TakeCare is a health maintenance organization (HMO) and gives you a choice of enrollment in a High Option, a Standard Option, or a High Deductible Health Plan (HDHP) Option. OPM requires that PSHB plans be accredited to validate that plan operations and/or care management meet nationally recognized standards. TakeCare holds the following accreditation: Accreditation Association for Ambulatory Health Care (AAAHC). The pharmacy benefit manager that supports TakeCare holds accreditations from URAC and NCQA. To learn more about this plan’s accreditation(s), please visit the following websites: www.aaahc.org or www.urac.org or www.ncqa.org
To get the highest level of coverage from this Plan, we recommend you see physicians, hospitals, and other providers that are contracted with us. These in-network providers coordinate your healthcare services. We are solely responsible for the selection of these providers in your area. Please view or download our most current Provider Directory at www.takecareasia.com for the most updated list of in-network Providers.
We emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to treatment for illness and injury. Our in-network providers follow generally accepted medical practice when prescribing any course of treatment.
When you receive services from in-network plan providers you will not have to submit claim forms or pay bills. You pay only the copayment and coinsurance. HDHP Option members pay the coinsurance and deductibles as described in this brochure. Once you’ve accumulated the total deductible, you will have to submit a deductible claim form together with all the required documents.
You should join the High Option, Standard Option, or HDHP Option because you prefer the option’s benefits, not because a particular provider is available. You cannot change Plans because a provider leaves our network. We cannot guarantee that any one physician, hospital, or other provider will be available and/or remain under contract with us.
How we pay providers
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These in-network providers accept a negotiated payment from us, and you will only be responsible for your cost-sharing (copayments, coinsurance, deductibles, and non-covered services and supplies). TakeCare is a Mixed Model Plan. This means the doctors provide care in contracted medical centers or their own offices.
General features of our High and Standard Options
Deductibles
For the High and Standard Options, there are no deductibles to meet.
Preventive care services
Preventive care services are generally covered with no cost-sharing and are not subject to copayments, deductibles or annual limits when received from an in-network provider.
General features of our High Deductible Health Plan (HDHP) Option
Deductibles
HDHPs have higher annual deductibles and annual out-of-pocket maximum limits than other types of PSHB plans. PSHB Program HDHPs also offer health savings accounts (HSAs) or health reimbursement arrangements (HRAs). Please see below for more information about these savings features.
Medical Deductible - this HDHP Option offers a combined in-network and out-of-network medical deductible of $1,500 for Self Only or $3,000 for Self Plus One or $4,000 for Self and Family enrollment each calendar year. The deductible must be met before plan benefits are paid for care other than preventive care services. See pages 97-98 for details.
Prescription Drugs Deductible - this HDHP Option offers a combined in-network and out-of-network prescription drug deductible of $500 for Self Only or $1,000 for Self Plus One or $1,000 for Self and Family enrollment each calendar year. The deductible must be met before plan benefits are paid for care other than preventive care medications. See pages 97-98 for details.
Preventive Care Services & Medications
Preventive care services are generally covered with no cost-sharing and are not subject to copayments, deductibles or annual limits when received from an in-network provider.
Health Savings Account (HSA)
You are eligible for an HSA if you are enrolled in an HDHP, not covered by any other health plan that is not an HDHP (including a spouse’s health plan, excluding specific injury insurance and accident, disability, dental care, vision care, or long-term coverage), not enrolled in Medicare, not received VA (except for veterans with a service-connected disability) or Indian Health Service (IHS) benefits within the last three months, not covered by your own or your spouse’s flexible spending account (FSA), and are not claimed as a dependent on someone else’s tax return.
- You may use the money in your HSA to pay all or a portion of the annual deductible, copayments, coinsurance, or other out-of-pocket costs that meet the IRS definition of a qualified medical expense.
- Distributions from your HSA are tax-free for qualified medical expenses for you, your spouse, and your dependents, even if they are not covered by a HDHP.
- You may withdraw money from your HSA for items other than qualified medical expenses, but it will be subject to income tax and, if you are under 65 years old, an additional 20% penalty tax on the amount withdrawn.
- For each month that you are enrolled in an HDHP and eligible for an HSA, the HDHP will pass through (contribute) a portion of the health plan premium to your HSA. In addition, you (the account holder) may contribute your own money to your HSA up to an allowable amount determined by IRS rules. Your HSA dollars earn tax-free interest.
- You may allow the contributions in your HSA to grow over time, like a savings account. The HSA is portable – you may take the HSA with you if you leave the Federal government or switch to another plan.
Health Reimbursement Arrangement (HRA)
If you are not eligible for an HSA, or become ineligible to continue an HSA, you are eligible for a Health Reimbursement Arrangement (HRA). Although an HRA is similar to an HSA, there are major differences.
- An HRA does not earn interest.
- An HRA is not portable if you leave the Federal government or switch to another plan.
Health education resources and accounts management tools
There are a variety of health resources and account management tools available to our members. Account management tools are also available from your chosen fiduciary to provide account balance and transaction history.
Catastrophic protection
We protect you against catastrophic out-of-pocket expenses for covered services. You have two separate out-of-pocket annual maximums.
