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

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

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

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

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

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

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

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

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

Contact your carrier to add a family member when there is already family coverage. 

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

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

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

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

Family members covered under your Self and Family enrollment are your spouse (including your spouse by a 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.

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

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

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

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

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

The benefits in this brochure are effective January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be processed according to the 2023 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 2022 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.

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 Temporary Continuation of Coverage (TCC), or a conversion policy (a non-FEHB individual policy).

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. 

If you leave Federal service, Tribal employment, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC). For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if you lose your Federal or Tribal job, or if you are a covered child and you turn 26. 

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

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

Alternatively, you can buy coverage through the Health Insurance Marketplace where, depending on your income,  you could be eligible for a tax credit that lowers your monthly premiums.  Visit www.HealthCare.gov to compare plans and see what your premium, deductible, and out-of-pocket costs would be before you make a decision to enroll.  Finally, if you qualify for coverage under another group health plan (such as your spouse's plan), you may be able to enroll in that plan, as long as you apply within 30 days of losing FEHBP 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, 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 850-383-3311 or visit our website at www.capitalhealth.com.

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

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

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

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

Plan providers are physicians and other healthcare 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. 

This plan recognizes that transgender, non-binary, and other gender diverse members require health care delivered by healthcare providers experienced in gender affirming health.

Benefits described in this brochure are available to all members meeting medical necessity guidelines regardless of race, color, national origin, age, disability, religion, sex, or gender. 

This plan provides Care Coordinators for complex conditions and can be reached Capital Health Plan Member Services 850-383-3311 for assistance.  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, www.capitalhealth.com. Primary care physician offices in our two health centers at Centerville Road and Governors Square Boulevard also offer the convenience of lab, x-ray, and vision 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.  

Your primary care physician can be a family practitioner, internist, or pediatrician.   Your primary care physician will provide most of your healthcare, 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.

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.

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 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. Your primary care physician will decide what treatment you need. If they decide to refer you to a specialist, ask if you can see your current specialist.
• If your current specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.
• If you are seeing a specialist and your specialist leaves the Plan, call your primary care 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.

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.

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.

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

You must get prior approval for certain services.  Failure to do so will result in services not being covered. 

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. 

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. You must obtain prior authorization for: 

• 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
• Gender Reassignment Surgeries (limited to those surgeries that can be performed by a general surgeon such as mastectomies, hysterectomies, oophorectomies and gonadectomies.) 

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 they 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 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.

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

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

If you have an urgent care claim (i.e. when waiting for the regular time limit for your medical care or treatment could seriously jeopardize your life, health, or ability to regain maximum function, or in the opinion of a physician with knowledge of your medical condition, would subject you to severe pain that cannot be adequately managed without this care or treatment), we will expedite our review and notify you of our decision 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 Health Insurance 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).

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.

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 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.

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 may 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, they 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 United States, they 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, they 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, they 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.  If your claim is in reference to a contraceptive call 850-383-3311.  

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

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

In the case of a pre-service claim and 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 healthcare provider to give you the care or grant your request for prior approval for a service, drug, or supply; or

2. Ask you or your provider for more information.

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

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

3. Write to you and maintain our denial.

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

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

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 day (maximum 2 days) per admission.

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

After your copayments total $3,500 for Self Only, $7,000 for Self Plus One, or $7,000 per person 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 enrollment 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.

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.

The No Surprises Act (NSA) is a federal law that provides you with protections against “surprise billing” and “balance billing” under certain circumstances. A surprise bill is an unexpected bill you receive from a nonparticipating health care provider, facility, or air ambulance service for healthcare. Surprise bills can happen when you receive emergency care – when you have little or no say in the facility or provider from whom you receive care. They can also happen when you receive non-emergency services at participating facilities, but you receive some care from nonparticipating providers.

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

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

For specific information on surprise billing, the rights and protections you have, and  your responsibilities go to https://capitalhealth.com/transparency-in-coverage or contact the health plan at 850-383-3311. 

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

Professional services of physicians

• In physician’s office
• Office medical consultations

$15 per primary care visit

$60 per specialist visit

• Telehealth services

$15 per primary care visit

$60 per specialist visit

• Second Surgical Opinion

$60 per specialist visit

Professional services of physicians

• In an urgent care center

$50 per visit

• During a hospital stay
• In a skilled nursing facility
• At home
• Advance care planning

Nothing

Tests, such as:

• Blood tests
• Urinalysis
• Non-routine Pap test
• Pathology
• X-ray
• Non-routine mammogram
• Ultrasound
• Electrocardiogram and EEG

Nothing

• MRI/PET/CT Scans

$250 per visit

Routine annual physical every year 

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

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

Routine mammogram - covered

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

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

Not covered:

• Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel.
• Immunizations, boosters, and medications for travel or work-related exposure.

