• 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

• 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 an enrollment 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 Plus One or Self and Family enrollment begins on the first day of the pay period in which the child is born or becomes an eligible family member. When you change to Self Plus One or Self and Family because you marry, the change is effective on the first day of the pay period that begins after your employing office receives your enrollment form. Benefits will not be available to your spouse until you are married. A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee’s FEHB enrollment.

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 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 fee-for-service plan or in an HMO that serves the area where your children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the same option of the same plan; or
• If you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the lowest cost nationwide plan option as determined by OPM.

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

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

• 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 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 Temporary Continuation of Coverage (TCC), or 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 Patient Protection and 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 1-877-835-9861.

• 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 1-877-835-9861 or write to us at UnitedHealthcare’s Federal Employees Health Benefits (FEHB) Program at P.O. Box 30432, Salt Lake City, UT 84130-0432. You may also request replacement cards and print temporary ID cards through our web site: www.myuhc.com. 

Where you get covered care

You get care from “Plan providers” and “Plan facilities.”  You will only pay copayments, deductibles, and/or coinsurance, if you use our network providers, you can also get care from non-Plan providers but it will cost you more.  If you use our Open Access program you can receive covered services from a participating provider without a required referral from your primary care physician or by another participating provider in the network

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 periodically.  The list is also on our website at www.uhc.com for members and www.uhcfeds.com for all. 

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 periodically. The list is also on our web site at www.uhcfeds.com. You should also contact that provider to verify that they participate with the Plan.

What you must do to get covered care

You do not need to select a primary care physician and you do not need written referrals to see a specialist for medical services. The provider must be participating for services to be covered in-network. Services provided out of network may need prior authorization to be covered.

Call us at 1-877-835-9861 to determine if you need  authorization for benefits as some services do require preauthorization.

The Plan will provide benefits for covered services only when the services are medically necessary to prevent, diagnose or treat your illness or condition.

Specialty care

If you have a chronic or disabling condition and lose access to your network specialist because we:

• Terminate our contract with your specialist for other than cause; or
• 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 and receive in-network benefits for up to 90 days after you receive notice of the change at in-network benefit level. Contact us, or if we drop out of the Program, contact your new plan.

If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist until the end of your postpartum care, even if it is beyond the 90 days and receive the in-network benefit level.

Primary Care

Your primary care physician will provide most of your health care or give you a referral to see a specialist.

Hospital Care

Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care.  This includes admission to a skilled nursing or other type of facility. 

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 1-877-835-9861. 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; or
• The day your benefits from your former plan run out; or
• The 92^nd day after you become a member of this Plan, whichever happens first.

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

You need prior Plan approval for certain services

Preauthorization is the process by which we evaluate the medical necessity of your hospital stay and the number of days required to treat your condition.   In most cases, your Network physician will make necessary hospital arrangements and supervise your care. If you are using a non-network provider or facility, you are responsible for contacting the Plan at 1-877-835-9861.

Inpatient hospital admission

Your plan physician or specialist will make necessary hospital arrangements and supervisor your care.  This includes admission to a skilled nursing or other type of facility. Because you are still responsible for ensuring that we are asked to precertify your care, you should always ask your physician or hospital whether they have contacted the Plan.

If you are using a non-network provider or facility, you are responsible for contacting the Plan at 1-877-835-9861.

If the admission is a non-urgent admission or if you are being admitted to a non-network hospital, you must get the admission authorized by calling the Plan at 1-877-835-9861. This must be done at least 4 business days before the admission. If the admission is an emergency or an urgent admission, you, the person’s provider, or the hospital must notify us by calling 1-877-835-9861 within one business day or the same day of admission, or as soon as reasonably possible.

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

NOTE: If you do not notify us, your benefits will be reduced by $100 per admission for covered services.

Other Services

Certain services require that you or your physician must obtain prior approval from us. We call this review and approval process prior authorization. You or your physician must obtain prior authorization for most out-of-network services as well as some network services such as, but not limited to the following: 

• Accidental dental injury
• Ambulance Non Emergency or Air ambulance
• Applied Behavioral Analysis (ABA)
• Bariatric surgery - Morbid obesity surgery
• Capsule endoscopy
• Clinical trials 
• Computed tomography (CT) scans
• Congenital anomaly repair
• Dialysis
• Discetomy/fusion
• Durable medical equipment over $1,000
• Electro-convulsive Therapy
• Growth hormone therapy (GHT)
• Inpatient admissions
• Intensive outpatient therapy
• Magnetic resonance imaging (MRI)
• Magnetic resonance angiogram (MRA)
• Non emergency ambulance services
• Nuclear medicine studies including nuclear cardiology
• Orthopedic and prosthetic devices over $1,000
• Partial Hospitalization
• PET scans
• Psychological, neurophysiological and extended developmental testing
• Reconstructive surgery
• Sleep apnea - surgery and appliance with sleep studies; sleep studies (polysomnograms) attended
• Substance Use Disorder treatment
• Transplants
• Vein ablation

Please note this list is subject to change upon notification to Plan providers. Please call customer service 1-877-835-9861 to verify if your procedure/services do require prior authorization.

