Minimum essential coverage (MEC)

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

Where you can get information about enrolling in the FEHB Program

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

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

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

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

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

Types of coverage available for you and your family

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

If you have a Self Only enrollment, you may change to a Self Plus One or Self and Family enrollment if you marry, give birth, or add a child to your family.  You may change your enrollment 31 days before to 60 days after that event. The Self and Family or Self Plus One 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 orSelf 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.

We have no authority to require enrollees or agencies to notify plans of changes in family composition. Under a Self and Family enrollment, a new family member is automatically covered by the Plan as of the date the member joined the family. The Plan cannot require the enrollee to file a new SF 2809. A Plan may request evidence of eligibility. If a Plan has questions about a member's eligibility, they should ask the agency personnel office for assistance.  If there is a question, the agency will determine eligibility.

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 QLE's, visit the FEHB website at www.opm.gov/healthcare-insurance/life-events.  If you need assistance, please contact your employing agency, Tribal Benefits Officer, personnel/payroll office, or retirement office.

Family member coverage

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

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

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

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

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

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

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

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

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

Children’s Equity Act

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

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

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

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

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

When benefits and premiums start

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

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

When you retire

When you retire, you can usually stay in the FEHB Program.  Generally, you must have been enrolled in the FEHB Program for the last five years of your Federal service.  If you do not meet this requirement, you may be eligible for other forms of coverage, such as Temporary Continuation of Coverage (TCC).

When FEHB coverage ends

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

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

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

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

Upon divorce

If you are divorced from a Federal employee, or annuitant, you may not continue to get benefits under your former spouse’s enrollment.  This is the case even when the court has ordered your former spouse to provide health coverage for you.  However, you may be eligible for your own FEHB coverage under either the spouse equity law or Temporary Continuation of Coverage (TCC).  If you are recently divorced or are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get additional information about your coverage choices.  You can also visit OPM's website at www.opm.gov/healthcare-insurance/healthcare/plan-information/. A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee's FEHB enrollment.

Temporary Continuation of Coverage (TCC)

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

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

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

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

Converting to individual coverage

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

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

If you leave Federal or Tribal service, your employing office will notify you of your right to convert.  You must contact us in writing within 31 days after you receive this notice.  However, if you are a family member who is losing coverage, the employing or retirement office will not notify you.  You must contact us in writing within 31 days after you are no longer eligible for coverage.

Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, waiting period will not be imposed and your coverage will not be limited due to pre-existing conditions. When you contact us we will assist you in obtaining information about health benefits coverage inside or outside the Affordable Care Act's Health Insurance Marketplace in your state.  For assistance in finding coverage, please contact us at 800-235-7111 or visit our website at www.qualchoice.com.

Health Insurance Marketplace

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

Identification cards

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

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at (800) 235-7111 or write to us at QualChoice, P.O. Box 25610, Little Rock, AR 72221.  You may also request replacement cards through our website: www.qualchoice.com.

Where you get covered care

Under High Option, you can use both In-Network and Out-of-Network Providers.  In-Network Providers will submit claims to us on your behalf and obtain any necessary preauthorization.  You have direct access to In-Network Providers without a referral.  Under the High Option Point of Service Plan, you can also get care from Out-of-Network Providers. It is your responsibility to obtain pre-authorizations for  Out-of-Network  services that require pre-authorizations.  If you use In-Network Providers, you will pay less.

Under Standard Option, you have direct access to see In-Network Providers without a referral.  You must use In-Network Providers under the Standard Option to be eligible for benefits, except in circumstances such as emergency care.  In-Network Providers will submit claims on your behalf and obtain any necessary preauthorization.

Plan providers are In-Network Providers and other health care professionals in our service area that we contract with to provide covered services to our members.  We credential Plan providers according to national standards.

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

Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members.

We publish an online directory listing of physicians, facilities, and other healthcare providers who have contractually agreed to provide covered services to enrollees and have them reimbursed at In-Network Benefits. You may search the directory on our website at www.qualchoice.com. Because agreements can change, you should verify that a physician or provider is participating in our Network before you seek care.