Well-child care visits, examinations, and other preventive services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics.  For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to https://brightfutures.aap.org.

• Immunizations such as DTaP, Polio, Measles, Mumps, and Rubella (MMR), and Varicella.  For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cc.gov/vaccines/schedules/index.html.
• You can also find a complete list of preventive care services recommended under the U. S. Preventive Services Task Force (USPSTF) online at https://www.uspreventiveservicestaskforce.org

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

Complete maternity (obstetrical) care, such as:

• Prenatal care
• Screening for gestational diabetes
• Delivery
• Postnatal care

$15 for initial visit for primary care

$60 for initial visit to specialist

$250 copay day/maximum 2 days per admission

Breastfeeding support, supplies and counseling for each birth.

Note:  Comprehensive lactation support and counseling by a trained provider during pregnancy and/or in the postpartum period, and costs for 1 breast pump per pregnancy as breastfeeding equipment.

Note: Here are some things to keep in mind:

• You do not need to precertify your vaginal delivery, see page 17 for other circumstances, such as extended stays for you or your baby.
• You may remain in the hospital up to 48 hours after a vaginal delivery and 96 hours after a cesarean delivery (you do not need to precertify the normal length of stay). We will extend your inpatient stay if medically necessary.
• We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and family enrollment. Surgical benefits, not maternity benefits, apply to circumcision.
• We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury.
• Hospital services are covered under Section 5(c) and Surgical benefits Section 5(b).

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

Note: Maternity Care is defined as care 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

Nothing

Contraceptive counseling on an annual basis

A range of voluntary family planning services, limited to:

• Intrauterine devices (IUDs)
• Voluntary sterilization (See Surgical procedures Section 5 (b)
• Surgically implanted contraceptives
• Injectable contraceptive drugs (such as Depo Provera)
• Diaphragms
• Tubal ligation

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

Not covered:

• Reversal of voluntary surgical sterilization
• Genetic testing and counseling

Diagnosis of infertility such as:

Limited to endometrial biopsy, sperm count measurement and hysterosalpingography.

Fertility preservation for medical reasons that cause irreversible infertility related to but not limited to those facing chemotherapy, radiation treatment, surgery, or other treatments including medical / surgical gender transition treatments that could affect reproductive organs or processes.

 This type of coverage does not include:

• “Elective” fertility preservation, such as egg freezing sought due to natural aging;
• Infertility treatments such as in vitro fertilization that might be needed after the necessary medical intervention, such as cancer treatment to achieve a pregnancy; or 
• Long-term storage

Iatrogenic Fertilization Benefits will be limited to standard fertility preservation
procedures. Storage will not exceed a period of one (1) year and benefits are limited to one cycle of fertility preservation
per covered person during the entire period a member is enrolled with Capital Health Plan. Members utilizing this service
will pay a $60 copayment for a specialist visit; $250 copayment per ambulatory surgical center facility visit; and $250
copayment per day with a maximum of two (2) days per hospital admission.

$15 per primary care visit

$60 per specialist visit

Not covered:

Infertility treatment and services except as specified above, including but not limited to:

• Services and medications to treat infertility;
• Reversal of voluntary surgical sterilization procedures;
• Assisted reproductive technology (ART) procedures, such as:
  •  Artificial insemination (AI)
  • In vitro fertilization (IVF)
  • Embryo transfer, Gamete intrafallopian transfer (GIFT) and Zygote intra-fallopian transfer (ZIFT)
  • Intravaginal insemination (IVI)
  • Intracervial insemination (ICI)
  • Intrauterine insemination (IUI) and 
• Services and supplies associated with ART procedures
• All Services associated with the donation or purchase of sperm or donor eggs

• Testing and treatment
• Allergy injections

$15 per primary care visit

$60 per specialist visit

Nothing

Not covered:

• Provocative food testing
• Sublingual allergy desensitization

• Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue Transplants on page 45.

• Respiratory and inhalation therapy
• Dialysis – hemodialysis and peritoneal dialysis
• Intravenous (IV)/Infusion Therapy-Home IV and antibiotic therapy
• Applied Behavior Analysis (ABA) - Children with autism spectrum disorder
• Growth hormone therapy (GHT)

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

Note: We only cover GHT when we preauthorized the treatment. Your physician will request preauthorization. Ask us to authorize GHT before you begin treatment. We will only cover GHT services and related services and supplies that we determine are medically necessary. See Other services under "You need prior Plan approval" for certain services page 17.

$15 per primary care visit

$60 per specialist visit

Limited per member per condition to the number of medically necessary rehabilitation services received by the member within the consecutive 62-day period immediately following the first date that the member begins such services for each of the following:

• Qualified Physical Therapists
• Occupational Therapists
• Habilitative Services
  • Applied Behavior Analysis (ABA) Therapy for Autism Spectrum Disorder

Note:  We only cover therapy when a physician:

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

$60 per specialist visit

Included in inpatient hospital facility admission

Not covered:

• Long-term rehabilitative therapy
• Exercise programs

Limited per member per condition to the number of medically necessary rehabilitation, habilitative, and speech services which are received by the member within the consecutive 62-day period immediately following the first date that the member begins such services.

