• No pre-existing condition limitation

• Minimum essential coverage (MEC)

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

• Minimum value standard

Our health coverage meets the minimum value standard of 60% established by the ACA. This means that we provide benefits to cover at least 60% of the total allowed costs of essential health benefits. The 60% standard is an actuarial value; your specific out-of-pocket costs are determined as explained in this brochure.

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

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

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

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

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

• Family member coverage

Family members covered under your Self and Family enrollment are your spouse (including a valid common law marriage) and children as described below.  A Self Plus One enrollment covers you and your spouse, or one other eligible family ember 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 and Family coverage in the FEHB Program if you are an employee subject to a court or administrative order requiring you to provide health benefits for your child(ren).

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

• If you have no FEHB coverage, your employing office will enroll you for Self Plus One or Self and Family coverage, as appropriate in the lowest-cost nationwide plan option as determined by OPM.
• If you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your employing office will change your enrollment to Self and Family 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. Contact your employing office for further information.

• When benefits and premiums start

The benefits of 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 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 31st 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 60th day after the end of the 31 day temporary extension.

You may be eligible for spouse equity coverage or Temporary Continuation of Coverage (TCC).

• 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 RI 70-5, the Guide to Federal Benefits for Temporary Continuation of Coverage and Former Spouse Enrollees, or other information about your coverage choices. You can also download the guide from OPM’s website, www.opm.gov/healthcare-insurance/healthcare/plan-information/.  A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee's FEHB enrollment.

• Temporary Continuation of Coverage (TCC)

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

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

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

Alternatively, you can buy coverage through the Health Insurance Marketplace where, depending on your income, you could be eligible for a new kind of tax credit that lowers your monthly premiums. Visit www.HealthCare.gov to compare plans and see what your premium, deductible, and out-of-pocket costs would be before you make a decision to enroll. Finally, if you qualify for coverage under another group health plan (such as your spouse’s plan), you may be able to enroll in that plan, as long as you apply within 30 days of losing 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, a waiting period will not be imposed, and your coverage will not be limited due to pre-existing conditions.  When you contact us we will assist you in obtaining information about health benefits coverage inside or outside the Affordable Care Act's Health Insurance Marketplace in your state.  For assistance in finding coverage, please contact us at 844-633-5325 or visit our website at https://fehb.swhp.org.

• 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 844-633-5325 or write to us at:

Scott and White Health Plan
1206 West Campus Drive
Temple, TX 76502

You may also request replacement cards through our website: https://fehb.swhp.org.

Plan providers

Plan providers are physicians 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 monthly on our website, https://fehb.swhp.org.

Please be aware the Standard Plan option utilizes the SWHP HMO network and the Basic Plan option utilizes the BSW Preferred HMO network.

Plan facilities

Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members.  We list these in the provider directory, which we update monthly on our website, https://fehb.swhp.org.

Please be aware the Standard Plan option utilizes the SWHP HMO network and the Basic Plan option utilizes the BSW Preferred HMO network.

Now that you have chosen SWHP, your next choice will be deciding who will provide most of your health care services. SWHP is an Open Access Health Plan. A member can go to any network provider without a referral.

Primary care

Members may choose a network primary care physician (PCP) if they would like, but PCP designation is not required by SWHP. If you choose a PCP, you may choose from the following:

• Family Medicine doctors treat all age groups from newborn to the elderly
• Internal Medicine doctors treat patients 18 age or older
• Pediatric doctors treat children up to age 18

In selecting a PCP, consider which clinic or doctor would be most convenient to meet your own medical needs. You and your dependents may select his or her own PCP.  You can change your PCP at any time you choose.

All non-emergent medical care must be provided by SWHP network providers. SWHP does not require a referral from a primary care physician before you can access a specialist. Simply call the specialist’s office and make an appointment.

Please note: Due to the nature of some specialties, some physician offices may require a referral prior to making your appointment. This is the choice of that physician’s office and not a requirement of SWHP.