How to request precertification for an admission or get prior authorization for Other services 

First, your physician, your hospital, you, or your representative, must call us at 1-877-835-9861 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 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 1-877-835-9861.  You may also call OPM’s FEHB 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 1-877-835-9861. 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 Admissions

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 phone us within two business days following the day of the emergency admission, even if you have been discharged from the hospital. 

Maternity care

You do not need to precertify a maternity admission for a routine delivery in a Network facility. We will provide benefits for an Inpatient Stay of at least:

• 48 hours for the mother and newborn child following a normal vaginal delivery;
• 96 hours for the mother and newborn child following a cesarean section delivery.

NOTE: Non-network benefits require that you notify us as soon as reasonably possible if the Inpatient Stay for the mother and/or the newborn will be more than the time frames described above. If you do not notify us, your benefits will be reduced by $100 per admission.

• 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

What happens when you do not follow the precertification rules when using non-network facilities

If you fail to obtain authorization/precertifications when using non-network facilities you can be responsible for a portion or all of the charges.

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.

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.

To file an appeal with OPM

After we reconsider your pre-service claim, if you do not agree with our decision, you may ask OPM to review it by following Step 3 of the disputed claims process detailed in Section 8 of this brochure.

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 $15 per office visit, and when you go in the hospital, you pay $500 per admission. 

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. 

• The calendar year deductible is $1,500 for Self Only or $3,000 for Self Plus One or Self and Family enrollment in-network. The deductible is $2,500 for Self Only or $5,000 for Self Plus One or Self and Family enrollment out-of-network. The full Self plus One or Self and Family deductible must be satisfied before the traditional medical plan benefits apply. 

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.

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

Network providers and facilities have contracted with the Plan to accept our Plan allowance. If you use a network provider or facility, you do not have to pay the difference between our Plan allowance and the billed amount for covered services.

Your catastrophic protection out-of-pocket maximum

After your in-network (copayments and coinsurance) total $4,000 for a Self Only or $6,850 for Self Plus One or Self and Family enrollment in any calendar year, you do not have to pay any more for covered services. Your out-of-network limitation is 6,850 for Self Only enrollment or $10,000 for Self Plus One or Self and Family enrollment in any calendar year, then you do not have to pay any more for covered services. 

However, copayments and coinsurance, for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay copayments and coinsurance for these services:

• Expenses paid by the plan for your preventive care benefits
• Charges incurred by failure to obtain pre-certification when using non-network facilities and other amounts you pay because benefits have been reduced/denied for non compliance with the plans requirements
• The balance billing charges incurred when you see a non-network provider
• Copayments or coinsurance for chiropractic services
• Eyeglasses or contact lenses
• Expenses for services and supplies that exceed the stated maximum dollar or day limit

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.

• Preventive care

This Plan covers preventive care services, such as periodic health evaluations (e.g., annual physicals), screening services (e.g., mammograms), routine prenatal and well-child care, child and adult immunizations, tobacco cessation programs, obesity weight loss programs, disease management and wellness programs. These services are covered at 100% if you use a network provider and the services are described in Section 5 Preventive care. You do not have to meet the deductible before using these services.

• Traditional medical coverage

After you have paid the Plan’s deductible, we pay benefits under traditional medical coverage described in Section 5.  Many of the benefits in this plan are subject to copayments when care is provided by an in-network plan provider. Benefits subject to coinsurance are paid at 80% by the plan. The Plan typically pays 70%  for out-of-network care.