Note:  We only cover therapy when a physician

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

$60 per specialist visit

Included in inpatient hospital facility admission

Not covered:

• Speech therapy beyond 62-day period per condition

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

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

$15 per primary care visit

$60 per specialist visit

Not covered:

• Hearing aids, testing and examinations for them
• Hearing services and testing that are not shown as covered
• Services related to the fitting or provision of hearing aids, included tinnitus maskers.

• One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery (such as for cataracts). 

Note:  Initial pair of eyeglasses or contact lenses following cataract surgery or accidental injury which would necessitate corrective lenses (initial pair of eyeglasses are limited to the cost of the basic plastic lens and up to $65.00 for the frames obtained only at Capital Health Plan's Eye Care Centers.) 

• Annual eye refractions, including eye exam to determine the need for vision correction for children through age 17.

Note: See Preventive care, children for eye exams for children.

$15 per primary care visit

$60 per specialist visit

Not covered:

• Eye exercises and orthoptics
• Radial keratotomy and other refractive surgery
• Eyeglasses, except initial pair following cataract surgery or an accidental injury which requires corrective lenses.
• An examination and fitting for contact lenses.
• Contact lenses and examinations required for fitting of contact lenses.
• Replacements for any lenses provided during the same calendar year.

Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes.

Note: See Orthopedic and prosthetic devices for information on podiatric shoe inserts.

$15 per primary care visit

$60 per specialist visit

Not covered:

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

All charges

• Artificial limbs and eyes
• Prosthetic sleeve or sock
• Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy
• Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome
• Implanted hearing-related devices, such as cochlear implants
• Internal prosthetic devices, such as artificial joints, pacemakers, and surgically implanted breast implant following mastectomy
• Braces and covered prosthetic devices (except cardiac pacemaker) are limited to the first such item prescribed for each specific medical condition
• Cardiac pacemakers

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

Not covered:

• Orthopedic and corrective shoes, arch supports, foot orthotics, heel pads and heel cups
• External hearing aids
• Lumbosacral supports
• Corsets, trusses, elastic stockings, support hose, and other supportive devices
• All other prosthetic devices, including braces used during athletic activities, are excluded.

Note: Benefits may be provided for necessary replacement of a prosthetic or orthotic device which is owned by the member when due to irreparable damage, wear, a change in the member's condition, or when necessitated due to growth of a dependent child.

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

• Crutches
• Canes
• Manual wheelchairs
• Basic hospital beds
• Walkers
• Blood glucose monitors
• Insulin pumps
• Oxygen for home use including equipment
• prescription and non-prescription enteral formulas for home use when prescribed by a contracted physician when medically necessary to treat inherited diseases of amino acid, organic acid, carbohydrate, or fat metabolism as well as malabsorption originating from congenital defects present at birth or acquired during the neonatal period. This also includes coverage to treat inherited diseases of amino acid and organic acids including food products modified to be low protein.  The annual dollar limit is $2,500. Enteral formulas may be administered intermittently or continuously through nasogastric, gastrostomy, or jejunostomy tubes directly into the gastrointestinal tract with or without the assistance of an infusion pump, or they may be administered orally

Note: Durable Medical Equipment must be prescribed by your plan physician and authorized by CHP.  CHP reserves the right to rent or purchase the most cost-effective DME that meets the member's needs.    

Note: Call us at 850-383-3311 as soon as your Plan physician prescribes this equipment. We will arrange with a healthcare provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call.

Not covered:

• Cost to repair or replace Durable Medical Equipment except when authorized by CHP
• Durable Medical Equipment that has not been authorized by CHP
• Durable Medical Equipment that is for patient convenience and/or comfort
• Water therapy devices such as jacuzzis, hot tubs, swimming pools, or whirlpools 
• Exercise and massage equipment
• Electric scooters 
• Hearing aids
• Dental braces, air conditioners, humidifiers, water purifiers, hypo-allergenic pillows, mattresses or waterbeds, emergency alert equipment.
• This exclusion includes but is not limited to:  
  • Modifications to motor vehicles
  • Modifications to homes, such as wheelchair lifts or ramps 
  • Escalators or elevators, stair glides, handrails, heat appliances and dehumidifiers.

• Home healthcare ordered by a Plan physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.), or home health aide.

Note:  The Plan physician periodically will review the program for continuing appropriateness and need.

• Services include oxygen therapy, intravenous therapy and medications.

Nothing

Not covered

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

• Manipulation of the spine and extremities

Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application

$60 per specialist office visit

Not covered:

• Services that maintain rather than improve a physical function
• Services that we determine will not result in significant improvement of the member's condition within a 62-day period.