Behavioral Health Services as well as certain other services may require prior authorization through SWHP Health Services. Examples of services, procedures, or tests that may require prior notification and/or authorization by SWHP are listed on page 16.

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

• If your current specialist does not participate with us, you must receive treatment from a specialist who does.  Generally, we will not pay for you to see a specialist who does not participate with our Plan.
• If you are seeing a specialist and your specialist leaves the Plan, call Health Services and they will arrange for you to see another specialist.  You may receive services from your current specialist until we can make arrangements for you to see someone else.
• If you have a chronic and disabling condition and lose access to your specialist because we:
  • terminate our contract with your specialist for other than cause;
  • drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB program plan; or
  • reduce our service area and you enroll in another FEHB plan;

You may be able to continue seeing your specialist for up to 90 days after you receive notice of the change.  Contact us, or if we drop out of the Program, contact your new plan.

Hospital care

For elective hospital admissions and certain types of procedures, you need a prior authorization from the SWHP Health Services before the day of the procedure, if you want to be sure SWHP will pay for the hospital and procedure. Each day you are in the hospital, SWHP nurses and Medical Directors review with your physician the level of care you require and work with him/her to determine the amount of time you need to stay in the hospital.

If you are hospitalized as a result of an emergency, you should contact the SWHP Health Services within 24 – 48 hours of any admission at 844-633-5325. Coverage for continued treatment is assured when approval is obtained from SWHP Health Services. SWHP will approve or deny the requested post-stabilization treatment within one hour if contacted by the provider or facility. Emergency care in a hospital emergency room requires a copayment, which will be waived if hospital admission occurs within 24 hours.

If you are hospitalized when your enrollment begins

We pay for covered services from the effective date of your enrollment.  However, if you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 844-633-5325.  If you are new to the FEHB Program, we will arrange for you to receive care and provide benefits for your covered services while you are in the hospital beginning on the effective date of your coverage.

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

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

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

You need prior Plan approval for certain services

For elective hospital admissions and certain types of procedures listed under "Other Services," you need a prior authorization from the SWHP Health Services before the day of the procedure.  If you want to be sure SWHP will pay for the hospital and procedure, you must get prior approval for certain services.  Failure to do so could result in denial of benefits.

Other services

For certain services, your physician must obtain prior approval from us.  Before giving approval, we consider if the service is covered, medically necessary, and follows generally accepted medical practice.

Notification requested:  

1. Acute (contracted ) hospital admissions (medical, surgical, behavioral health)
2. Admissions to inpatient or outpatient (contracted) hospice programs

Prior Authorization required:

All services requested to be provided by non-contracted providers must have prior authorization.

1. Admissions to LTAC, Rehabilitation, and SNF facilities
2. Admissions to behavioral health/substance abuse residential, partial hospitalization, and day programs (not office visits to contracted providers)
3. Neuropsychological and psychological testing
4. Applied behavioral analysis therapy
5. Outpatient electroconvulsive therapy (ECT)
6. Solid organ and stem cell transplants (Pre-Transplant Eval; Transplant; Post-Transplant Care)
7. Weight loss (bariatric) surgeries (if a covered benefit, not covered by many plans)
8. Procedures which may be considered cosmetic and thus not covered (e.g. facelift, brow lift, blepharoplasty, liposuction, abdominoplasty, breast reconstruction (not associated with medically indicated mastectomy), surgery for gynecomastia, rhinoplasty, genioplasty, treatment of varicose veins, etc.)
9. Orthognathic surgery
10. Treatments for sleep apnea (other than CPAP/CPAP-related supplies)
11. Home health services, including all requests for hourly or private duty nursing
12. Durable medical equipment (DME) – See Addendum A for specific items
13. Orthotics and prosthetics – See Addendum B for specific items
14. Spinal fusion and vertebroplasty
15. X-Stop Spacer for Spinal Stenosis
16. Artificial Disc Implantation/Replacement
17. Ventricular assist devices (VAD)
18. Genetic testing (Except chromosome testing)
19. Intrathecal Pain Pump Implantation/Therapy
20. Spinal Stimulators
21. Vagal Nerve Stimulators
22. Fixed Wing or Jet Medical Transports
23. IVIG Therapy
24. Lung Volume Reduction Surgery
25. Transaortic or Transapical Valve Insertion or Replacement (TAVI/TAVR)
26. Insulin Pumps and/or Continuous Glucose Monitors
27. Bone-Anchored Hearing Aids (BAHA)
28. Cochlear Implants
29. Dental Services and Anesthesia for Dental Services
30. Epidural Adhesiolysis

