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. Calvo's SelectCare holds the following accreditation: Accreditation Association of Ambulatory Health Care. To learn more about this plan's accreditation, please visit the following websites: www.aaahc.org. We require you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your health care 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. We give you the choice of enrollment in a High Option or a Standard Option.
HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You pay only the copayments, coinsurance, and deductibles described in this brochure. When you receive services from non-Plan providers, you may have to submit claim forms.
You should join an 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.
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).
In-Network/Plan Participating Providers
In-Network/Plan Provider means a physician employed by Calvo's SelectCare or any person, organization, health facility, institution or physician who has entered into a contract with Calvo's SelectCare to provide services to our members. Please view or download the most current Calvo's SelectCare Provider Directory at www.calvos.net for the most updated list of Participating Providers.
We encourage you to access your benefits through our Plan/Participating Providers to minimize higher out of pocket expenses for you and your dependents. When you go to a Plan provider, you are assured that your copayments or coinsurance will not be more than the amount shown in this brochure.
Medical, dental, and vision services outside our service area must be prior authorized and approved even if your Plan option has an out-of-network benefit. This is to ensure that these services are covered under your Plan, help you coordinate your care, and minimize your out of pocket expenses. (see Section 3, You need prior Plan approval for certain services). Members may coordinate services for their approved referrals with Out-of-Network/Non-Plan/Non-Participating Providers of their choice through their out-of-network benefit. However, because we do not have contracts with out-of-Network/Non-network providers, some may require payment from you at the time of service. If this occurs, you will need to seek reimbursement from Calvo's SelectCare for the eligible charges (see Section 7 - Filing a claim for covered services).
Out-of-Network/Non-Plan/Non-Participating Providers
Out-of-Network/Non-Plan providers means a physician not employed by Calvo's SelectCare or any person, organization health facility, institution, or physician who has not entered into a contract with Calvo's SelectCare to provide services to our members. Because Out-of-Network/Non-Plan providers are not under contract to limit their charges, Members will be held responsible for any charges in excess of eligible charges.
You may go to a Out-of-Network/non-Plan provider; however, the Plan pays a reduced benefit for certain services from Out-of-Network/non-Plan providers. You may have to pay for the services first and file a claim (which should include all required information and documentation, and translated in English if originals are not in English) with us in order for the Plan to reimburse you (see Section 7 - Filing a claim for covered services). Because Out-of-Network/Non-Plan providers are not under contract to provide specific services, should you decide to go to a Out-of-Network/Non-Plan provider, you may be responsible for coordinating and scheduling services with Out-of-network/Non-Plan providers. Certain services always require prior approval, regardless of whether they are rendered in-network or out-of-network (see Section 3 You need prior Plan approval for certain services). If you self-refer to a provider and/or facility for services which require prior authorization, those services will not be covered.
When covered healthcare services are provided outside of the Service Area by Out-of-Network/Non-Plan healthcare providers, the amount you pay for such services will generally be based on either the Out-of-Network/Non-Plan healthcare provider local payment or the pricing arrangements required by applicable state law. In these situations, you will be liable for the difference between the amount the Out-of-Network/Non-Plan provider bills and the payment we will make for the covered services as set forth in this paragraph. Please be advised that some services may not be covered under your Plan.
In certain situations, we may use other payment bases, such as billed covered charges, the payment we would make if the healthcare services had been obtained within our Service Area and/or by an In-Network provider, or a special negotiated payment, to determine the amount we will pay for services rendered by Out-of-Network/Non-Plan healthcare providers. In these situations, you will be liable for the difference between the amount that the Out-of-Network/Non-Plan healthcare provider bills and the payment we will make for covered services as set forth in this paragraph. Please be advised that some services may not be covered under your Plan.
Preventive care services
Preventive care services are generally covered with no cost-sharing and are not subject to copayments, deductibles or annual limits when received from a network provider in our service area and the Philippines and in accordance with the guidelines set by United States Preventive Services Task Force (USPSTF), the American Academy of Pediatrics, the Health Resources and Services Administration (HRSA), and the Center for Disease Control's (CDC) Advisory Committee on Immunization Practices.
Catastrophic Protection
We protect you against catastrophic out-of-pocket expenses for covered services provided by in-network providers. The IRS limits annual out-of-pocket expenses for covered services, including deductibles and copayments to no more than $7,000 for Self Only enrollment, and $14,000 for a Self Plus One or Self and Family enrollment. The out-of-pocket limit for this Plan may differ from the IRS limit, but cannot exceed that amount.