No Benefit

All Charges

Coverage is provided:

• Tobacco cessation programs, including individual/group/ telephone counseling, over the counter (OTC)  and prescription drugs approved by the FDA to treat nicotine dependence.

Note:  OTC drugs require a prescription. 

• Members may choose one or more of the options below if desired:
  • Healthwise Knowledgebase accessed from www.capitalhealth.com/: enter tobacco into the search bar
  • Tobacco Free Florida: (877)822-6669 (Maintained by the Florida Department of Health)
  • Big Bend AHEC (Area Health Education Centers): (850-224-1177)
  • Quit Smoking Now: a 6 week in person class series offered by Big Bend AHEC
  • Tools to Quit: A 2 hour program that provides individuals with essential tools to stop all types of tobacco use

Nothing

Diabetes Empowerment Education Program™ (DEEP™)  is a Medicare-approved, evidence-based diabetes self-management education (DSME) program for people 18 and older with prediabetes or diabetes and their loved ones. Big Bend AHEC can be reached at 850-224-1177 for registration in the program or for more information.  Minor children must be accompanied by parent/guardian. 

Nothing

A comprehensive range of services, such as:

• Operative procedures
• Treatment of fractures, including casting
• Normal pre- and post-operative care by the surgeon
• Correction of amblyopia and strabismus
• Endoscopy procedures
• Biopsy procedures
• Removal of tumors and cysts
• Correction of congenital anomalies (see Reconstructive surgery)
• Surgical treatment of morbid obesity (bariatric surgery) – a condition in which an individual weighs 100 pounds or 100% over his or her normal weight according to current underwriting standards;
  
  Note:  To meet requirements of bariatric surgery eligible members must be age 18 or over.  Preauthorization is required.
• Presence of morbid obesity, defined as a body mass index (BMI) greater than or equal to 40 or greater than or equal to 35 in conjunction with severe co-morbidities such as cardiopulmonary complications or severe diabetes; and
• An adequately documented history of consistent participation in a weight management program for 12 consecutive months that is similar to that described in the document, Surgical Treatment of Morbid Obesity Responsibilities, including regular PCP visits to document compliance; and
• An adequately documented history of adaptation of sound nutritional principles as evidenced by a 10% weight reduction at the end of the 12-month program; and
• An adequately documented absence of active substance abuse or major uncontrolled psychiatric disorder; or
• Life threatening morbid obesity with evidence of imminently life threatening co-morbid conditions that cannot be treated safely and effectively through other means.
• Insertion of internal prosthetic devices. See 5(a), Orthopedic and prosthetic devices, for device coverage information
• Voluntary sterilization (e.g., tubal ligation, vasectomy)
• Treatment of burns

Note: Generally, we pay for internal prostheses (devices) according to where the procedure is done. For example, we pay Hospital benefits for a pacemaker and Surgery benefits for insertion of the pacemaker.

$15 per primary care visit

$60 per specialist visit

Included in inpatient hospital facility admission

Not covered:

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

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

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

Gender Affirming Surgery

• Gender Affirming Surgery limited to those surgeries that can be performed by a general surgeon such as mastectomies, hysterectomies, oophorectomies and gonadectomies.  Prior authorization is required. 

$15 per primary care visit

$60 per specialist visit

Included in inpatient hospital facility admission.

Not covered:

• Cosmetic services - any service to improve the physical appearance or self-perception of an individual, including without limitation:  cosmetic surgery and procedures or supplies to correct loss of skin wrinkling (e.g., Minoxidil, Rogaine, Retin-A).  Unless required to restore or correct a part of the body that has been altered as a result of accidental injury, or disease (does not include anomalies related to the teeth or structures supporting the teeth). 
• The following surgeries are considered cosmetic and do not meet the definition of medical necessity when used to improve the gender specific appearance of an individual who has undergone or is planning to undergo gender reassignment surgery (contact Member Services at 850-383-3311 for a more detailed list):
  • Blepharoplasty
  • Breast augmentation
  • Face lift
  • Facial bone reconstruction
  • Hair removal/hairplasty
  • Liposuction
  • Reduction thyroid chondroplasty
  • Rhinoplasty
  • Voice Modification surgery

Oral surgical procedures, limited to:

• Reduction of fractures of the jaws or facial bones;
• Surgical correction of cleft lip, cleft palate or severe functional malocclusion;
• Removal of stones from salivary ducts;
• Excision of leukoplakia or malignancies;
• Excision of cysts and incision of abscesses when done as independent procedures; and
• Other surgical procedures that do not involve the teeth or their supporting structures.
• Surgical treatment of TMJ

$15 per primary care visit

$60 per specialist visit

Included in inpatient hospital facility admission

Not covered:

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

These solid organ transplants are covered.  These solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan.  See Other services under You need prior Plan approval for certain services on page 17.  Solid organ transplants are limited to:

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

$15 per primary care visit

$60 per specialist visit

Included in inpatient hospital facility admission.