Addendum A - Durable Medical Equipment (purchase or rental):

• Oral appliances
• Electric, semi-electric, air fluidized, and advanced technology beds and related equipment
• Oxygen and related equipment
• Ventilators and related equipment
• High frequency chest wall oscillation air-pulse generator system; including vest, hose, and related equipment
• Bone stimulators
• Spinal Cord Stimulators
• Functional neuromuscular stimulation, transcutaneous stimulation of sequential muscle groups of ambulation with computer control, the entire system
• Functional electrical stimulation, transcutaneous stimulation of nerve and/or muscle groups, complete system
• Power wheelchairs and related equipment
• Power operated vehicles and related equipment
• Custom made and specially sized wheelchairs and related equipment
• Dialysis equipment
• Defibrillators and related equipment (includes chest/vest defibrillators)
• Non-specific, miscellaneous, and unlisted DME codes

Addendum B – Orthotics and Prosthetics

• Breast implants (unless status post medically indicated mastectomy)
• Lower and upper limb prosthetics (including myoelectric and microprocessor controlled) and related equipment/supplies
• Facial, nasal, and auricular prostheses
• Non-specific, miscellaneous, and unlisted orthotic and prosthetic codes

First, your physician, your hospital, you, or your representative, must call us at 888-316-7947 before admission or services requiring prior authorization are rendered.

Next, provide the following information:

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

Non-urgent care claims

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

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

Urgent care claims

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

If you fail to provide sufficient information, we will contact you within 24 hours after we receive the claim to provide notice of the specific information we need to complete our review of the claim.  We will allow you up to 48 hours from the receipt of this notice to provide the necessary information.  We will make our decision on the claim within 48 hours of (1) the time we received the additional information or (2) to 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 888-316-7947.  You may also call OPM’s Health Insurance 3 at 202-606-0737 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 888-316-7947. 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, deducitbles, 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 reimbursementfor 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.

Maternity care

For each person covered for maternity/childbirth benefits, we will provide inpatient care for the mother and her newborn child in a healthcare facility for a minimum of:

• 48 hours following an uncomplicated vaginal delivery, and
• 96 hours following an uncomplicated delivery by cesarean section.

This benefit does not require a covered female who is eligible for maternity/childbirth benefits to (a) give birth in a hospital or other healthcare facility; or (b) remain in a hospital or other healthcare facility for the minimum number of hours following birth of the child.

If a covered mother or her newborn child is discharged before the 48 or 96 hours has expired, we will provide coverage for post delivery care. Post delivery care includes parent education, assistance and training in breast-feeding and bottle-feeding, and the performance of any necessary and appropriate clinical tests. Care will be provided by a physician, registered nurse, or other appropriate licensed healthcare provider, and the mother will have the option of receiving the care at her home, the healthcare provider’s office, or a healthcare facility.

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.

Without preauthorization, SWHP does not pay for out-of-network elective procedures, or treatment for minor illness. SWHP will not assume financial responsibility for out-of-network treatment if you are well enough to return to a SWHP provider or facility.

SWHP out-of-network benefits are limited to accidental injuries and sudden illnesses.

When seeking treatment in an out-of-network emergency room, provide your member identification card. This will speed up the processing and payment of your bill by SWHP. This will also allow the treating physician to discuss your emergency care with your provider if necessary.

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

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

To reconsider a non-urgent care claim

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

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

1. Precertify your hospital stay or, if applicable, arrange for the health care provider to give you the care or grant your request for prior approval for a service, drug, or supply; or
2. Ask you or your provider for more information.
   