What you must do to get covered care

Under High Option, you can go to any In-Network Provider you want to, but in some circumstances, we must approve your care in advance.  You also have Out-of-Network benefits under this Plan option.  If you receive care from Out-of-Network Providers, you will be responsible for a separate deductible and coinsurance amount and you will be responsible for any difference between our allowance and the billed amount.  Please refer to Section 4, “Your costs for covered services”, for related benefits information.

Under Standard Option, you must use In-Network Providers in order to receive benefits, except under the special situations listed below.  In addition, we must approve certain types of care in advance.  Please refer to Section 4, “Your costs for covered services”, for related benefit information.

1. Medical emergency or accidental injury care in a hospital emergency room and related ambulance transport as described in Section 5(d), Emergency services/accidents
2. Professional care provided at In-Network facilities by  Out-of -Network radiologists, anesthesiologists, certified registered nurse anesthetists (CRNAs), laboratory, pathologists, emergency room physicians, and assistant surgeons
3. Special provider access situations

Unless otherwise noted in Section 5, when services of Out-of-Network Providers are covered in a special exception, you are responsible for the applicable deductible, coinsurance or copayment.

Specialty care

You are always encouraged to seek care directly from an In-Network Primary Care Provider first. You may also seek care with any In-Network Provider under this Plan without a Referral.  The Specialty Care benefits will apply to services provided to you by a Specialty Care Provider, as described in Section 5.

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

If you have a medical condition that needs special services, you may need to see an In-Network specialist. If you require certain complex covered services for which expertise is not available In-Network, we may direct you to an Out-of-Network Provider.  In-Network Benefits will only be paid if the Out-of-Network Provider and services are approved by us.  Call (800) 235-7111 to request review.  The following do not constitute approval for Benefits:

• A referral, whether written or oral, by your In-Network Provider to an Out-of-Network Provider
• An order or prescription for services to an Out-of-Network Provider

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
• 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 provider based on the above circumstances, you can continue to see your provider until the end of your postpartum care, even if it is beyond the 90 days. 

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 (800) 235-7111.  If you are new to the FEHB Program, we will arrange for you to receive care and provide benefits for your covered services while you are in the hospital beginning on the effective date of coverage.

If you 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
• the 92^nd day after you become a member of this Plan, whichever happens first

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

You must get prior approval for certain services.  Failure to do so for out of network services, on the High Option, will result in the service not being eligible for coverage. 

Since we do not have a primary care physician requirement and we allow you to use non-Plan providers if you select the High Option plan, if you seek services from a non-Plan provider you need to obtain our approval before you receive certain services. The pre-service claim approval processes for inpatient hospital admissions (called precertification) and for other services, are detailed in this Section. A pre-service claim is any claim, in whole or in part, that requires approval from us in advance of obtaining medical care or services. In other words, a pre-service claim for benefits
(1) requires precertification or prior approval and (2) will result in a denial or reduction of benefits if you do not obtain precertification or prior approval.

Other Services   

Pre-authorization is a determination made prior to services or supplies being provided on whether the services or supplies are medically necessary. We must receive sufficient clinical information to establish medical necessity. The medical necessity for an Out-of-Network Referral will include the absence of or the exhaustion of all In-Network resources. Pre-authorizations are all time-limited.

QualChoice requires that certain covered services must be pre-authorized. The specific procedures requiring pre-authorization can change based upon new or changing medical technology.  A listing of the services requiring pre-authorization is maintained on our website at www.qualchoice.com on the Member Home Page. You may also contact our Customer Service Department to obtain a copy of the listing.