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

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

$15 per primary care visit

$60 per specialist visit

Included in inpatient hospital facility admission

Blood or marrow stem cell transplants

The Plan extends coverage for the diagnoses as indicated below.

• Allogeneic transplants for
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute lymphocytic or
  • Advanced Hodgkins lymphoma with recurrence (relapsed)
  • Advanced Myeloproliferative Disorders (MPDs)
  • Advanced non-Hodgkin's lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic leukemia (CLL/SLL)
  • Hemoglobinopathy
  • Marrow failure and related disorders (i.e. Fanconi's Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Asplasia)
  • Myelodysplasia/Myelodysplastic syndromes
  • Paroxysmal Nocturnal Hemoglobinuria
  • Phagocytic/Hemophagocytic deficiency disease (e.g. Wiskott-Aldrich syndrome)
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
  • Sickle cell anemia
  • X-linked lymphoproliferative syndrome
• Autologous transplants for:
  • Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin's lymphoma with reoccurrence (relapsed)
  • Advanced non-Hodgkin's lymphoma with reoccurrence (relapsed)
  • Amyloidosis
  • Breast Cancer
  • Epithelial ovarian cancer
  • Multiple myeloma
  • Neuroblastoma
  • Testicular, Mediastinal, Retroperitoneal, and Ovarian germcell tumors

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

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

• Allogeneic transplants for
  •  Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Advanced Hodgkin's lymphoma with reoccurrence (relapsed)
  • Advanced Myeloproliferative Disorders (MPDs)
  • Advanced non-Hodgkin's lymphoma with reoccurrence (relapsed)
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CCL/SLL)
  • Hemoglobinopathy
  • Marrow failure and related disorders (i.e., Fanconis, PNH, Pure Red Cell Aplasia)
  • Myelodysplasia/Myelodysplastic syndromes
  • Paroxysmal Nocturnal Hemoglobinuria
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
• Autologous transplants for
  • Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
  • Advance Hodgkin's lymphoma with reoccurrence (relapse)
  • Advanced non-Hodgkin's lymphoma with reoccurrence (relapsed)
  • Amyloidosis
  • Neuroblastoma

$15 per primary care visit

$60 per specialist visit

Included in inpatient hospital facility admission

Not covered:

• Donor screening tests and donor search expenses associated with the identification of a potential donor from a local, state, or national listing, except those performed for the actual donor.
• Any organ which is sold rather than donated to the member
• Any service in connection with the implant of an artificial organ, including the implant of the artificial organ.
• Any service related to the transplantation of any non-human organ or tissue
• Services related to the acquisition of an organ or tissue for a recipient who is not a covered member of CHP
• Transplants not listed as covered
• Travel and/or lodging and related expenses

Professional services provided in –

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

Nothing

• Office visit

$60 per specialist visit

Room and board, such as

• Ward, semiprivate, or intensive care accommodations;
• General nursing care
• Meals and special diets
• Special duty nursing when medically necessary
• Private rooms when medically necessary

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

$250 copay per day/maximum 2 days per admission

Other hospital services and supplies, such as:

• Operating, recovery, maternity, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests and x-rays
• Dressings, splints, casts, and sterile tray services
• Medical supplies and equipment, including oxygen
• Blood or blood plasma, if not donated or replaced
• Anesthetics, including nurse anesthetist services
• Take-home items
• Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home.

Not covered:

• Custodial care
• Non-covered facilities, such as nursing homes, schools
• Personal comfort items, such as telephone, television, barber services, guest meals and beds
• Private nursing care, except when medically necessary

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

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

$250 per ambulatory surgical center facility visit

$250 copay per day/maximum 2 days per admission

Not Covered:  Blood and blood derivatives not replaced by the member

All charges

Extended care/skilled nursing facility (SNF):   The Plan provides a comprehensive range of benefits for up to 60 days per admission with subsequent admission following 180 days from discharge date of previous admission.

All necessary services are covered, including:

• Bed, board and general nursing care
• Drug biological supplies, and equipment ordinarily provided or arranged by the facility when prescribed by a Plan doctor.

Note:  When full-time care is necessary and confinement in a facility is medically appropriate as determined by a Capital Health Plan doctor and approved by Capital Health Plan. 

Not covered:

• Custodial care

Supportive and palliative care for a terminally ill member is covered in the home or hospice facility.  Services include inpatient and outpatient care, and family counseling and are provided under the direction of a Plan doctor who certifies that the patient is in the terminal stage of illness, with a life expectancy of approximately six months or less

Advance Directive (Five Wishes). An advanced directive ensures that both medical professionals and your loved ones understand the end-of-life decisions you want in the event you're unable to explain them due to a medical emergency.  An advanced directive is simply a statement, made while you are competent, about the medical treatment you want if you can't make those decisions later. Decisions made early and communicated plainly may have tremendous value for you and your family.