   You or your provider must send the information so that we receive it within 60 days, of our request.  We will then decide within 30 more days.
   
   If we do not receive the information within 60 days we will decide within 30 days of the date the information was due.  We will base our decision on the information we already have.  We will write to you with our decision.
3. Write to you and maintain our denial.

To reconsider an urgent care claim

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

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

Copayments

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

Example: When you see your primary care physician, you pay a copayment of $25 per office visit, and when you go into an Urgent Care center, you pay $50 per visit.

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.

A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for them. Copayments and coinsurance amounts do not count toward your deductible.  When a covered service or supply is subject to a deductible, only the Plan allowance for the service or supply that you then pay counts toward meeting your deductible.

Under Standard Option, the calendar year deductible is $300 per person.  After the deductible amount is satisfied for an individual, covered services are payable for that individual.  Under Self Plus One enrollment, both family members must meet the individual deductible. Under Self and Family enrollment, an individual may meet the individual deductible, or all family members' individual deductibles are considered to be satisfied when the family members' deductibles are combined and reach $600.

Under Basic Option, the calendar year deductible is $1,500 per person.  After the deductible amount is satisfied for an individual, covered services are payable for that individual.  Under Self Plus One enrollment, both family members must meet the individual deductible. Under Self and Family enrollment, an individual may meet the individual deductible, or all family members' individual deductibles are considered to be satisfied when the family members' deductibles are combined and reach $3,000.

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 number 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. 

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.  See definition of Plan allowance in Section 10.

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

Your catastrophic protection out-of-pocket maximum

Under Standard and Basic Options, we limit your annual out-of-pocket expenses for the covered services you receive to protect you from unexpected healthcare costs. When your eligible out-of-pocket expenses reach this catastrophic protection maximum, you no longer have to pay the associated cost-sharing amounts for the rest of the calendar year.  For Self Plus One and Self and Family enrollments, once any individual family member reaches the Self Only catastrophic protection out-of-pocket maximum during the calendar year, that member's claims will no longer be subject to associated cost-sharing amounts for the rest of the year. All other family members will be required to meet the balance of the catastrophic protection out-of-pocket maximum.

Note: Certain types of expenses do not accumulate to the maximum.

Standard Option - For Self Only enrollment, your out-of-pocket maximum for the deductible, and for eligible coinsurance and copayment amounts, is $5,500 for Self Only, $11,000 for Self Plus One, or $11,000 for Self and Family.

Basic Option - For Self Only enrollment, your out-of-pocket maximum for the deductible, and for eligible coinsurance and copayment amounts, is $6,000 for Self Only, $12,000 for Self Plus One, or $12,000 for Self and Family.

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

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

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.

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 page (Applies to printed brochure only).

24 hour nurse line

For any of your health concerns, 24 hours a day, 7 days a week, you may call and talk with a registered nurse who will discuss treatment options and answer your health questions. Our nurses can give you information about how to take care of yourself at home or can help you decide if an appointment, an urgent care visit or an emergency room visit is best for your symptoms. If you want to talk to a nurse, call 800-724-7037. The nurse advice line is available to all SWHP members.

Services for deaf and hearing impaired

SWHP utilizes a toll-free TTY number 711 to assist with communication services for Members with hearing or speech difficulties.

Appointment Advocates 

Scott and White Health Plan will help you get an appointment when you need to be seen!

If you are having difficulty getting an appointment to see one of our participating providers, please call us. Our personalized service will get you an appointment to see a clinician when you need to be seen. Please call us at  844-633-5325.

Language Line

In an effort to improve communication with non-English speaking members, SWHP uses the interpretive services of CQfluency.  Members do not have to call a special line for this service. When contacting SWHP, Members may notify the Health Services (HSD) staff and/or Customer Advocates of their primary language and the call will be completed with the help of a CQfluency interpreter at no charge to the Member. SWHP HSD staff follows established internal SWHP policies related to the provision of interpretive services for SWHP members.