Your physician must obtain pre-authorization for services such as those listed below: 

• Equipment such as Bone stimulators, DME
• ALL Inpatient services, including Hospice
• Home Care 
• Medications, such as “off  label” usage, Injectables, specialty medications
• Certain Outpatient Services, and out-of-network outpatient services 
• Specialized scanning diagnostic exams, and advanced imaging procedures such as, MRI, CT Scans and PET Scans
• Surgical treatments
• Transplants  
• Out of Network Services [Applies to Point-of-Service (POS) benefit/available only if enrolled in the High Option]

First, your physician, your hospital, you or your representative, must call us at (800) 235-7111 before admission or services requiring prior authorization are rendered.

Next, provide the following information:

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

• Non-urgent care claims

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

If we need an extension because we have not received necessary inforamtion from you, our notice will describe the specific information required and we will allow you up to 45 days from the receipt of the notice to provide the information.

• Urgent care claims   

If you have an urgent care claims (i.e., when waiting for the regular time limit for your medical care or treatment could seriously jeopardize your life, health, or abiliity 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 youof our decision within 72 hours.  If you request that we review your claim as an urgent care claim, we will review the documentation you provide and decide whether or not it is an urgent care claim by applying the judgement of a prudnet 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 800-235-7111.  You may also call OPM’s FEHB 3 at 202-606-0755 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review.  We will cooperate with OPM so they can quickly review your claim on appeal.  In addition, if you did not indicate that your claim was a claim for urgent care, call us at 800-235-7111. If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim).

Concurrent care claims

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

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

The Federal Flexible Spending Account Program - FSAFEDS

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

• Emergency inpatient admission

If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your representative, the physician, or the hospital must telephone us within 24 hours or the next business day following the day of the emergency admission, even if you have been discharged from the hospital. 

• Maternity Care

Your OB/GYN or your contracted Medical Group will pre-arrange your hospital stay.

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

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

• If your treatment needs to be extended

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

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

• To reconsider a non-urgent care claim

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

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

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

2. Ask you or your provider for more information.

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

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

3.  Write to you and maintain our denial.

• To reconsider an urgent care claim

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

• To file an appeal with OPM

A co-payment is a fixed dollar amount you must pay each time you receive a covered service to which a co-payment applies. Co-payment amounts do not apply to the satisfaction of the deductible amounts.  Medical and Prescription Drug Co-payments do apply to satisfaction of catastrophic out-of-pocket limits for each enrollee or family. Please see your Benefits Summary for a list of those benefits to which co-payments apply.

Deductible

A deductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for them.  Copayments do not count toward any deductible. 

• Under Standard Option, there is no calendar year deductible
• Under High Option, the calendar year deductible for In-Network Providers is $500 per person.  Under a Self Only enrollment, the deductible is considered satisfied and benefits are payable for you when your covered expenses applied to the calendar year deductible for your enrollment reach $500.  Under a Self Plus One enrollment, the deductible is considered satisfied and benefits are payable for you and one other eligible family member when the combined covered expenses applied to the calendar year deductible for your enrollment reach $1000.  Under a Self and Family enrollment, the deductible is considered satisfied and benefits are payable for all family members when the combined covered expenses applied to the calendar year deductible for family members reaches $1000.  The calendar year deductible for Out-of-Network Providers is $1000 per person($3,000 Self Plus One and Self Plus Family). Deductibles for In-Network providers and Out-of-Network providers are accumulated separately.

Note: If you change plans during Open Season, you do not have to start a new deductible under your prior plan between January 1 and the effective date of your new plan.  If you change plans at another time during the year, you must begin a new deductible under your new plan.

If you change options in this Plan during the year, we will credit the amount of covered expenses already applied toward the deductible of your old option to the deductible of your new option.

Coinsurance is the percentage of our allowance that you must pay for your care.  Coinsurance does not begin until you have met your calendar year deductible.

Differences between our Plan allowance and the bill

Our "Plan allowance" is the amount we use to calculate our payment for certain types of covered services.  Often, the provider’s bill is more than the plan’s allowance.

In-Network providers. These providers have agreements with QualChoice to limit what they bill our members. Because of that, when you use an In-Network provider, your share of the provider’s bill for covered care is limited.

