare provider will automatically file a claim for the Out-of-Area Covered Healthcare Services provided to the Member, so there are no claim forms for the Member to complete. The Member will be responsible for the Member Copayment amount, as stated in his or her Summary of Benefits and Coverage.  

Emergency Care Services: If a Member experiences a Medical Emergency while traveling outside Capital Health Plan’s Service Area, the Member should go to the nearest Emergency (or Urgent Care) facility. 

When a Member receives Out-of-Area Covered Healthcare Services outside of the Service Area, and the claim is processed through the BlueCard® Program, the amount the Member pays for Out-of-Area Covered health Care Services, if not a flat dollar copayment, is calculated based on the lower of:

• The billed covered charges for Covered Services; or

• The negotiated price that the Host Blue makes available to Capital Health Plan. 

Often, this “negotiated price” will be a simple discount that reflects an actual price that the Host Blue pays to  the Member's healthcare provider. Sometimes, it is an estimated price that takes into account special arrangements with the Member's healthcare provider or provider group.  These arrangements ma include types of settlements, incentive payments, and/or other credits or charges. Occasionally, it may be an average price, based on a discount that results in expected average savings for similar types of healthcare providers after taking into account the same types of transactions as with an estimated price.

Estimated pricing and average pricing, going forward, also take into account adjustments to correct for over- or underestimation of modifications of past pricing of claims, as noted above. However, such adjustments will not affect the price Capital Health Plan uses for the Member's claim because they will not be applied retroactively to claims already paid.

Federal or state laws or regulations may require a surcharge, tax or other fee that applies to insured accounts. If applicable, Capital Health Plan will include any such surcharge, tax or other fee as part of the claim charge passed on to you.

B.       Non-Participating Healthcare Providers Outside Our Service Area

1.         Member Liability Calculation

When Out-of-Area Covered Healthcare Services are provided outside of Capital Health Plan by nonparticipating providers, the amount the Member pays for such services will generally be based on either the Host Blue’s nonparticipating healthcare provider local payment or the pricing arrangements required by applicable state law. In these situations, the Member may be responsible for the difference between the amount that the nonparticipating healthcare provider bills and the payment Capital Health Plan will make for the Out-of-Area Covered Healthcare Services as set forth in the Member's Employer Sponsored Plan. Federal or state law, as applicable, will govern payments for out-of-network emergency services.

2.         Exceptions

In certain situations, Capital Health Plan may use other payment bases, such as billed covered charges, the payment Capital Health Plan would make if the healthcare services had been obtained within the Service Area, or a special negotiated payment to determine the amount Capital Health Plan will pay for services provided by nonparticipating providers. In situations where services are provided by nonparticipating providers, the Member may be liable for the difference between the amount that the nonparticipating healthcare provider bills and the payment Capital Health Plan will make for the Out-of-Area Covered Services.

C.      BlueCross BlueShield Global® Core

If a Member is outside the United States, he or she may be able to take advantage of the BlueCross BlueShield Global® Core Program when accessing covered healthcare services.  The BlueCross BlueShield Global® Core Program is unlike the BlueCard Program available in the United States in certain ways.  For instance, although the BlueCross BlueShield Global® Core Program assists Members with accessing a network of inpatient, outpatient and professional providers, the network is not served by a Host Blue.  As such, when a Member receives care from providers outside the Untied States, he or she may typically have to pay the providers and submit the claims as provided below to obtain reimbursement for these services.  If a member needs to access emergency services (including locating a doctor or hospital) outside the United States, he or she should (a) go to https://bcbsglobalcore.com or download the BlueCross BlueShield Global® Core mobile app to access a list of providers and facilities, or (b) call BlueCross BlueShield Global® Core Program Service Center at 1-800-810-BLUE (2583) or collect at 1-804-673-1177, 24 hours a day, seven days a week.  An assistance coordinator, working with a medical professional, will arrange a Physician appointment or Hospitalization, if necessary.  Please note:  Medical services obtained internationally that are not urgent or emergent in nature are not covered services.  