Additional services

We also offer other valuable services to our members 24/7 including:

Standard Option:

• Health Coaches - 888-360-1555 - call anytime you need information on a health issue
• Dialog Center - https://fehb.swhp.org - includes shared decision making, e-mail a health coach, interactive tools
• SWHP Member Portal - https://fehb.swhp.org - check on your claims and benefits

Basic Option:

• SWHP Member Portal - https://fehb.swhp.org - check on your claims and benefits

Medical and hospital benefits

In most cases, providers and facilities file claims for you. Providers must file on the form CMS-1500, Health Insurance Claim Form. Your facility will file on the UB-04 form. For claims questions and assistance, contact us at 844-633-5325, or at our website at https://fehb.swhp.org.

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 supplies
• 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 payer – such as the Medicare Summary Notice (MSN)
• Receipts, if you paid for your services

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

Scott and White Health Plan
Attn: Claims Department
1206 West Campus Drive
Temple, TX 76502

Submit your claims to:

Scott and White Health Plan
Attn: Pharmacy Claims Department
1206 West Campus Drive
Temple, TX 76502

Submit your claims to:

Scott and White Health Plan
Attn: Claims Department
1206 West Campus Drive
Temple, TX 76502

Deadline for filing your claim

Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you received the service, unless timely filing was prevented by administrative operations of Government or legal incapacity, provided the claim was submitted as soon as reasonably possible.

Post-service claims procedures

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.

Authorized Representative

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

Notice Requirements

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 phone customer assistance), and help with filing claims and appeals (including external reviews) in the applicable non-English language. The English versions of your EOBs and related correspondence will include information in the non-English language about how to access language services in that non-English language.

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

1

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

• Write to us within 6 months from the date of our decision; and
• Send your request to us at Scott and White Health Plan, Attn: Customer Service Department, 1206 West Campus Drive, Temple, TX 76502; and
• Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and
• Include copies of documents that support your claims, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms.
• Include your email address (optional for member), if you would like to receive our decision via email. Please note that by giving us your email, we may be able to provide our decision more quickly.

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

2

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

• Pay the claim or
• Write to you and maintain our denial or
• 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, Health Insurance 3, 1900 E Street, NW, Washington, DC 20415-3630.

Send OPM the following information:

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

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

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

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

4

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

If you do not agree with OPM’s decision, your only recourse is to file a lawsuit. If you decide to sue, 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 or 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 https://fehb.swhp.org.

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.

TRICARE and CHAMPVA

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

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

Workers' Compensation

We do not cover services that:

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

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

Medicaid

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

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

When other Government agencies are responsible for your care

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

When others are responsible for injuries

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 whether you are "made whole" or fully compensated for the full amount of damages claimed.

We may, at our option, choose to exercise our right of subrogation and pursue a 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.

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

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

Clinical trials

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

If you are a participant in a 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

For more detailed information on "What is Medicare?" and "Should I Enroll in Medicare?"  please contract Medicare at 1-800-MEDICARE (1-800-633-4227), (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 844-633-5325 or see our website at https://fehb.swhp.org.

We waive all costs if the Original Medicare Plan is your primary payor-

• Medical services and supplies provided by physicians and other healthcare professionals.

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
Standard Option You Pay Without Medicare: $300
Standard Option You Pay With Medicare Part B: $0.00

Benefit Description: Out of Pocket Maximum
Standard Option You Pay Without Medicare: $5,500
Standard Option You Pay With Medicare Part B: $5,500

Benefit Description: Part B Premium Reimbursement Offered
Standard Option You Pay Without Medicare: N/A
Standard Option You Pay With Medicare Part B: N/A

Benefit Description: Primary Care Physician
Standard Option You Pay Without Medicare: $25
Standard Option You Pay With Medicare Part B: $0.00

Benefit Description: Specialist
Standard Option You Pay Without Medicare: $50
Standard Option You Pay With Medicare Part B: $0.00

Benefit Description: Inpatient Hospital
Standard Option You Pay Without Medicare: $300 per day/ $1,500 copay max per admit
Standard Option You Pay With Medicare Part B: $0.00