• Under High Option, your cost consists only of your deductible and coinsurance or copayment. Here is an example involving a copayment:  You see an In-Network physician who charges $150, but our allowance is $100.  You pay just $20 of our $100 allowance. Because of the agreement, your In-Network provider will not bill you for the $50 difference between our allowance and his/her bill.
• Under Standard Option, your cost consists only of your copayment or coinsurance amount, since there is no calendar year deductible. Here is an example involving a copayment: You see an In-Network specialist provider who charges $150 for covered services subject to a $40 copayment. Even though our allowance may be $100, you still pay just the $40 copayment. Because of the agreement, your Preferred physician will not bill you for the $110 difference.Under Standard Option, there is no Out-of-Network benefit. If you choose to receive care from an out-of-network provider, you will be responsible for all charges.  See page 17 for the exceptions to this requirement.
• Under High Option/Point-of-Service (POS) benefit, when you use an Out-of-Network provider, you will pay your deductible and coinsurance –plus any difference between our maximum plan allowance and the charges on the bill (except in certain circumstances – see pg. 12). For example, you see an Out-of-Network provider who charges $150. The Plan allowance is again $100, and you have met your deductible. You are responsible for your coinsurance, so you pay 40% of the $100 Plan allowance or $40. Plus, because there is no agreement between the Non-participating physician and us, the physician can bill you for the $50 difference between our allowance and his/her bill. Out-of-Network providers. These providers have no agreement to limit what they will bill you.

Your catastrophic protection out-of-pocket maximum

• Standard Option-After your out-of-pocket expenses, any copayments and coinsurance total $5,500 for Self Only enrollment or $11,000 for Self Plus One and Self Plus Family enrollment in any calendar year, you do not have to pay any more for covered for services. The maximum annual limitation on cost sharing listed under Self Only of $5,500 applies to each individual, regardless of whether the individual is enrolled in Self Only, Self Plus One, or Self and Family.
• High Option-After your out-of-pocket expenses, an deductibles, copayments and coinsurance total $5,000 for Self Only enrollment or $10,000 for Self Plus One and Self Plus Family enrollment in any calendar year, you do not have to pay any more for covered services.  The Out-of-Network Out-of-Pocket limit under the High Option Plan is $13,200 for Self Only enrollment and $26,400 for Self Plus One and Self Plus Family enrollment. The maximum annual limitation on cost sharing listed under Self Only of $5,000 applies to each individual, regardless of whether the individual is enrolled in Self Only, Self Plus One, or Self and Family.

Example Scenario:  Your plan has a $5,000 Self Only maximum out-of-pocket limit and a $10,000 Self Plus One or Self and Family maximum out-of-pocket limit.  If you or one of your eligible family members has out-of-pocket qualified medical expenses of $5,000 or more for the calendar year, any remaining qualified medical expenses for that individual will be covered fully by your health plan.  With a Self and Family enrollment out of pocket maximum of $10,000, 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 $5,000 for the calendar year before their qualified medical expenses will begin to be covered in full.

However, 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:

• Eyeglass and or contact lense discount plan

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

Carryover

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

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

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).

QCARE

The QCARE program is designed to give members the tools and information needed to help them better understand and manage their health. Services include:

• Education and information on diet, exercise and other topics that are important for your health
• Contact with your Care Manager at regular intervals to discuss your medication and other health needs or concerns
• The assurance that your health information will be kept confidential, and will not be shared with anyone other than those you request

Care Coach

This QualChoice representative serves as a support system to you and your family, providing information and guidance concerning your medical condition, treatment plans and available options.

Better Health Advisor

Got questions? Get answers. This tool lets you compare hospitals, learn about costs and find out more about procedures, chronic diseases and pharmaceuticals.

Teledoc

Access a Physician via electronic device such as a cell phone or a computer.