• Inpatient Services

In most cases, if a Member contacts the BlueCross BlueShield Global® Core Program BlueCard Worldwide Service Center for assistance, Hospitals will not require the Member to pay for covered inpatient services, except for his or her cost share amount. In such cases, the Hospital will submit the Member's claims to the BlueCross BlueShield Global® Core Program BlueCard Worldwide Service Center to begin claims processing. However, if the member paid in full at the time of service, he or she must submit a claim to receive reimbursement for covered healthcare services.

• Outpatient Services

Physicians, urgent care centers and other outpatient providers located outside the United States will typically require a Member to pay in full at the time of service. In such cases, the Member must submit a claim to obtain reimbursement for covered healthcare services.

• Submitting a BlueCross BlueShield Global® Core Program Claim

When a Member pays for covered emergency healthcare services outside the BlueCard service area, he or she must submit a claim to obtain reimbursement. For institutional and professional claims, the Member should register and complete the claim form online at https://bcbsglobalcore.com to initiate claims processing. Following the instructions on the website will help ensure timely processing of the claim. If a Member needs assistance with his or her claim submission, the Member should call the BlueCross BlueShield Global® Core Program Service Center at 1-800-810-BLUE (2583) or call collect at 1-804-673-1177, 24 hours a day, seven days a week.

Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will make all reasonable efforts to provide you with the necessary care.

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 telephone, electronic mail, facsimile, or other expeditious methods.

To file an appeal with OPM

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

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

Example:  When you see your primary care physician, you pay a copayment of $15 per office visit, and when you go in the hospital, you pay $250 per admission.

Your catastrophic protection out-of-pocket maximum

After your copayments total $3,500 for Self Only, $7,000 for Self Plus One, or $7,000 for Self and Family for medical maximum-out-of-pocket (MOOP) and $4,600 for Self Only $8,700 for Self Plus One, or $8,700 per Self and Family for pharmacy MOOP in any calendar year, you do not have to pay any more for covered services.

The medical maximum annual limitation on cost sharing listed under Self Only of $3,500 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 $3,500 Self Only medical maximum out-of-pocket limit and a $7,000 Self Plus One or Self and Family medical maximum out-of-pocket limit. If you or one of your eligible family members has out-of-pocket qualified medical expenses of $3,500 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 $7,000, a second family member, or an aggregate of other eligible family members, will continue to accrue out-of-pocket qualified medical expenses up to a maximum of $7,000 for the calendar year before their qualified medical expenses will begin to be covered in full.

The pharmacy maximum annual limitation on cost sharing listed under Self Only of $4,600 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 $4,600 Self Only pharmacy maximum out-of-pocket limit and a $8,700 Self Plus One or Self and Family pharmacy maximum out-of-pocket limit. If you or one of your eligible family members has out-of-pocket qualified pharmacy expenses of $4,600 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 $8,700, a second family member, or an aggregate of other eligible family members, will continue to accrue out-of-pocket qualified pharmacy expenses up to a maximum of $8,700 for the calendar year before their qualified pharmacy expenses will begin to be covered in full.

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

• Medical Services not covered by Capital Health Plan.  (Medical services not approved or authorized by Capital Health Plan.)

Be sure to keep accurate records of your copayments since you are responsible for informing us when you reach the maximum.

Carryover

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

Benefits

Capital Health Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other providers that contract with us. These plan providers coordinate your health care services. Capital Health Plan is solely responsible for the selection of these providers in your area. To receive our most recent provider directory, call 850-383-3311 or visit our website at www.capitalhealth.com.

HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any course of treatment.

When you receive services from plan providers, you will not have to submit claim forms or pay bills. You pay only the copayments described in this brochure. When you receive emergency services from non-plan providers, you may have to submit claim forms.

Contact Lenses

Capital Health Plan offers services for contact lenses, and contact lenses on a fee for service basis. 