Covered services include:

• Medical services and supplies provided by physicians and other health care professionals
• Surgical and anesthesia services provided by physicians and other health care professionals
• Hospital services; other facility or ambulance services
• Emergency services/accidents
• Mental health and substance misuse disorder benefits
• Prescription drug benefits
• Accidental dental injury benefits

• Savings

• Health Savings Accounts (HSA)

By law, HSAs are available to members who are not enrolled in Medicare, cannot be claimed as a dependent on someone else’s tax return, have not received VA (except for veterans with a service-connected disability) and/or Indian Health Services (IHS) benefits within the last three months or do not have other health insurance coverage other than another High Deductible Health Plan.  In 2021, for each month you are eligible for an HSA premium pass through, we will contribute to your HSA $62.50 per month for a Self Only enrollment or $125 per month for a Self Plus One enrollment or Self and Family enrollment.  In addition to our monthly contribution, you have the option to make additional tax-free contributions to your HSA, so long as total contributions do not exceed the limit established by law, which is $3,600 for an individual and $7,200 for a family.  See maximum contribution information on page 30.  You can use funds in your HSA to help pay your health plan deductible.  You own your HSA, so the funds can go with you if you change plans or employment.

Federal tax tip: There are tax advantages to fully funding your HSA as quickly as possible.  Your HSA contribution payments are fully deductible on your Federal tax return.  By fully funding your HSA early in the year, you have the flexibility of paying medical expenses from tax-free HSA dollars or after tax out-of-pocket dollars.  If you don’t deplete your HSA and you allow the contributions and the tax-free interest to accumulate, your HSA grows more quickly for future expenses.

HSA features include:

• Your HSA is administered by Optum Bank.
• Your contributions to the HSA are tax deductible
• You may establish pre-tax HSA deductions from your paycheck to fund your HSA up to IRS limits using the same method that you use to establish other deductions (i.e., Employee Express, MyPay, etc.)
• Your HSA earns tax-free interest
• You can make tax-free withdrawals for qualified medical expenses for you, your spouse and dependents  (see IRS publication 502 for a complete list of eligible expenses)
• Your unused HSA funds and interest accumulate from year to year
• It’s portable - the HSA is owned by you and is yours to keep, even when you leave Federal employment or retire
• When you need it, funds up to the actual HSA balance are available.

Important consideration if you want to participate in a Health Care Flexible Spending Account (HCFSA):  If you are enrolled in this HDHP with a Health Savings Account (HSA),  and start or become covered by a HCFSA health care flexible spending account (such as FSAFEDS offers – see Section 11), this HDHP cannot continue to contribute to your HSA.  Similarly, you cannot contribute to an HSA if your spouse enrolls in an HCFSA.  Instead, when you inform us of your coverage in an HCFSA, we will establish an HRA for you.

• Health Reimbursement Account (HRA)

If you are not eligible for an HSA, for example, you are enrolled in Medicare or have another health plan, we will administer and provide an HRA instead.  You must notify us that you are ineligible for an HSA.

In 2021, we will give you an HRA credit of $750 per year for a Self Only enrollment  or $1,500 per year for a Self Plus One Self and Family enrollment.  You can use funds in your HRA to help pay your health plan deductible and/or for certain expenses that don’t count toward the deductible. 

HRA features include:

• For our HDHP option, the HRA is administered by Optum Bank
• Entire HRA credit (prorated from your effective date to the end of the plan year) is available to cover claims from your effective date of enrollment.
• Tax-free credit can be used to pay for qualified medical expenses for you and any individuals covered by this HDHP.
• Unused credits carryover from year to year.
• HRA credit does not earn interest.
• HRA credit is forfeited if you leave Federal employment or switch health insurance plans.
• An HRA does not affect your ability to participate in an FSAFEDS Health Care Flexible Spending Account (HCFSA).  However, you must meet FSAFEDS eligibility requirements

• Catastrophic protection for out-of-pocket expenses

When you use network providers, your annual maximum for out-of-pocket expenses (deductibles, coinsurance and copayments) for covered services is limited to $4,000 per person or $6,850 per Self Plus One or Self and Family enrollment.  When you use out of network providers your annual maximum  is limited to $6,850 Plus One or $10,000 per Self Plus One or Self and Family enrollment. However,  certain expenses do not count toward your out-of-pocket maximum and you must continue to pay these expenses once you reach your out-of-pocket maximum (such as expenses in excess of the Plan’s allowable amount or benefit maximum).  Refer to Section 4 Your catastrophic protection out-of-pocket maximum and HDHP Section 5 Traditional medical coverage subject to the deductible for more details. 

• Health education resources and account management tools

HDHP Section 5(i) describes the health education resources and account management tools available to you to help you manage your health care and your health care dollars.

Health Savings Account (HSA)

Health Reimbursement Account (HRA):

Provided  only when you are
ineligible for an HSA

Administrator

The Plan will provide you the documents required to establish a HSA with Optum Financial Bank, this HDHP’s fiduciary (an administrator, trustee or custodian as defined by Federal tax code and approved by IRS). You will be responsible for opening the bank account -the Plan does not open the account for you.

