This Plan is a health maintenance organization (HMO). OPM requires that FEHB plans be accredited to validate that plan operations and/or care management meet nationally recognized standards. UPMC Health Plan holds the following accreditations: a rating of Excellent from the National Committee for Quality Assurance (NCQA). To learn more about this plan's accreditation, please visit the following website: www.ncqa.org. We require you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your healthcare services. We are solely responsible for the selection of these providers in your area. Contact us for a copy of our most recent provider directory or visit our website at www.upmchealthplan.com/FEHB. We give you a choice of enrollment in a Standard Option or a High Deductible Health Plan (HDHP).
All plans emphasize preventive care such as physical exams, well-baby care, and immunizations, in addition to treatment for illness and injury. Our providers follow generally accepted medical practices when prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You pay only the copayments, coinsurance, and deductibles described in this brochure. When you receive emergency services from non-Plan providers, you may have to submit claim forms.
You should join a HMO because you prefer the Plan’s benefits, not because a particular provider is available. You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician, hospital, or other provider will be available and/or remain under contract with us.
All of our Plan options include a Health Incentive opportunity
Take a Healthy Step
Take a Healthy Step rewards you for making healthy choices. By completing healthy activities, you earn points. There are many activities to choose from, each with a point value. The first step is to complete the MyHealth Questionnaire. Then, every time you complete an eligible activity, you will earn points. The points are tied to levels. Each time you complete a level, UPMC will deposit reward dollars onto a debit card. You can use the reward dollars you earn on your debit card to help pay your out-of-pocket medical expenses, including deductible, coinsurance, and pharmacy copayments.
If you have the Standard Option HMO, any unused reward dollars (up to two times your annual deductible) will roll over to the next year. You can earn up to $250 for yourself or $500 for your family during the plan year.
If you have the High Deductible Health Plan Option: The reward dollars will be deposited into your HSA account available on your HSA debit card. Up to $75 for Self or $150 for Self plus One or Self plus Family per plan year. Please include the reward dollars you earn in the HSA in your yearly contribution maximums of $4,150 for Self and $8,300 for Self plus One or Self plus Family.
If you have an HRA because you are not eligible for an HSA it will be applied automatically to your debit card to be used toward deductible, coinsurance or copayment incurred.
Take a Healthy Step is a voluntary wellness program available to all employees. The program is administered according to federal rules permitting employer-sponsored wellness programs that seek to improve employee health or prevent disease, including the Americans with Disabilities Act of 1990, the Genetic Information Nondiscrimination Act of 2008, and the Health Insurance Portability and Accountability Act, as applicable, among others. If you choose to participate in the wellness program you will be asked to complete a voluntary well-being assessment or "health questionnaire" that asks a series of questions about your health-related activities and behaviors and whether you have or had certain medical conditions (e.g., cancer, diabetes, or heart disease). You are not required to complete the health questionnaire.
Although you are not required to complete the health questionnaire only employees who do so will receive the selected reward dollars.
Additional incentives as noted above may be available for employees who participate in certain health-related customized activities. If you are unable to participate in any of the health-related activities, you may be entitled to a reasonable accommodation or an alternative standard. You may request a reasonable accommodation or an alternative standard by contacting UPMC Health Plan at 877-648-9641.
The information from your health questionnaire will be used to provide you with information to help you understand your current health and potential risks, and may also be used to offer you services through the wellness program, such as recommended healthy activities. You also are encouraged to share your results or concerns with your own doctor.
General features of our Standard Option
Under the Standard Option HMO, you select a Primary Care Provider from among the thousands of doctors who participate in the UPMC Health Plan's HMO Premium network. You and each of your enrolled family members may select a different PCP. The goal of the PCP is to keep you and your family healthy, not merely to treat you when you are sick.
Preventive care services
Preventive care services are generally covered with no cost-sharing when received from a participating provider.
Calendar year deductible
The calendar year deductible must be met before Plan benefits are paid for care other than preventive care services. Office visits and prescription medications only require a copayment and are not subject to the calendar year deductible.
Catastrophic protection
We protect you against catastrophic out-of-pocket expenses for covered services. Under the Standard Option, after your share of coinsurance, copayments and deductibles total $6,000 for Self Only, or $12,000 for Self Plus One or Self and Family in any calendar year, benefits for covered services increases to 100% for the remainder of the calendar year and copayments are waived for the remainder of the calendar year. Funds paid from the HIA apply to the annual out-of-pocket maximum.
We have Open Access benefits
Our HMO offers Open Access benefits. This means that you can receive covered services from a participating provider without a referral from your primary care provider or by another participating provider in the network.
You pay a copayment each time you visit the doctor. Under the Standard Option, most other medical and surgical services are payable at 80% after you meet the plan deductible. These benefits include inpatient and outpatient hospital services, diagnostic services, medical therapy (such as radiation and dialysis), and other services prescribed by a participating physician such as home healthcare or durable medical equipment and supplies.