• Five Wishes, for anyone 18 or older, is an advance directive document that addresses all of an individual's needs (medical, personal, emotional and spiritual),  please call CHP's Health Information Line:  850-383-3400 for more information.
• Planning Early About Care at the End (PEACE) Program at Big Bend Hospice provides information needed for you to get started.  Results from the PEACE assessment will help you articulate your preference, values and goals to  your family and loved ones.  To reach a PEACE facilitator, please contact Big Bend Hospice at 850-878-5310

.

• Local professional ambulance service when medically appropriate

$175 per transport

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

$50 per visit

• Telehealth through Amwell (call 1-844-733-3627) for urgent care services. 

$15 per visit

• Emergency care as an outpatient at a hospital, including observation as well as doctors’ services

Note:  We waive the ER copay if you are admitted to the hospital. 

$500 per visit

Not covered:

• Elective care or non-emergency care and follow-up care recommended by non-plan providers that has not been approved by the Plan or provided by Plan providers.

All charges

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

$50 per visit

• Telehealth through Amwell (call 1-844-733-3627) for urgent care services. 

$15 per visit

• Emergency care as an outpatient at a hospital, including observation as well as doctors’ services

Note:  We waive the ER copay if you are admitted to the hospital. 

$500 per visit

Not covered:

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

Professional ambulance service when medically appropriate.

$175 per transport

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

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

$15 per primary care visit

$60 per specialist office visit

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

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

$15 per primary care visit

$60 per specialist visit

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

$15 per primary care visit

$60 per specialist visit

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

• Room and board, such as semiprivate or intensive accommodations, general nursing care, meals and special diets, and other hospital services
• Members needing extensive treatment such as intensive outpatient substance use disorder or residential treatment for substance use disorders or eating disorders must request these services through their PCP and will be expected to meet clinical criteria for approval.

$250 copay per day/maximum 2 days per admission

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

$250 copay per day/maximum 2 days per admission

• Treatment specific to, and solely for, learning, communication and motor skills disorders, academic or career counseling
• Scholastic/Educational Testing, Intelligence, and Learning disability testing and evaluations should be requested and conducted by the child's school district
• Court-ordered counseling or treatment, as a condition of release or probation, such as residential substance misuse disorder treatment, intensive outpatient counseling and individual or family counseling
• Work or school ordered assessment and treatment in the absence of a clinical need
• Counseling for marital and relationship enhancement and religious purposes including counseling provided by a religious counselor
• Experimental/investigational or unproven treatment and services, including biofeedback, hypnotherapy, non-network or non-participating clinics specifically for methadone maintenance, neurofeedback, light boxes for phototherapy and outward bound or other wilderness type therapies
• Cognitive remediation except for the following conditions and if criteria is met: traumatic brain injury or brain injury due to cerebrovascular accident (stroke), intracranial aneurysm, anoxia, encephalitis, brain tumors, or brain toxins
• Elective therapies such as Gestalt, Transactional Analysis, Transcendental Meditation, Z-therapy, Mind expansion therapy and Erhard Seminar Training (EST)
• Custodial Care or basic care provided in a residential, institutional or assisted living setting.  Non-skilled care received in a home or facility on a temporary or permanent basis.  Examples of such care include room and board, health care aids, and personal care designed to help the member in activities of daily living or to keep the member from continuing unhealthy activities
• Transitional living centers, non-licensed programs, therapeutic boarding schools, and services typically provided by community mental health services program settings 

We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy.

• Drugs and medicines that by Federal law of the United States require a physician's prescription for their purchase, except those listed as Not covered.
• Insulin
• Diabetic supplies limited to needles, syringes, and test strips. 
• Disposable needles and syringes for the administration of covered medications
• Drugs for sexual dysfunction (see Prior Authorization)
• Drugs to treat gender dysphoria
  • Hormone products may require prior authorization and quantity limits may apply 
  • CHP provides treatment prescribed by a medical provider for gender dysphoria. Drug treatments for all covered members may be subject to certain coverage limitations such as prior authorization or quantity limits as listed on the Commercial formulary.
• Oral and injectable contraceptive drugs

Note:

• A prescription unit or refill will be covered up to a 90-day supply for generic and brand drugs (at 3 times the member's cost share per 90-day supply) at retail and mail order pharmacies.  Specialty drugs are limited up to a 30-day supply. 
• Refills that are authorized by the prescriber must be filled within six months or one year from the original prescription date, depending on federal law designations.  Refills on prescriptions shall not be covered until at least 75% of the previous prescription has been used by the member based on the dosage schedule prescribed.
• Syringes and needles will be covered only when prescribed and obtained with a prescription for administration of diabetic products.
• Certain prescription drugs, require prior authorization.  For a list of these drugs, refer to www.capitalhealth.com.  For instructions about how to get prior authorization, call Member Services at 850-383-3311 (toll-free 1-877-247-6512); TTY 850-383-3534 (1-877-870-8943).
• If a member or the prescriber requests a prescription drug not listed on the posted formulary as Tier 1, Tier 2 or Tier 3, if approved, the member must pay the Tier 4 member cost share.
• CHP retains the right to limit coverage of the quantities of prescribed drugs.