Health Promotion

• Extensive online services provided to encourage healthy behavior at www.qualchoice.com
• Take our personal health assessment and identify your health risks
• We offer both eFitness and eDietitian to answer online diet and exercise questions
• Our health coaches can assist you in developing an action plan to make positive lifestyle choices
• We offer online journals so you can track your progress

Childhood Health and Activity

• Learn about ways to keep your children healthy and active through material our health coaches can provide
• We also utilize material through www.Choosemyplate.gov that promotes healthy nutrition for children and preschoolers including interactive online games and coloring sheets encouraging healthy food selection
• Our health coaches will work with parents to plan healthy menus and build a healthy recipe selection

Special Additions Maternity Program

Special Additions Maternity Program is especially designed to provide you with guidance and information during your pregnancy.  When you enroll in the program you will receive informative education material that will keep you up to date on what to expect during your pregnancy. 

Medical and hospital benefits

In most cases, providers and facilities file claims for you.  Provider must file on the form CMS-1500, Health Insurance Claim Form.  Your facility will file on the UB-04 form.  For claims questions and assistance, contact us at 800-235-7111 or at our website at www.qualchoice.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.

Prescription Drugs

Submit your claims to:  QualChoice P.O. Box 25610, Little Rock, AR 72221,Little Rock, AR 72211

Other supplies or services

Submit your claims to:  QualChoice P.O. Box 25610, Little Rock, AR 72221, Little Rock, AR 72211

We will notify you of our decision within 30 days after we receive your post-service claim.  If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you before the expiration of the original 30-day period.  Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

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

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

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

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: QualChoice, PO Box 25610, Little Rock, AR 72221; 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; and

    e)    Include 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.

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

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

    a)     Pay the claim or  

    b)     Write to you and maintain our denial or

    c)    Ask you or your provider for more information

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

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

3    

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

You must write to OPM within:

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

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

Send OPM the following information:

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

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

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

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

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

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

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

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

When you have other health coverage

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

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

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

When we are the secondary payor, we will determine our allowance.  After the primary plan pays, we will pay what is left of our allowance, up to our regular benefit.  We will not pay more than our allowance.

The most common rules for determining the order of payment are the Non-Dependent / Dependent Rule, the Active / Inactive Rule and the Birthday Rule.

• Non-Dependent / Dependent Rule:  The plan that covers an individual as an active employee or subscriber is the primary payer over a plan that covers an individual as a dependent, for example, as a spouse.
• Active / Inactive Rule:  The plan that covers an individual as an active employee or as a dependent of an active employee is the primary payer over the plan that covers the individual as a retiree or laid off employee or as the dependent of such an employee.
• Birthday Rule:  This rule determines whether a plan is primary or secondary for a dependent child who is covered by both parents' benefit plans and those parents live together.  The plan covering the parent whose birthday (month and day only) falls first in a calendar year provides primary coverage for the child.  If both parents have the same birthday, then the plan that has been in effect the longest pays as primary.

A different set of rules applies to a dependent child whose parents are divorced or separated or are not living together, whether or not they have ever been married:

1. If a court decree states that one of the parents is responsible for the child's health care expenses / coverage ("health care coverage responsibility:) and the plan covering that parent has actual knowledge of those terms, that plan is primary.  If the responsible parent has no coverage for the child's health care expenses, but that parent's spouse does, that parent's spouse's plan is the primary plan.
2. If a court decree states that both parents are responsible for the child's health care expenses / coverage, the Birthday Rule determines the order of benefits;
3. If a court decree states that the parents have joint custody without specifying that one parent has health care coverage responsibility, the Birthday Rule determines the order of benefits; or
4. If there is no court decree allocating health care coverage responsibility for the child, the order of benefits for the child is as follows:
   • The plan covering the custodial parent:
   • The plan covering the custodial parent's spouse:
   • The plan covering the non-custodial parent; and then
   • The plan covering the non-custodial parent's spouse.

For additional information on NAIC rules regarding the coordinating of benefits, visit the NAIC website at www.NAIC.org.

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

Workers’ Compensation

We do not cover services that:

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

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

Medicaid

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

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

When other Government agencies are responsible for your care

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

Our right to pursue and receive subrogation and reimbursement recoveries is a condition of, and a limitation on, the nature of benefits or benefit payments and on the provisions of benefits under our coverage.