For non-emergency services, you must use a participating provider. The Standard Option covers emergency services at any medical facility, whether or not that medical facility participates in the UPMC Health Plan's HMO Premium Network.
Using your Reward Dollars with the Standard Option
Reward dollars earned on your debit card can be used toward your deductible, pharmacy copayments and coinsurance which you and or your family incur. Any unused reward dollars at the end of the plan year carry over from year to year, up to two times the annual deductible.
How we pay providers
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan providers accept a negotiated payment from us, and you will only be responsible for your cost-sharing (copayments, coinsurance, deductibles, and non-covered services and supplies).
General features of our High Deductible Health Plan (HDHP) Option
HDHPs have higher annual deductibles and annual out-of-pocket maximum limits than other types of FEHB plans. FEHB Program HDHPs also offer Health Savings Accounts (HSA) or Health Reimbursement Arrangements (HRA). Please see below for more information about these savings features.
Preventive care services
Preventive care services are generally covered with no cost-sharing when received from a participating provider.
Calendar year deductible
The calendar year deductible must be met before Plan benefits are paid for care other than preventive care services.
This plan option is a Preferred Provider Organization (PPO)
Our HDHP is a PPO. In-network benefits apply only when you use a participating provider, when a non-participating provider is utilized, out-of-network benefits apply.
You pay a coinsurance each time you visit the doctor. Under the HDHP, most medical and surgical services are payable at 85% after you meet the Plan deductible. If you receive care from an out-of-network provider, coinsurance is 60%. These benefits include inpatient and outpatient hospital services, diagnostic services, medical therapy (such as radiation and dialysis), and other services prescribed by a participating physician such as home healthcare or durable medical equipment and supplies.
Using your Reward Dollars with the HDHP Option
Reward dollars earned are deposited into your HSA account debit card for you to use to reimburse any qualified 213B expense. If you have an HRA because you are not eligible for an HSA you will receive a debit card with your reward dollars to use toward deductible, coinsurance or copayment incurred by anyone enrolled in your plan.
HDHP Section 5 (i) describes the health education resources and account management tools available to you to help you manage your healthcare and healthcare dollars.
Health Savings Account (HSA)
You are eligible for an HSA if you are enrolled in an HDHP, not covered by any other health plan that is not a HDHP (including a spouse’s health plan, excluding specific injury insurance and accident, disability, dental care, vision care, or long-term coverage), not enrolled in Medicare, not (except for veterans with a service-connected disability) or Indian Health Service (IHS) benefits within the last three months, not covered by your own or your spouse's flexible spending accounts (FSA), and are not claimed as a dependent on someone else’s tax return.
- You may use the money in your HSA to pay all or a portion of the annual deductible, prescription copayments, coinsurance, or other out-of-pocket costs that meet the IRS definition of a qualified medical expense.
- Distributions from your HSA are tax-free for qualified medical expenses for you, your spouse, and your dependents, even if they are not covered by an HDHP.
- You may withdraw money from your HSA for items other than qualified medical expenses, but it will be subject to income tax and, if you are under 65 years old, an additional 20% penalty tax on the amount withdrawn.
- For each month that you are enrolled in an HDHP and eligible for an HSA, the HDHP will pass through (contribute) a portion of the health plan premium to your HSA. In addition, you (the account holder) may contribute your own money to your HSA up to an allowable amount determined by IRS rules. Your HSA dollars earn tax-free interest.
- You may allow the contributions in your HSA to grow over time, like a savings account. Your contributions are tax deductible up to the specified annual limit minus the amount contributed through your premium pass through. The HSA is portable – you may take the HSA with you if you leave the Federal government or switch to another plan.
Health Reimbursement Arrangement (HRA)
If you are not eligible for an HSA, or become ineligible to continue an HSA, you are eligible for a Health Reimbursement Arrangement (HRA). Although an HRA is similar to an HSA, there are major differences.
- An HRA does not earn interest.
- An HRA is not portable if you leave the Federal government or switch to another plan.
- With the HRA you will receive a debit card and will be able to use to reimburse deductible, copayments and coinsurance which are incurred by anyone enrolled in your plan.
- You must let UPMC Health Plan know if you are not eligible for an HSA (see page 19 of this brochure).
Catastrophic protection
We protect you against catastrophic out-of-pocket expenses for covered services. UPMC has separate catastrophic out-of-pocket expense limits for its regular HMO and High Deductible Health Plan (HDHP).