Prescription Drugs - The Plan will limit the prescription for controlled substances in Schedules II-V to a 3-day supply for the initial fill for patients with acute conditions unless there is medical documentation for a 7-day supply due to a Florida State statute. 

Tier 1 Drugs Preferred (Retail and Mail order):

• $15 per prescription Tier 1 drugs (30-day supply)
• $30 per prescription Tier 1 drugs (60-day supply)
• $45 per prescription Tier 1 drugs (90-day supply)

Tier 2 Drugs Non-Preferred (Retail and Mail order):

• $15 per prescription Tier 1 drugs (30-day supply)
• $30 per prescription Tier 1 drugs (60-day supply)
• $45 per prescription Tier 1 drugs (90-day supply)

Tier 3 Drugs Preferred (Retail and Mail order)

• $40 per prescription Tier 2 drugs (30-day supply)
• $80 per prescription Tier 2 drugs (60-day supply)
• $120 per prescription Tier 2 drugs (90-day supply)

Tier 4 Drugs  Non-Preferred(Retail and Mail order):

• $100 per prescription Tier 3 drugs (30-day supply)
• $200 per prescription Tier 3 drugs (60-day supply)
• $300 per prescription Tier 3 drugs (90-day supply)

Tier 5 Preferred Specialty Drugs are limited to a 30-day supply.

• $100 per prescription Tier 5 drugs (30-day supply)

Tier 6 Non-Preferred Specialty Drugs are limited to a 30-day supply.

• $100 per prescription Tier 6 drugs (30-day supply)

Note: If there is no generic equivalent available, you will still have to pay the brand name copay.

Contraceptive drugs and devices as listed on the ACA/HRSA site.  Contraceptive coverage is available at no cost to FEHB members.  The contraceptive benefit includes at least one option in all methods of contraception (as well as the screening, education, counseling, and follow-up care).  Any contraceptive that is not on the formulary can be requested through the contraceptive exceptions process described below:

• Contraceptive medication exception can be requested by the prescribing physician/provider for contraceptive formulations not available on the formulary.  
• Reimbursement for over-the-counter contraceptives can be submitted by submitting a reimbursement request form with appropriate receipts and proof of payment.  The form may be found at capitalhealth.com/sites/default/files/uploaded-documents/Non-Medicare%20Prescription%20Drug%20Reimbursement%20Request_0.pdf .

Note:  Must be prescribed by a physician and purchased at a network pharmacy.  (Please refer to CHP formulary.)

Nothing

Not covered:

• Non-formulary drugs and devices
• Drugs and supplies for cosmetic purposes
• Drugs to enhance athletic performance
• Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies
• Nonprescription medications unless specifically indicated elsewhere

Note:  Over-the-counter and appropriate prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation program benefits (See page 42). 

All charges

The following are covered. 

• Aspirin (81 mg) for men age 45-79 and women age 55-79 and women of childbearing age
• Folic acid supplements for women of childbearing age 400 & 800 mcg
• Liquid iron supplements for children age 6 months -1 year
• Vitamin D supplements (prescription strength-400 & 1000 units) for members 65 or older
• Fluoride tablets, solution (not toothpaste, rinses) for children age 0 - 6
• Statins for the primary prevention of Cardiovascular Disease (CVD) for adults aged 40 to 75 years with no history of CVD, 1 or more CVD risk factors and a calculated 10-year CVD event risk of 10% or greater.    

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

Note: Preventive Medications with a USPSTF recommendation of A or B are covered without cost-share when prescribed by a healthcare professional and filled by a network pharmacy. These may include some over-the counter vitamins, nicotine replacement medications, and low dose aspirin for certain patients. For current recommendations go to www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations

Nothing

Not covered:

• Drugs that can be purchased over the counter without a prescription, even though a prescription was provided by prescriber with the exclusion of Insulin and over the counter medications covered under the Preventive Services as defined by the Patient Protection and Affordable Care Act (ACA).
• Drugs that are dispensed before the effective date, or after the termination date, of this brochure.
• All syringes and needles except as otherwise covered.
• Mineral supplements or vitamins, except as mandated by Federal, State and local regulations and noted above. 
• Fertility drugs or any drugs used for the purpose of enhancing the probability of conception.
• Drugs that are not approved by the FDA.
• Certain generic drugs when competitively priced brand drugs are covered on the formulary.
• Drugs purchased from a non-participating pharmacy, except as a result of an emergency medical condition or when authorized by CHP.
• Any drug administered by intravenous infusion or injection, regardless of the setting in which it is administered or the type of provider administering the drug, except as specified in the Covered Items section.
• Vitamins, nutrients and food supplements not listed as a covered benefit even if a physician prescribes or administers them. 
• Nonprescription medications.