Benefit Description: Outpatient Hospital
Standard Option You Pay Without Medicare: $250 per visit/ procedure
Standard Option You Pay With Medicare Part B: $0.00

Benefit Description: Incentives Offered
Standard Option You Pay Without Medicare: N/A
Standard Option You Pay With Medicare Part B:N/A

Benefit Description: Deductible
Basic Option You Pay Without Medicare: $1,500
Basic Option You Pay With Medicare Part B: $0.00

Benefit Description: Out of Pocket Maximum
Basic Option You Pay Without Medicare: $6,000
Basic Option You Pay With Medicare Part B: $6,000

Benefit Description: Part B Premium Reimbursement Offered
Basic Option You Pay Without Medicare: N/A
Basic Option You Pay With Medicare Part B: N/A

Benefit Description: Primary Care Physician
Basic Option You Pay Without Medicare: $25
Basic Option You Pay With Medicare Part B: $0.00

Benefit Description: Specialist
Basic Option You Pay Without Medicare: $50
Basic Option You Pay With Medicare Part B: $0.00

Benefit Description: Inpatient Hospital
Basic Option You Pay Without Medicare: 20% Coinsurance
Basic Option You Pay With Medicare Part B: $0.00

Benefit Description: Outpatient Hospital
Basic Option You Pay Without Medicare: 20% Coinsurance
Basic Option You Pay With Medicare Part B: $0.00

Benefit Description: Incentives Offered
Basic Option You Pay Without Medicare: N/A
Basic Option You Pay With Medicare Part B: N/A

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: 877-486-2048) or at www.medicare.gov.

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

This Plan and our Medicare Advantage plan: You may enroll in our plan's Medicare Advantage plan and also remain enrolled in our FEHB plan.

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.

Medicare prescription drug coverage (Part D)

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

Calendar year

January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of the same year.

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; or is a drug trial that is exempt from the requirement of an investigational new drug application.

• Routine care costs – costs for routine services such as doctor visits, lab tests, x-rays and scans, and hospitalizations related to treating the patient’s cancer, whether the patient is in a clinical trial or is receiving standard therapy
• Extra care costs – costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the 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, (Applies to printed brochure only).

Copayment

 See Section 4, (Applies to printed brochure only).

Cost-sharing

 See Section 4, (Applies to printed brochure only).

Covered services

Care we provide benefits for, as described in this brochure.

Custodial Care

“Custodial Care” means care designed principally to assist an individual in engaging in the activities of daily living, or services which constitute personal care, such as help in walking and getting in and out of bed; assistance in bathing, dressing, feeding and using the toilet; preparation of special diets; and supervision of medication, which can usually be self-administered and which does not entail or require the continuing attention of trained medical or other paramedical personnel. Custodial Care is normally, but not necessarily, provided in a nursing home, convalescent home, or rest home or similar institution.

Deductible

 See Section 4, (Applies to printed brochure only).

Experimental or investigational services

“Experimental” or “Investigational” means, in the opinion of the Medical Director, Treatment that has not been proven successful in improving the health of patients.

Health care professional

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

Medical necessity

Those Health Care Services which, in the opinion of Member's Primary Care Physician or Referral Physician, whose opinions are subject to the review, approval or disapproval, and actions of the Medical Director or the Quality Assurance Committee in their appointed duties, are:

1. Essential to preserving the health of Member; and
2. Consistent with the symptoms or diagnosis and Treatment of the Member's condition, disease, ailment or injury; and
3. Appropriate with regard to standards of good medical practice within the surrounding community; and
4. Not solely for the convenience of the Member, Member's Physician, Hospital, or other health care provider; and
5. The most appropriate supply or level of service which can be safely provided to the Member.

Plan allowance

Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Plans determine their allowances in different ways. We determine our allowance as follows:

Our plan allowance is the amount our contracted providers have agreed to accept as payment in full.  For emergency care received at any doctor’s office, outside our Plan’s service area, our Plan’s allowance is the amount SWHP has determined to be the allowable prevailing charge for a particular professional service in the geographical area in which the service is performed.