UnitedHealthcare Insurance Company, Inc. is the HRA fiduciary for this Plan. We will begin funding your HRA once this account has been established by UnitedHealthcare.

Fees  

When you enroll in our HSA, you will automatically be enrolled in the Health eAccess HSA option.  This account does not earn interest, but may be the right choice for you if you would like lower monthly fees and are an active spender.  A letter will be mailed to you within approximately 90-days after you have opened your HSA explaining interest bearing options.  These options have higher monthly fees. 

There is no fee to set up your account while you are enrolled in our High Deductible Health Plan, however there may be fees associated with your account.  

Your account may be subject to fees for services such as:

• ATM transaction fees $2
• Transfer fees to transfer your HSA to another bank or custodian (all or portion of balance) $20
• Monthly maintenance fees $2.75

We are not charging fees for some routine charges.  Information can be obtained at www.optumbank.com.  

None

Eligibility

You must:

• Enroll in the UnitedHealthcare Insurance Company, Inc. High Deductible Health Plan (HDHP)
• Have no other health insurance coverage (does not apply to specific injury, accident, disability, dental, vision or long-term care coverage)
• Not be enrolled in Medicare
• Not be claimed as a dependent on someone else’s tax return
• Not have received VA (except for veterans with a service-connected disability) and/or Indian Health Service (IHS) benefits in the last three months
• Complete and return all banking paperwork including the initial application to open your HSA with Optum Financial Bank
• Eligibility is determined on the first day of the month following your effective day of enrollment and will be prorated for length of enrollment.

You must enroll in the UnitedHealthcare Insurance Company, Inc. High Deductible Health Plan HDHP.

Eligibility is determined on the day of enrollment and will be prorated for length of enrollment.

If you do not meet the requirements above to participate in the HSA please contact customer service at 1-877-835-9861 and we will have you moved to the HRA. 

Funding 

If you are eligible for HSA contributions, a portion of your monthly health plan premium is deposited to your HSA each month when the premium is received. Premium pass through contributions are based on the effective date of your enrollment in the UnitedHealthcare Insurance Company Inc. High Deductible Health Plan.  Note: If you are new to this Plan based on an Open Season change, your first premium pass-through will be made available  on or about the 10th of February as new enrollees and terminations from open season are still being received in January. This is due to the Government payment cycle.

Note: If your effective date in the HDHP is after the 1st of the month, the earliest your HSA will be funded is by the 10th of the following month as long as your account has been opened before the 20th of the month prior. We encourage you to open your account immediately upon enrollment into the plan.

In addition, you may establish pre-tax HSA deductions from your paycheck to fund your HSA up to IRS limits using the same method that you use to establish other deductions (i.e. Employee Express, MyPay, etc.).

Eligibility for the annual credit will be determined on the first day of the month and will be prorated for length of enrollment.  The entire amount of your HRA will be available to you upon your enrollment.

• Self Only enrollment

For 2021, a monthly premium pass through of $62.50 will be made by the HDHP directly into your HSA each month upon receipt of premium. 

For 2021, your HRA annual credit will be $750 which (prorated for mid-year enrollment).

• Self Plus One enrollment

For 2021, a monthly premium pass through of $125 will be made by the HDHP directly into your HSA each month upon receipt of premium.

For 2021, your HRA annual credit is $1,500 (prorated for mid-year enrollment).

• Self and Family enrollment

For 2021, a monthly premium pass through of $125 will be made by the HDHP directly into your HSA account each month upon receipt of premium. 

For 2021, your HRA annual credit is $1,500 (prorated for mid-year enrollment)

Contributions/credits 

The maximum that can be contributed to your HSA is an annual combination of HDHP premium pass through and enrollee contribution funds, which when combined, do not exceed the maximum contribution amount set by the IRS of $3,600 for an individual and $7,200 for a family.

If you enroll during Open Season, you are eligible to fund your account up to the maximum contribution limit set by the IRS.  To determine the amount you may contribute, subtract the amount the Plan will contribute to your account for the year from the maximum allowable contribution.

You are eligible to contribute up to the IRS limit for partial year coverage as long as you maintain your HDHP enrollment for 12 months following the last month of the year of your first year of eligibility.  To determine the amount you may contribute, take the IRS limit and subtract the amount the Plan will contribute to your account for the year.

If you do not meet the 12 month requirement, the maximum contribution amount is reduced by 1/12 for any month you were ineligible to contribute to an HSA. If you exceed the maximum contribution amount, a portion of your tax reduction is lost and a 10% penalty is imposed. There is an exception for death or disability.

You may rollover funds you have in other HSAs to this HDHP HSA (rollover funds do not affect your annual maximum contribution under this HDHP).