 Note:  Over-the counter and prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation benefit.  (See page 41).

All charges

We cover restorative services and supplies necessary to promptly (within 62 days of an accidental dental injury) repair (but not replace) sound natural teeth. The need for these services must result from an accidental injury.

Note:  Accidental dental injury means an injury to sound natural teeth (not previously compromised by decay), caused by a sudden unintentional, and unexpected event or force. This term does not include injuries to the mouth, structures within the oral cavity, or natural teeth caused by biting or chewing, surgery, or treatment for a disease or illness.

Nothing

We have no other dental benefits.

All charges

Flexible Benefits Option

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

• We may identify medically appropriate alternatives to regular contract benefits as a less costly alternative. If we identify a less costly alternative, we will ask you to sign an alternative benefits agreement that will include all of the following terms in addition to other terms as necessary. Until you sign and return the agreement, regular contract benefits will continue.

• Alternative benefits will be made available for a limited time period and are subject to our ongoing review. You must cooperate with the review process.

• By approving an alternative benefit, we do not guarantee you will get it in the future.

• The decision to offer an alternative benefit is solely ours, and except as expressly provided in the agreement, we may withdraw it at any time and resume regular contract benefits.

• If you sign the agreement, we will provide the agreed-upon alternative benefits for the stated time period (unless circumstances change). You may request an extension of the time period, but regular contract benefits will resume if we do not approve your request.

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

Services for deaf and hearing imparied

TDD Line: 850-383-3534

Toll Free TDD Line:  877-870-8943

CHPConnect

CHPConnect a secure, online electronic personal health record

• A personal history of your doctor's visits and procedures
• Diagnoses
• Current medications
• Children's immunizations and visit dates
• Referrals
• Benefits, including copayments
• Prescription drug information
• View multiple lab test results
• Online health risk appraisal

Call 850-383-3311 or go online to www.capitalhealth.com for additional information.

CHP Health Information Line

CHP Health Information Line 850-383-3400 is a 24/7 benefit staffed by health care professionals who are able to assist members with their health related questions. While not a substitute for a visit with the physician, the Health Information Line staff can provide members with tips, tools and resources to help members manage their health. 

Foreign Language Assistance

Contact Member Services at 850-383-3311 for foreign language assistance.  Member Services representatives use interpreters to communicate with our members by telephone in many different languages.

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

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.

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

If you live in a county where at least 10% of the population is literate only in a non-English language (as determined by the Secretary of Health and Human Services), we will provide language assistance in that non-English language.  You can request a copy of your Explanation of Benefits (EOB) statement, related correspondence, oral language services (such as 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.

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

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

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

b) Send your request to us at: 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 our decision via email.  Please note that by giving us your email address 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.

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, Health Insurance 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 healthcare professional with knowledge of your medical condition may act as your authorized representative without your express consent.

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

OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct.  OPM will send you a final decision 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 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 healthcare expenses without regard to fault. This is called “double coverage.”

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

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

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

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

We do not cover services that:

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

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

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

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

The right to reimbursement means that if it is alleged that any third party caused or is responsible, in whole or in part, for a Sickness or Injury for which you receive a settlement, judgment, or other recovery from any third party, you must use those proceeds to fully return to us 100% of any Benefits you receive for that sickness or injury.  The right of reimbursement shall apply to any benefits received at any time until the rights are extinguished, resolved or waived in writing.

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.

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.

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

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

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

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 (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 Capital Health Plan's FEHB Brochure at capitalhealth.com/FEHB.

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.

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

To learn more about Medicare Advantage plans, contact Medicare at 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 or employing office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage or move out of the Medicare Advantage plan’s service area.

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.

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

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

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

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

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

• Medicare was the primary payor before eligibility due to ESRD

• Medicare based on age and disability

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

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

An 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.

See Section 4, page 29.

See Section 4, page 29.

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

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.

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.

Plan allowance is the amount we use to determine our payment and your copayment for covered services. Plans determine their allowances in different ways.

You should also see Important Notice About Surprise Billing-Know your Rights in Section 4 that describes your protections against surprise billing under the No Surprise Act.

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.

Office visit copay:  $15 primary care;

$60 specialist

32

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

49

$250 per visit ambulatory surgical center visit

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

50

$500 per emergency room visit

52

$500 per emergency room visit

53

$60 per office visit

54

$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)

57

No benefit.

61

Limited benefit.

38

TDD Line: 850-383-3534

62

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.

27