Pre-service claims

Those claims (1) that require precertification, prior approval, or a referral and (2) where failure to obtain precertification, prior approval, or a referral results in a reduction of benefits.

Reimbursement

A carrier's pursuit of a recovery if a covered individual has suffered an illness or injury and has received, in connection with that illness or injury, a payment from any party that may be liable, any applicable insurance policy, or a workers' compensation program or insurance policy, and the terms of the carrier's health benefits plan require the covered individual, as a result of such payment, to reimburse the carrier out of the payment to the extent of the benefits initially paid or provided. The right of reimbursement is cumulative with and not exclusive of the right of subrogation.

Subrogation

A carrier's pursuit of a recovery from any party that may be liable, any applicable insurance policy, or a workers' compensation program or insurance policy, as successor to the rights of a covered individual who suffered an illness or injury and has obtained benefits from that carrier's health benefits plan.

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 determine whether or not a claim is an urgent care claim by applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine.

If you believe your claim qualifies as an urgent care claim, please contact our Customer Service Department at 844-633-5325. You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care.

Medical services provided by physicians:

Diagnostic and treatment services provided in the office

Office visit copay: $25 primary care; $50 specialist

27

Services provided by a hospital:

• Inpatient

$300 per day/$1,500 copay max per admit*

45

Services provided by a hospital:

• Outpatient

$250 per visit/procedure*

46

Emergency benefits:

• In and out-of-area

$250 per visit to an emergency room*

47

Mental health and substance use disorder treatment:

• Outpatient - $25 per visit
• Inpatient - $300 copay per day / $1,500 copay max per admit*

49

Prescription drugs:

• Retail Pharmacy Drugs (30 day supply)

• $10 (Preferred Generic) 30-day supply
• $60 (Preferred Brand) 30-day supply
• $150 (Non-Preferred Brand ) 30-day supply
• $400 (Preferred Generic and Brand Specialty drug) 30-day supply
• $600 (Non-Preferred Specialty drug) 30-day supply

51

Prescription drugs:

• Maintenance or Mail Order Prescription Drugs – (90-day supply)
  
  

• $25 (Preferred Generic) 90-day supply
• $150 (Preferred Brand) 90-day supply
• $375 (Non-Preferred brand) 90-day supply

53

Dental Care: No benefit except for services related to accidental injury.

$50 outpatient

55

Vision care: Annual eye refraction

$50 specialist copay

34

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

$5,500 Self Only, $11,000 Self Plus One , $11,000 Self and Family

24

Medical services provided by physicians:

Diagnostic and treatment services provided in the office

Office visit copay: $25 primary care; $50 specialist

27

Services provided by a hospital:

• Inpatient

20% coinsurance*

45

Services provided by a hospital:

• Outpatient 

20% coinsurance*

46

Emergency benefits:

• In and out-of-area

20% coinsurance*

47

Mental Health and substance use disorder treatment:

• Inpatient - 20% coinsurance*
• Outpatient - $25 per visit

49

Prescription drugs:

• Retail Pharmacy Drugs (30-day supply)

• $12 (Preferred Generic) 30-day supply
• $60 (Preferred Brand) 30-day supply
• $120 (Non-Preferred Brand) 30-day supply
• $400 (Preferred Generic and Brand Specialty drug) 30-day supply
• $600 (Non-Preferred Specialty drug) 30-day supply

51

Prescription drugs:

• Maintenance or Mail Order Prescription Drugs - (90 day supply)
  
  

• $30 (Preferred Generic) 90-day supply
• $150 (Preferred Brand) 90-day supply
• $300 (Non-Preferred Brand) 90-day supply 

53

Dental care:  No benefit except for services related to accidental injury

$50 outpatient

55

Vision care:     Annual eye refraction

$50 specialist copay

34

Protection against catastrophic costs

(out-of-pocket maximium):

$6,000 Self Only, $12,000 Self Plus One, $12,000 Self and Family

24