If you have received benefits or benefit payments as a result of an injury or illness and you or your representatives, heirs, administrators, successors, or assignees receive payment from any party that may be liable, a third party's insurance policies, your own insurance policies, or a workers' compensation program or policy, you must reimburse us out of that payment.  Our right of reimbursement extends to any payment received by settlement, judgment, or otherwise.

We are entitled to reimbursement to the extent of the benefits we have paid or provided in connection with your injury or illness.  However, we will cover the cost of treatment that exceeds the amount of the payment you received.

Reimbursement to us out of the payment shall take first priority (before any of the rights of any other parties are honored) and is not impacted by how the judgment, settlement, or other recovery is characterized, designated, or apportioned.  Our right of reimbursement is not subject to reduction based on attorney fees or costs under the "common fund" doctrine and is fully enforceable regardless of wheather you are "made whole" or fully compensated for the full amount of the damages claimed.

We may, at our option, choose to exercise our right of subrogation and pursue recovery from any liable party as successor to your rights.

If you do pursue a claim or case related to your injury or illness, you must promptly notify us and cooperate with our reimbursement or subrogation efforts.

Clinical trials

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

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

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

When You have Medicare

When you have Medicare

For more detailed information on "What is Medicare?" and "Should I Enroll in Medicare?" plaese contact Medicare at 1-800-MEDICARE (1-800-644-4227), (TTY 1-877-486-2048) or at www.medicare.gov.

The Original Medicare Plan (Part A or Part B)

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

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

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

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

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

When Original Medicare is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. To find out if you need to do something to file your claim, call us at 800-235-7111 or see our website at www.qualchoice.com.

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

When Medicare Part A is primary -

• Under High Option, we will waive our:
  • Inpatient hospital per-day copayments; an
  • Inpatient Non-member hospital coinsurance.
• Under Standard Option, we will waive our:
  • Inpatient hospital per-day copayments.

When Medicare Part B is primary -

• Under High Option, we will waive our:
  • Calendar year deductible
  • Coinsurance for services and supplies provided provided by physicians and other covered health care professionals (inpatient and outpatient, including mental conditions and substance abuse care);
  • Copayments for office visits to In-network physicians and other health care professionals;
  • Outpatient facility coinsurance for medical, surgical, preventive, and mental conditions and substance abuse care; and
  • Copayments for professional care provided in an emergency room
• Under Standard Option, we will waive our:
  • Copayments and coinsurance for care received from covered professional and facility providers.

Note: We do not waive benefit limitations, such as the the 40-visit limit for home health visits. In addition, we do not waive any copayments for prescription drugs.

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

Benefit Description: Deductible
High Option you pay without Medicare: $500 Self Only/$1,000 Self Plus One or Self and Family
Standard Option you pay without Medicare: N/A
High Option you pay with Medicare: $500 Self Only/$1,000 Self Plus One or Self and Family
Standard Option you pay with Medicare: N/A

Benefit Description: Out-of-Pocket Maximum
High Option you pay without Medicare: $5,000 Self Only/$10,000 Self Plus One or Self and Family
Standard Option you pay without Medicare: $5,000 Self Only/$11,000 Self Plus One or Self and Family
High Option you pay with Medicare: $5,000 Self Only/$10,000 Self Plus One or Self and Family
Standard Option you pay with Medicare: $5,000 Self Only/$11,000 Self Plus One or Self and Family

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

Benefit Description: Primary Care Physician
High Option you pay without Medicare: $20
Standard Option you pay without Medicare: $20
High Option you pay with Medicare: $0
Standard Option you pay with Medicare: $0

Benefit Description: Specialist
High Option you pay without Medicare: $40
Standard Option you pay without Medicare: $40
High Option you pay with Medicare: $0
Standard Option you pay with Medicare: $0

Benefit Description: Inpatient Hospital
High Option you pay without Medicare: $100
Standard Option you pay without Medicare: $200
High Option you pay with Medicare: $0
Standard Option you pay with Medicare: $0

Benefit Description: Outpatient Hospital
High Option you pay without Medicare: $100
Standard Option you pay without Medicare: $200
High Option you pay with Medicare: $0
Standard Option you pay with Medicare: $0

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

You can find more information about how our plan coordinates benefits with Medicare at www.qualchoice.com.