Medical, hospital and prescription  drug benefits

In most cases, providers and facilities file claims for you. Providers must file on the form CMS-1500, Health Insurance Claim Form. Your facility will file on the UB-04 form. For claims questions and assistance, contact us at 850-383-3311, or at our website at www.capitalhealth.com.

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

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

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

Submit your claims to:                     

Capital Health Plan
P. O. Box 15349
Tallahassee, Fl. 32317-5349

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 as long as we notify you before the expiration of the original 30-day period.  Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

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

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

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 telephone 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.

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: Capital Health Plan, ATTN: Grievance Manager, P. O. Box 15349, Tallahassee, FL. 32317-5349; and

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

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

e) Include your email address (optional for member), if you would like to receive OPM's decision via email.  Please note that by providing your email address you may receive OPM's decision more quickly.

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

2

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

a) Pay the claim or  

b) Write to you and maintain our denial or.

c) Ask you or your provider for more information

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

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

3 

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

You must write to OPM within:

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

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

Send OPM the following information:

• A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
• Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;
• Copies of all letters you sent to us about the claim;
• Copies of all letters we sent to you about the claim; 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 file a lawsuit.  If you decide to file a lawsuite, 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 have coverage under any other health plan or have automobile insurance that pays health care expenses without regard to fault. This is called “double coverage.”

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

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

When we are the secondary payor, we will determine our allowance. After the primary plan pays, we will pay what is left of our allowance, up to our regular benefit. We will not pay more than our allowance. The Plan will not pay in a secondary position for visits beyond the benefit limits.

TRICARE and CHAMPVA

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

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

Workers' Compensation

We do not cover services that:

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

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

Medicaid

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

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

When other Government agencies are responsible for your care

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

When others are responsible for injuries

If a Member is injured or becomes ill as a result of another party's intentional act or negligence, the Member must notify Capital Health Plan concerning the circumstances under which the Member was injured. Under §768.76, Florida Statutes the Member or the Member's lawyer must notify Capital Health Plan, by certified or registered mail, if the Member intends to claim damages from someone for injuries or Illness. If the Member recovers money to compensate for the cost/expense of health care services to treat the Member's Illness or injury, Capital Health Plan is legally entitled to be reimbursed for payments made on the Member's behalf to the doctors, Hospitals, or other providers who treated the Member. Capital Health Plan's legal right to be reimbursed in such cases is called "subrogation." Normally, Capital Health Plan may recover the amount of any payments it made on the Member's behalf, minus its pro rata share, for any costs and attorney fees incurred by the Member in pursuing and recovering damages. Capital Health Plan may "subrogate" against all money recovered regardless of the source of the money including, but not limited to, uninsured motorists coverage.

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

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

Clinical Trials

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

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

• Routine care costs – costs for routine services such as doctor visits, lab tests, x-rays and scans, and hospitalizations related to treating the patient’s 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.  The 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.

When you have Medicare

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

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

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

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

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

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

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

When Original Medicare is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. To find out if you need to do something to file your claim, call us at 850-383-3311 or see our website at www.capitalhealth.com.  The plan will not pay in a secondary position for visits beyond the benefit limits. 

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

Please review the following table it illustrates your cost share if you are enrolled in Medicare Part B.  Medicare will be primary for all Medicare eligible services.  Members must use CHP providers who accept Medicare's assignment.

Benefit Description: Out of Pocket Maximum
High Option you pay without Medicare: Medical Services: $3,500/Self Only, $7,000/Self Plus One or $7,000/Self And Family and for Pharmacy: $4,600/Self Only, $8,700/Self Plus One or $8,700/Self and Family
High Option you pay with Medicare Part B: Medical Services: $3,500/Self Only, $7,000/Self Plus One or $7,000/Self And Family and for Pharmacy: $4,600/Self Only, $8,700/Self Plus One or $8,700/Self and Family

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

Benefit Description: Primary Care Physician
High Option you pay without Medicare: $15
High Option you pay with Medicare Part B: $15