HSAs earn tax-free interest (does not affect your annual maximum contribution).

Catch-up contribution discussed later in this section.

The full HRA credit will be available, subject to proration, within 30-days of the effective date of enrollment (unless date is retroactive at which time the credit will be made available within 30-days of plan notification of enrollment). The HRA does not earn interest.

• Self Only enrollment

You may make an annual maximum contribution of $2,850.

You cannot contribute to the HRA.

• Self Plus One enrollment

You may make an annual maximum contribution of $5,700 (per family)

You cannot contribute to the HRA

• Self and Family enrollment

You may make an annual maximum contribution of $5,700 (per family)

You cannot contribute to the HRA.

You can access your HSA by the following methods:

UnitedHealthcare Health Savings Account MasterCard® Debit Card must be activated in order to have access to HSA funds

On-line bill payment

Checks (if you choose to purchase these)

Distributions/withdrawals (this section continues on the next page)

• Medical

You can pay the out-of-pocket expenses for yourself, your spouse or your dependents (even if they are not coverd by the HDHP) from the funds available in your HSA.

See IRS Publication 502 for a list of eligible medical expenses.

You may use the UnitedHealthcare Health Savings Account MasterCard® Debit Card or checks (optional) for all qualified expenses.

You can pay the out-of-pocket expenses for qualified medical expenses for individuals covered under the UnitedHealthcare Insurance Company Inc. HDHP.

Non-reimbursed qualified medical expenses are allowable if they occur after the effective date of your enrollment in this Plan.

See Availability of funds below for information on when funds are available in the HRA.

See IRS Publication 502 for a list of eligible medical expenses. Physician prescribed over-the-counter drugs and Medicare premiums are also reimbursable.  Most other types of medical insurance premiums are not reimbursable.

• Non-medical

If you are under age 65, withdrawal of funds for non-medical expenses will create a 20% income tax penalty in addition to any other income taxes you may owe on the withdrawn funds.

When you turn age 65, distributions can be used for any reason without being subject to the 20% penalty, however they will be subject to ordinary income tax.

Not applicable – distributions will not be made for anything other than non-reimbursed qualified medical expenses.

Availability of funds

Funds are not available for withdrawal until all the following steps are completed:

• Your enrollment in the UnitedHealthcare Insurance Company Inc. High Deductible Health Plan is effective (effective date is determined by your agency in accord with the event permitting the enrollment change).
• You must complete and send the HSA application to Optum Financial Bank or complete the application on line.  An application will be mailed to you however you may find the application on our web site, www.uhcfeds.com. You need to include your group number to ensure that your account is tied to the appropriate plan.
• The UnitedHealthcare Insurance Company Inc. High Deductible Health Plan's fuduciary (Optum Financial Bank) receives completed HSA application for your HSA Account either via fax or online.
• In the event your enrollment is backdated (retro enrollment) your bank account, once active, will be funded back to the date your enrollment became effective within the current plan year. 
• The fiduciary (Optum Financial Bank) receives the completed paperwork back from you and your HSA is completely established. Any information required by Optum Financial Bank from you will be sent directly to you. Communications to you with any questions occur via email to expedite the process.
• The contribution to your HSA is prorated for partial months of enrollment.
• Accounts opened by the 15th of the month will be funded the following month. Accounts opened after the 15th of the month will be funded the second month following.
• Plan contributions are typically deposited around the middle of the month
• Note: Annual premium pass through contributions will be forfeited if you do not open your HSA by December 31 of the current plan year.

The entire amount of your HRA will be available to you by month close of the month your enrollment in the UnitedHealthcare Insurance Company, Inc. High Deductible Health Plan is received,  and verification received by the plan that you are not eligible for a Health Savings Account.  (The amount of your HRA will be prorated based on the effective date of coverage.)

FEHB enrollee

UnitedHealthcare Insurance Company Inc. High Deductible Health Plan

Portable

You can take this account with you when you change plans, separate or retire.

If you do not enroll in another HDHP, you can no longer contribute to your HSA.  See "HSA eligibility".

If you retire and remain in this HDHP, you may continue to use and accumulate credits in your HRA.

If you terminate employment or change health plans, only eligible expenses incurred while covered under the HDHP will be eligible for reimbursement subject to timely filing requirements.  Unused funds are forfeited.

Yes, accumulates without a maximum cap.