Tell us about your Medicare coverage

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

Medicare Advantage (Part C)

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

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

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

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

Clinical Trials Cost Categories

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

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

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

Coinsurance

See Section 4, page 21

Copayment

See Section 4, page 21

Cost-sharing

See Section 4, page 21

Deductible

See Section 4, page 21

A drug, device, or biological product is experimental or investigational if the drug, device, or biological product cannot be lawfully marketed without approval of the U.S. Food and Drug Administration (FDA); and, approval for marketing has not been given at the time it is furnished. Note: Approval means all forms of acceptance by the FDA.

A medical treatment or procedure, or a drug, device, or biological product, is experimental or investigational if:

1. Reliable evidence shows that it is the subject of ongoing phase I, II, or III clinical trials or under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis; or
2. Reliable evidence shows that the consensus of opinion among experts regarding the drug, device, or biological product or medical treatment or procedure, is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis.

Reliable evidence shall mean only:

• Published reports and articles in the authoritative medical and scientific literature;
• The written protocol or protocols used by the treating facility or the protocol(s) of another facility studying substantially the same drug, device, or biological product or medical treatment or procedure; or
• The written informed consent used by the treating facility or by another facility studying substantially the same drug, device, or biological product or medical treatment or procedure.

QualChoice has a Medical Review department that determines whether a claimed service is experimental or investigational after consulting with internal or external experts or nationally recognized guidelines in a particular field or specialty.

Maintenance Medications

“Maintenance Medications” are defined as follows:

A.   A drug that is usually administered continuously, rather than intermittently, and for longer than 90 days, typically for the remainder of one’s life. This means the patient taking the medication on a scheduled basis year round and not as needed or seasonally.

B.   A drug in which the most common use is to treat a chronic disease state when a therapeutic endpoint cannot be determined. Therapy with the drug is not considered curative.

C.   A drug that has a low probability for dosage or therapy changes due to side effects, serum drug concentration monitoring, or therapeutic responses over a course of prolonged therapy.

D.   While certain drugs may sometimes be used on a chronic basis, the drug will only meet the above definition if it is most commonly used in this way. The most common examples of maintenance medications are medicines used to treat high blood pressure, diabetes, high cholesterol, or hypothyroidism.

E.   Drugs in the following classes are considered to be Maintenance Medications. If your medication falls in one of these categories you will be able to get a 90 days supply either from your retail pharmacy (if it participates in the 90-day network) or from the mail order pharmacy. You will need a prescription from your doctor with enough refills to allow 90 days. One Co-payment will be charged for each 31 day supply.

    i. Alzheimer Disease medication

    ii. Antipsychotic medication

    iii. Antivirals for HIV

    iv. Asthma and other respiratory medication

    v. Benign Prostatic Hyperplasia (BPH) medication

    vi. Blood pressure medication (e.g., beta blockers, calcium channel blockers, diuretics, ACE-inhibitors)

    vii. Cholesterol lowering drugs

   viii. Diabetes medication

    ix. Glaucoma medication

    x. Heart medication

    xi. Organ transplant medication

    xii. Osteoporosis medication

    xiii. Parkinson's Disease medication

    xiv. Potassium supplements

    xv. Seizure medication

    xvi. Thyroid medication

We determine whether services, drugs, supplies, or equipment provided by a hospital or other covered provider are:

1. Appropriate to prevent, diagnose, or treat your condition, illness, or injury;
2. Consistent with standards of good medical practice in the United States;
3. Not primarily for the personal comfort or convenience of the patient, the family, or the provider;
4. Not part of or associated with scholastic education or vocational training of the patient; and
5. In the case of inpatient care, cannot be provided safely on an outpatient basis.