Benefit Description: Specialist
High Option you pay without Medicare: $60
High Option you pay with Medicare Part B: $60

Benefit Description: Inpatient Hospital
High Option you pay without Medicare: $250 copay per day (2 day maximum per admission)
High Option you pay with Medicare Part B: $250 copay per day (2 day maximum per admission)

Benefit Description: Outpatient Hospital
High Option you pay without Medicare: $250
High Option you pay with Medicare Part B: $250

Benefit Description: Incentives Offered
High Option you pay without Medicare: N/A
High Option you pay with Medicare Part B: N/A

You can find more information about how our plan coordinates benefits with Medicare in FEHB Brochure at capitalhealth.com/FEHB.

• Tell us about your Medicare coverage

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

• 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 (1-800-633-4227) (TTY: 1-877-486-2048) or at www.medicare.gov.

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

This Plan and our Medicare Advantage plan: You may enroll in CHP’s Medicare Advantage plan and also remain enrolled in our FEHB plan. Your care must continue to be authorized by your CHP primary care physician, and we will not waive any of your copayments.

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. If you enroll in a Medicare Advantage plan, tell us. We will need to know whether you are in the Original Medicare Plan or in a Medicare Advantage plan so we can correctly coordinate benefits with Medicare.

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

• Medicare prescription drug coverage (Part D)

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

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 trail, 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.

Copayment

See Section 4, page 29.

Cost-sharing   

See Section 4, page 29.

Medical necessity

Medical necessity means, for coverage and payment purposes, that a medical service or supply is required for the identification, treatment, or management of a condition, and is, in the opinion of CHP: 1) consistent with the symptom, diagnosis, and treatment of the member's condition; 2) widely accepted by the practitioners' peer group as efficacious and reasonably safe based on scientific evidence; 3) universally accepted in clinical use so that omission of the service or supply in these circumstances raises questions regarding the accuracy of diagnosis or the appropriateness of the treatment; 4) not experimental or investigational; 5) not for cosmetic purposes; 6) not primarily for the convenience of the member, the member's family, the physician, or other provider; and 7) the most appropriate level of service, care, or supply that safely can be provided to the member. When applied to inpatient care, medical necessity further means that the services cannot be provided safely to the member in an alternative setting.

Morbid obesity

A condition in which an individual's body mass index (BMI) exceeds 40 or is greater than 35 in conjunction with severe co-morbidities such as cardiopulmonary complications or severe diabetes.

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 largely 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 Capital Health Plan Member Services Department at 850-383-3311.  You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care.

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

Office visit copay:  $15 primary care;

$60 specialist

33

Services provided by a hospital: Inpatient 

$250 copay per day/maximum 2 days copayments per admission

51

Services provided by a hospital: Outpatient

$250 per visit ambulatory surgical center visit

$250 per facility visit/maximum 2 days copayments per admission

52

Emergency benefits: In-area

$500 per emergency room visit

54

Emergency benefits: Out-of-area

$500 per emergency room visit

55

Mental health and substance use disorder treatment:

$60 per office visit

56

Prescription drugs:

• Retail Pharmacy and Mail Order

$15 Tier 1 drugs (30 day supply)  / $30 Tier 1 drugs (60 day supply) / $45 Tier 1 drugs (90 day supply)

$40 Tier 2 drugs (30 day supply) / $80 Tier 2 drugs (60 day supply) / $120 Tier 2 drugs (90 day supply)

$100 Tier 3 drugs (30 day supply) / $200 Tier 3 drugs (60 day supply) / $300 Tier 3 drugs (90 day supply)

$100 Tier 4 Specialty drugs (30 day supply)

59

Dental care:

No benefit.

63

Vision care:

Limited benefit.

39

Wellness and Other Special features:

TDD Line: 850-383-3534

64

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

Nothing after $3,500/Self Only, $7,000/Self Plus One or $7,000/Family enrollment for Medical Services and $4,600/Self Only, $8,700/Self Plus One or $8,700/Family enrollment for Pharmacy per year.

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