• Contributions

All contributions are aggregated and cannot exceed the maximum contribution amount set by the IRS.  You may contribute your own money to your account through payroll deductions, or you may make lump sum contributions at any time, in any amount not to exceed an annual maximum limit.  If you contribute, you can claim the total amount you contributed for the year as a tax deduction when you file your income taxes. Your own HSA contributions are either tax-deductible or pre-tax (if made by payroll deduction). You receive tax advantages in any case. To determine the amount you may contribute, subtract the amount the Plan will contribute to your account for the year from the maximum contribution amount set by the IRS. You have until April 15 of the following year to make HSA contributions for the current year.

If you newly enroll in an HDHP during Open Season and your effective data is after January 1st or you otherwise have partial year coverage, you are eligible to fund your account up to the maximum contribution limit set by the IRS as long as you maintain your HDHP enrollment for 12 months following the last month of the year of your first year of eligibility.  If you do not meet this requirement, a portion of your tax reduction is lost and a 10% penalty is imposed.  There is an exception for death or disability.

• Catch-up contributions

If you are age 55 or older, the IRS permits you to make additional “catch-up” contributions to your HSA. The allowable catch-up contribution is $1,000. Contributions must stop once an individual is enrolled in Medicare. Additional details are available on the U.S. Department of Treasury website at www.treasury.gov/resource-center/faqs/Taxes/Pages/Health-Savings-Accounts.aspx.

• If you die

If you have not named a beneficiary and you are married, your HSA becomes your spouse’s; otherwise, your HSA becomes part of your taxable estate.

• Qualified expenses

You can pay for “qualified medical expenses,” as defined by IRS Code 213(d).  These expenses include, but are not limited to, medical plan deductibles, diagnostic services covered by your plan, long-term care premiums, health insurance premiums if you are receiving Federal unemployment compensation, physician prescribed over-the-counter drugs, LASIK surgery, and some nursing services.

When you enroll in Medicare, you can use the account to pay Medicare premiums or to purchase health insurance other than a Medigap policy.  You may not, however, continue to make contributions to your HSA once you are enrolled in Medicare.

For a detailed list of IRS-allowable expenses, request a copy of IRS Publication 502 by calling 1-800-829-3676, or visit the IRS website at www.irs.gov and click on “Forms and Publications.”  Note: Although physician prescribed over-the-counter drugs are not listed in the publication, they are reimbursable from your HSA.  Also, insurance premiums are reimbursable under limited circumstances.

• Non-qualified expenses

• Tracking your HSA balance

• Minimum reimbursements from your HSA

• Why an HRA is established

If you do not qualify for an HSA when you enroll in this HDHP, or later become ineligible for an HSA, please advise us and we will establish an HRA for you.  If you are enrolled in Medicare, you are ineligible for an HSA and we will establish an HRA for you. You must tell us if you become ineligible to contribute to an HSA.

• How an HRA differs

Please review the chart on page 29 which details the differences between an HRA and an HSA.  The major differences are:

• you cannot make contributions to an HRA
• funds are forfeited if you leave the HDHP
• an HRA does not earn interest
• HRAs can only pay for qualified medical expenses, such as deductibles, copayments, and coinsurance expenses, for individuals covered by the HDHP.  FEHB law does not permit qualified medical expenses to include services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term, or when the pregnancy is the result of an act of rape or incest.

Care Options and Costs

Understand Your Care Options and Costs. Before You Get Care. (visit myuhc.com)

You can access step-by-step explanations for over 500 of the most common procedures, learn about doctors and hospitals from their quality and cost-efficiency ratings, and estimate the costs for office visits, treatments, lab tests and medications. And because the information is based on your individual benefits, there’s less of a chance for surprises.

• Learn about procedures and treatments
• Know what questions to ask the doctor
• Review hospital quality and safety data
• See if there are lower-cost drug options
• Find out how to use pharmacy options like mail order to reduce your out-of-pocket costs
• Locate providers and pharmacies near home or work
• Access maps and get driving directions

Track your care costs and payments

IT'S A FACT:

Many consumers receive care without knowing the costs beforehand. Now you can compare your estimated treatment costs before seeing the doctor and, after the treatment, view detailed graphic explanations of how each claim was processed, what was billed, what your health plan paid, what you owe and why.

• See which of your claims have been processed
• Note claims you want to watch or follow up on
• Add personalized notes
• Pay health care providers online or with the UnitedHealthcare Health4Me® mobile app when the claim is final

One Touch Reveal 3.0 Mobile App

The OneTouch Reveal® app changes the way you see your blood sugar ∞ Sync data, seamlessly, from your OneTouch Verio Flex® meter directly to your smartphone ∞ Draws a timeline of important blood sugar events and activities ∞ ColorSure™ technology transforms data into quick visual snapshots that connect your blood sugar with food, insulin and activity ∞ Helps you see and share progress with your family, friends, or your trusted care network.  Go to http://jnj.qumucloud.com/view/Iv7tTsukZXr#/ to view a video describing the benefits of this One Touch. 

www.uhc.com/health-and-wellness

Health and Wellness articles on topics including:

• Preventive Care
• Free Online Seminars
• Nutrition
• Family Health
• Quizzes and Calculators
• Slideshows
• Booklets to download

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, call us at 1-877-835-9861.