High Deductible Health Plan (HDHP)
The IRS HDHP annual catastrophic out-of-pocket expenses for covered services, including deductibles, coinsurance and copayments, cannot exceed $8,050 for Self Only enrollment and $16,100 for Self Plus One or Self and Family enrollment. UPMC's catastrophic out-of-pocket limits for your High Deductible Health Plan (HDHP) in-network are $6,000 for Self Only enrollment and $12,000 for Self Plus One and Self and Family enrollment and out-of-network are $8,000 for Self Only enrollment and $16,000 for Self Plus One and Self and Family enrollment.
Health education resources and account management tools
We publish periodic newsletters to keep you informed on a variety of issues related to your health. The newsletter is mailed to your home.
Visit our website at www.upmchealthplan.com/FEHB and log in to UPMC Health Plan member site to access tools to help you learn more about your health, including information about specific diseases and conditions. You can also learn about your health plan benefits, and it can even help you track your personal health information. You can view personalized information about your physicians, view an electronic explanation of benefits (EOB), review prescriptions, receive important reminders for preventive screenings, and review options to help you manage your health:
- Online tools for maximizing your health and wellness and reaching your personal health goals. You can check your symptoms online, update your medical history, and refill your prescriptions. You can also complete your MyHealth Questionnaire, which is the Take a Healthy Step well-being assessment. Your answers will automatically customize UPMC Health Plan member site for you. You will receive a summary of your current health status, and practical, personalized recommendations to improve your health and earn 50 points for completing the MyHealth Questionnaire.
- Benefits information that helps you manage your healthcare finances and maintain control over your healthcare dollars. You will find links to plan benefits, prescription savings, spending summaries, and claims review. You can also sign up to receive electronic explanation of benefits (EOBs).
- Expanded online services. You’ll be able to order a new member ID card and select or change your PCP. You’ll also be able to read frequently asked questions to popular health questions.
When you download the free UPMC Health Plan Mobile App to your smartphone you can:
- Access your UPMC Health Plan Member ID card.
- Contact your providers from a personalized list.
- Check the status of your claims.
If you have an HSA,
- You can receive a monthly statement mailed to your home outlining your account balance and activity for a minimal monthly fee.
- Your HSA balance will be available through UPMC Health Plan member site. Visit www.upmchealthplan.com/FEHB and login to UPMC Health Plan member site using the member identification number on your member ID card.
If you have an HRA,
- Your HRA balance will be available through UPMC Health Plan member site. Visit www.upmchealthplan.com/FEHB and login to UPMC Health Plan member site using the member identification number on your member ID card.
Your rights and responsibilities
OPM requires that all FEHB plans provide certain information to their FEHB members. You may get information about us, our networks, and our providers. OPM’s FEHB website www.opm.gov/healthcare-insurance/ lists the specific types of information that we must make available to you. Some of the required information is listed below.
- Years in existence – 27 years
- Profit status – For-profit subsidiary under a non-profit parent company
You are also entitled to a wide range of consumer protections and have specific responsibilities as a member of this Plan. You can view the complete list of these rights and responsibilities by visiting our website, UPMC Health Plan at
www.upmchealthplan.com/FEHB. You can also contact us to request that we mail a copy to you.
If you want more information about us, call 877-648-9641, or write to UPMC Health Plan Member Services, U.S. Steel Tower, 600 Grant Street, Pittsburgh, PA 15219. You may also visit our website at www.upmchealthplan.com/FEHB.
By law, you have the right to access your protected health information (PHI). For more information regarding access to PHI, visit our website at www.upmchealthplan.com/FEHB to obtain our Notice of Privacy Practices. You can also contact us to request that we mail you a copy of that Notice.
Your medical and claims records are confidential
We will keep your medical and claims records confidential. Please note that we may disclose your medical and claims information (including your prescription drug utilization) to any of your treating physicians or dispensing pharmacies.
Service Area
To enroll in this Plan, you must live in or work in our service area. This is where our providers practice. Our service area is: Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Cameron, Centre, Clarion, Clearfield, Crawford, Elk, Erie, Fayette, Forest, Greene, Huntingdon, Indiana, Jefferson, Lawrence, McKean, Mercer, Potter, Somerset, Venango, Warren, Washington and Westmoreland counties.
Under the Standard Option, typically you must get your care from providers who contract with us. If you receive care outside our service area, we will pay only for emergency care benefits. We will not pay for any other healthcare services out of our service area unless the services have prior UPMC Health Plan approval. Under the HDHP option, there are out-of-network benefits available if you receive care from providers who do not contract with us.
Covered dependents (up to age 26) residing or attending school outside of the service area have access to UPMC Health Plan’s extended network. This network includes Medical Mutual of Ohio’s SuperMed PPO network and Cigna's PPO network. Covered dependents receive the highest level of benefits when utilizing participating providers in one of these networks. Please go to www.upmchealthplan.com/find/ to find the providers in the area. If you or a family member move, you do not have to wait until Open Season to change plans. Contact your employing or retirement office.