The Plan does not have out-of-pocket maximums for any out-of-network covered services.
High Option: After your out-of-pocket expenses for services provided by in-network providers, including any applicable deductibles, copayments and coinsurance total $2,000 for Self Only, or $4,000 for a Self Plus One or $6,000 for Self and Family enrollment in any calendar year, you do not have to pay any more for in-network covered services. The maximum annual limitation on cost sharing for in-network services listed under Self Only of $2,000 applies to each individual, regardless of whether the individual is enrolled in Self Only, Self Plus One, or Self and Family.
Standard Option: After your out-of-pocket expenses for services provided by in-network providers, including any applicable deductibles, copayments and coinsurance total $3,000 for Self Only, or $6,000 for a Self Plus One or $8,000 for Self and Family enrollment in any calendar year, you do not have to pay any more for in-network covered services. The maximum annual limitation on cost sharing for in-network services listed under Self Only of $3,000 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 High Option $2,000 Self Only maximum out-of-pocket limit for covered services provided by in-network providers, a $4,000 Self Plus One maximum out-of-pocket limit for covered services provided by in-network providers, and a $6,000 Self and Family maximum out-of-pocket limit for covered services provided by in-network providers. If you or one of your eligible family members has out-of-pocket qualified medical expenses of $2,000 or more for the calendar year for covered services provided by in-network providers, any remaining qualified medical expenses provided by in-network providers for that individual will be covered fully by your health plan. With a Self Plus One enrollment out-of-pocket maximum of $4,000, the second family member, or an aggregate of enrollee and designated family member, will continue to accrue out-of-pocket qualified medical expenses up to a maximum of $4,000 for the calendar year before their qualified in-network medical expenses will begin to be covered in full. With a Self and Family enrollment out-of-pocket maximum of $6,000, a second family member, or an aggregate of other eligible family members, will continue to accrue out-of-pocket qualified in-network medical expenses up to a maximum of $6,000 for the calendar year before their qualified in-network medical expenses will begin to be covered in full.
High and Standard Options: There is a separate in-network out-of-pocket maximum for prescription drugs. After your out-of-pocket expenses for prescription drugs, including any applicable deductibles, copayments and coinsurance total $2,000 for Self Only, or $4,000 for a Self Plus One or Self and Family enrollment in any calendar year, you do not have to pay any more for in-network covered prescription drugs. The maximum annual limitation on cost sharing at in-network providers listed under Self Only of $2,000 applies to each individual, regardless of whether the individual is enrolled in Self Only, Self Plus One, or Self and Family.
However, copayments and coinsurance, if applicable for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay copayments, coinsurance, and any difference between billed charges and eligible charges for these services:
- Expenses for services and supplies that exceed the stated maximum dollar or day limit
- Expenses from utilizing out-of-network providers
- Expenses for non-covered benefits
Please be advised that the Plan does not have out-of-pocket maximums for any out-of-network covered services.
Be sure to keep accurate records of your coinsurance/copayments to ensure the plan's calculation of your out-of-pocket maximum is reflected accurately.
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/insure) lists the specific types of information that we must make available to you. Some of the required information is listed below.
- Calvo's SelectCare has been operating on Guam for 21 years.
- We are a for-profit organization.
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, www.calvos.net. You can also contact us to request that we mail a copy to you.
If you want more information about us, call 671-477-9808, or write to us at P.O. Box FJ, Hagatna, Guam 96932. You may also contact us by fax at 671-477-4141 or visit our website at www.calvos.net.
By law, you have the right to access your protected health information (PHI). For more information regarding access to PHI, visit our website www.calvos.net to obtain our Notice of Privacy Practices. You can also contact us to request that we mail a 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: The island of Guam, the Commonwealth of the Northern Mariana Islands and the Republic of Belau (Palau).
Ordinarily, 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 health care services out of our service area unless the services have prior plan approval.
If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live out of the area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service plan or an HMO that has agreements with affiliates in other areas. If your dependent lives out of the service area, he/she must still receive prior approval before receiving medical, dental, and/or vision services.
If you or a family member move outside of our services area, you can enroll in another plan. If your dependents live out of the area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service plan or an HMO that has agreements with affiliates in other areas. 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.