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 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); and
• Receipts, if you paid for your services.

Submit your claims to: UnitedHealthcare, PO Box 30555, Salt Lake City, UT 84130-0555

Submit your international claims to: UnitedHealthcare Insurance Company, PO Box 30555, Salt Lake City, UT 84130-0555.

Prescription drugs

Submit your claims to: OptumRx, PO Box 29044, Hot Springs, AR 71903

Post Service Claims

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.

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:

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

b) Send your request to us atUnitedHealthcare’s Federal Employee Health Benefits (FEHB) Program Appeals, P.O. Box 30573, Salt Lake City, UT 84130-0573 ; and:

c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and

d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms.

e) Include your email address (optional for member), if you would like to receive our decision via email.  Please note that by giving us your email, 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:

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, 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.

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.myuhc.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. 

• 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 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.

• When others are responsible for injuries

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 provision 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 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 or by phone at 1-877-888-3337, (TTY 1-877-889-5680), you will be asked to provide information on your FEHB plan so that your plans can coordinate benefits.  Providing your FEHB information may reduce your out-of-pocket cost.

• 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 contact 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)

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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 1-877-835-9861 or see our website at www.myuhc.com.

We do not waive any costs if the Original Medicare Plan is your primary payor

Please review the following table it illustrates your cost share if you are enrolled in Medicare Part B.  Medicare will be primary for all Medicare eligible services.  Members must use providers who accept Medicare’s assignment.

Medicare

Benefit Description: Deductible
HDHP Option - You pay without Medicare (In network) after deductible: $1,500 Self Only, $3,000 Self Plus One and Self and Family
HDHP Option - You pay with Medicare Part B (In network) after deductible: $1,500 Self Only, $3000 Self Plus One and Self and Family

Benefit Description: Out-of-Pocket Maximum
HDHP Option - You pay without Medicare (In network) after deductible: $4,000 Self Only, $6,850 Self Plus One and Self Plus Family
HDHP Option - You pay with Medicare Part B (In network) after deductible: $4,000 Self Only, $6,850 Self Plus One and Self and family

Benefit Description: Part B Premium Reimbursement offered
HDHP Option - You pay without Medicare (In network) after deductible: N/A
HDHP Option - You pay with Medicare Part B (In network) after deductible: N/A

Benefit Description: Primary Care Physician
HDHP Option - You pay without Medicare (In network) after deductible: $15 copayment per visit
HDHP Option - You pay with Medicare Part B (In network) after deductible: $15 copayment per visit

Benefit Description: Specialist
HDHP Option - You pay without Medicare (In network) after deductible: $30 copayment per visit
HDHP Option - You pay with Medicare Part B (In network) after deductible: $30 copayment per visit

Benefit Description: Inpatient Hospital
HDHP Option - You pay without Medicare (In network) after deductible: $500 copayment per admission
HDHP Option - You pay with Medicare Part B (In network) after deductible: $500 copayment per admission

Benefit Description: Outpatient Hospital
HDHP Option - You pay without Medicare (In network) after deductible: $250 copayment for surgery
HDHP Option - You pay with Medicare Part B (In network) after deductible: $250 copayment for surgery

Benefit Description: Incentives Offered
HDHP Option - You pay without Medicare (In network) after deductible: N/A
HDHP Option - You pay with Medicare Part B (In network) after deductible: N/A

• Tell us about your Medicare coverage

• 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 1-800-MEDICARE (1-800-633-4227), (TTY 1-877-486-2048) or at www.medicare.gov.

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

This Plan and our Medicare Advantage plan: You may enroll in our 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).  

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. 