Plan allowance

Plan allowance is the amount we use to determine our payment and your coinsurance or deductible (if applicable) for covered services.  Plans determine their allowances in different ways.  We determine our allowance by our contracted rate with In-Network providers.

(High Option/POS Only) You may seek Covered Services directly from a physician or other provider who is not in the Network under the Point of Service (POS) benefit if you are enrolled in the High Option. Services provided by an Out-of-Network Provider will be covered and reimbursed under your Out-of-Network Benefits unless prior authorization for coverage as an In-Network Benefit is received from us. The amounts allowed for Covered Services accessed under your Out-of-Network Benefits will be subject to the Maximum Allowable Payment. You will be responsible for the applicable Cost-Sharing Amounts related to such Covered Services and the difference between the charges billed by the Out-of-Network Provider and the Maximum Allowable Payment.  This does not apply to emergency services In-Network or Out-of-Network.  They will always be covered under the In-Network emergency benefit.  

Reimbursement

Specialty Drugs are defined as specialized therapies developed for chronic, complex illnesses and:

• may have special handling, storage, shipping requirements
• may require nursing services or special programs to support patient compliance
• require disease-specific treatment programs
• may have limited distribution requirements
• may be injections, infusions, or oral products
• are high cost, typically > $500 per treatment episode

Urgent care claims

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

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

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

If you believe your claim qualifies as an urgent care claim, please contact our Customer Service Department at (800) 235-7111.  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.

Deductible

Self Only deductible is $500.  Self Plus One and Self and Family deductible is $1,000.

22

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

Office visit copay: $20 primary care; $35
specialist

27

Services provided by a hospital: Inpatient

$100 copayment per day up to a maximum of
$500 per admission

48

Services provided by a hospital: Outpatient

$100 copayment

50

Emergency benefits:

• Medical emergency

$150 per Emergency Room visit

54

Emergency benefits:

• Ambulance Services:

Ground: $100 copayment per trip;
Air/Sea: $150 copayment per trip; $10,000
limit per trip

54

Mental health and substance use disorder treatment:

Regular cost-sharing

56

Protection against catastrophic costs (your catastrophic protection out-of-pocket maximum)

Nothing after $5,000 for Self Only. Nothing
after $10,000 for Self Plus One and Self and
Family.
Out-of-Network: $13,200 for Self Only.
Nothing after $26,400 for Self Plus One and
Self and Family

23

Prescription drugs:

• Retail pharmacy 

$10 Tier I, $40 Tier II, $60 Tier III

59

Prescription drugs:

• Self-administered Specialty drugs

$100 per fill Tier IV

59

Prescription drugs:

• Mail order

$0 Tier I, $120 Tier II, $180 Tier III

59

Medical services provided by physicians:

• Diagnostic and treatment services provided in the office

Office visit copay: $20 primary care; $40 specialist

28

Services provided by a hospital: Inpatient

$200 copayment per day up to a maximum of
$1,000 per admission

49

Services provided by a hospital: Outpatient

$200 copayment

50

Emergency benefits:

• Medical emergency

$150 per Emergency Room visit

54

Emergency benefits:

• Ambulance Services:

Ground: $100 copayment per trip;
Air/Sea: $150 copayment per trip; $10,000
limit per trip

54

Mental health and substance use disorder treatment:

Regular cost-sharing

56

Protection against catastrophic costs (your catastrophic protection out-of-pocket maximum)

Nothing after $5,500 for Self Only. Nothing
after $11,000 for Self Plus One and Self and
Family.

23

Prescription drugs:

• Retail pharmacy

$10 Tier I, $40 Tier II, $60 Tier III

59

Prescription drugs:

• Self-administered Specialty drugs

$100 per fill Tier IV

59

Prescription drugs:

• Mail order

$15 Tier I, $120 Tier II, $180 Tier III

59