• 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, page (Applies to printed brochure only)

Copayment

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

Cost-sharing

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

Deductible

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

Experimental or investigational service

Experimental or Investigational Service(s) - medical, surgical, diagnostic, psychiatric, mental health, substance use disorders or other health care services, technologies, supplies, treatments, procedures, drug therapies, medications or devices that , at the time we make a determination regarding coverage in a particular case are determined to be any of the following:

• Not approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed for the proposed use and not identified in the American Hospital Formulary Service or the United States American Hospital Pharmacopoeia Dispensing Information as appropriate for the proposed use
• Not recognized, in accordance with generally accepted medical standards, as being safe and effective for your condition;
• Subject to review and approval by any institution review board for the proposed use. (Devices which are FDA approved under the Humanitarian Use Device exemption are not considered to be
  Experimental or Investigational.
• The subject of an ongoing clinical trial that meets the definition of a  Phase 1, 2 or 3 clinical trial set forth in the  FDA regulations, regardless of whether the trial is actually subject to FDA oversight.

Medical necessity

Health care services provided for the purpose of preventing, evaluating, diagnosing or treating a sickness, injury, mental illness, substance use disorder or its symptoms, that are all of the following as determined by us or our designee, within our discretion.

• In accordance with Generally Accepted Standards of Medical Practice.
• Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for your sickness, injury, mental illness, substance misuse disorder, disease or its symptoms.
• Not mainly for your convenience or that of your doctor or other health care provider
• Not more costly than an alternate drug, service(s) or supply that is at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of your sickness, injury, disease or symptoms.

If no credible scientific evidence is available then standards are based on Physician specialty society recommendations or professional standards of care may be considered.  We reserve the right to consult expert opinion in determining whether health care services are Medically Necessary.

The amount of money we contribute to your HSA or HRA.

Unproven Services

Unproven services, including medications, that are determined not to be effective for treatment of the medical condition and/or not to have a beneficial effect on health outcomes due to insufficient and inadequate clinical evidence from well-conducted randomized controlled trials or cohort studies in the prevailing published peer-reviewed medical literature.

• Well-conducted randomized controlled trials. (Two or more treatments are compared to each other, and the patient is not allowed to choose which treatment is received.)
• Well-conducted cohort studies from more than one institution.  (Patients who receive study treatment are compared to a group of patients who receive standard therapy.  The comparison group must be nearly identical to the study treatment group.

We have a process by which we compile and review clinical evidence with respect to certain health services.  From time to time, we issue medical and drug policies that describe the clinical evidence available with respect to specific health care services.  These medical and drug policies are subject to change without prior notice.  You can view these policies at www.myuhc.com .

Please note:  If you have a life-threatening sickness or condition (one that is likely to cause death within one year of the request for treatment) we may, in our discretion, consider an otherwise unproven service to be a covered health service for that sickness or condition.  Prior to such a consideration, we must first establish that there is sufficient evidence to conclude that, albeit unproven, the service has significant potential as an effective treatment for that sickness or condition.

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 877-835-9861.  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 *: In-network medical preventive care

Nothing

37

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

In-network:

$15 copayment for PCP

$30 copayment for specialist

Out-of-network:

30% of our Plan allowance and any difference between our allowance and the billed amount

40

Services provided by a hospital *: Inpatient *

In-network: $500 copayment per admission

Out-of-network: 30% of our Plan allowance and any difference between our allowance and the billed amount

63

Services provided by a hospital *: Outpatient Services *

In-network: $50 copayment per visit non-surgical

Outpatient Surgery: $250 copayment per visit

Out-of-network: 30% of our Plan allowance and any difference between our allowance and the billed amount

64

Emergency benefits *: In-area or Out-of-area *

In-Network: $200 copayment per visit

Out-of-network: 30% of our Plan allowance and any difference between our allowance and the billed amount

66

Mental health and substance use disorder treatment *:

Regular cost-sharing

68

Prescription drugs *: Retail pharmacy (30-day supply) *
Note: In Network Pharmacy Benefits Only *

Tier 1:$10 copayment

Tier 2: $40 copayment

Tier 3: $85 copayment

Tier 4: $175 copayment

74

Prescription drugs *: Mail order (up to a 90-day supply) *

Tier 1: $25 copayment

Tier 2: $100 copayment

Tier 3: $212.50 copayment

Tier 4: $437.50 copayment

74

Dental care *

Emergency dental benefits* are located in section 5(g).

Our Non-FEHB benefits page provides detail on our non-FEHB dental benefit - this benefit is not subject to deductible.

74

Vision care *

One eye exam every other calendar year

47

Wellness and Other Special features

Health4Me, Quit for Life, Maternity Support, Spine and Joint, UnitedHealth Premium, Real Appeal, Specialty Pharmacy, Flexible Benefit Option, Cancer Clinical Trials

79

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

Note: Some costs do not count against the out of pocket maximum

In-network: Nothing after $4,000 Self Only or $6,850 Self Plus One and Self and Family per year.

Out-of-network: Nothing after $6,850 Self Only or $10,000 Self Plus One and Self and Family per year.

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