Medical Out-of-Pocket Annual Maximum
High Option: Your annual out-of-pocket expenses for covered medical services, including in-network and out-of-network copayments and coinsurance, cannot exceed $2,000 for Self Only or $4,000 for Self Plus One or $6,000 for Self and Family enrollment.
Standard Option: Your annual out-of-pocket expenses for covered medical services, including in-network and out-of-network copayments and coinsurance, cannot exceed $3,000 for Self Only or $6,000 for Self Plus One or $6,000 for Self and Family enrollment.
HDHP Option: Your annual out-of-pocket expenses for covered in-network medical services, including copayments and coinsurance, cannot exceed $3,000 for Self Only or $6,000 for Self Plus One or $6,000 for Self and Family enrollment.
Prescription Drugs Out-of-Pocket Annual Maximum
High Option: Your annual out-of-pocket in-network expenses for covered prescription drugs, including copayments and coinsurance, cannot exceed $2,000 for Self Only or $4,000 for Self Plus One or $6,000 for Self and Family enrollment.
Standard Option: Your annual out-of-pocket in-network expenses for covered prescription drugs, including copayments and coinsurance, cannot exceed $3,000 for Self Only or $6,000 for Self Plus One or $6,000 for Self and Family enrollment.
HDHP Option: Your annual out-of-pocket in-network expenses for covered prescription drugs, including copayments and coinsurance, cannot exceed $3,000 for Self Only or $6,000 for Self Plus One or $6,000 for Self and Family enrollment in any calendar year.
Under the PDP EGWP Prescription Drug Benefit program, the following applies:
High Option: Your annual out-of-pocket in-network expenses for covered prescription drugs, including copayments and coinsurance, cannot exceed $2,000 for Self Only or $4,000 for Self Plus One or $6,000 for Self and Family enrollment.
Standard Option: Your annual out-of-pocket in-network expenses for covered prescription drugs, including copayments and coinsurance, cannot exceed $2,000 for Self Only or $4,000 for Self Plus One or $6,000 for Self and Family enrollment.
HDHP Option: Your annual out-of-pocket in-network expenses for covered prescription drugs, including copayments and coinsurance, cannot exceed $2,000 for Self Only or $4,000 for Self Plus One or $6,000 for Self and Family enrollment in any calendar year.
Some expenses do not count toward the out-of-pocket maximum. See pages 27-28 for more information.
For all three of the plan options, an individual under Self Plus One or Self and Family enrollment will never have to satisfy more than what is required for the out-of-pocket maximum limit under a Self Only enrollment.
The IRS limits annual out-of-pocket expenses for covered medical services to no more than $7,000 for Self Only enrollment, and $14,000 for a Self Plus One or Self and Family. The out-of-pocket limit for this Plan may differ from the IRS limit, but cannot exceed that amount.
Your rights and responsibilities
OPM requires that all PSHB plans provide certain information to their PSHB members. You may get information about us, our networks, and our providers. OPM’s PSHB website www.opm.gov/healthcare-insurance/ lists the specific types of information that we must make available to you. Some of the required information is listed below:
- TakeCare Insurance Company, Inc., a Tan Holdings Company, has met all the licensing requirements needed on Guam, in the Commonwealth of the Northern Mariana Islands and the Republic of Belau (Palau) to conduct business as an insurance company.
- TakeCare is accredited by the Accreditation Association of Ambulatory Health Care (AAAHC), a distinction TakeCare has held since June 2016 as the first health plan on Guam accredited by AAAHC.
- TakeCare has been operating on Guam for 51 years.
- TakeCare wholly owns/operates the FHP Health and Vision Centers on Guam.
- TakeCare is a for-profit organization.
You are also entitled to a wide range of consumer protections and have specific responsibilities as a member of this Plan. You can view the complete list of these rights and responsibilities by visiting our website at www.takecareasia.com. You can also contact us to request that we mail a copy to you.
If you want more information about us, call 671-647-3526, or e-mail at customerservice@takecareasia.com, or write to TakeCare at P.O. Box 6578, Tamuning, Guam 96931. You may also contact us by fax at 671-647-3542 or visit our website at www.takecareasia.com
By law, you have the right to access your protected health information (PHI). For more information regarding access to PHI, visit our website and click on TakeCare Privacy Notice (www.takecareasia.com/sites/default/files/takecare_member_npp_05292019.pdf) at the bottom of each page to obtain our Notice of Privacy Practices. You can also contact us to request that we mail you a copy of that Notice.
Your medical and claims records are confidential
We will keep your medical and claims records confidential. Please note that we may disclose your medical and claims information (including your prescription drug utilization) to any of your treating physicians or dispensing pharmacies.
Service Area
To enroll in this Plan, you must live in or work in our Service Area. This is where our providers practice.
Our service area is: The island of Guam, the Commonwealth of the Northern Mariana Islands, and the Republic of Belau (Palau).
Benefits Outside Our Service Area
If you reside in our service area, all non-emergency services you receive outside our service area must be prior authorized and approved for coverage to apply, even though your Plan option has an out of network benefit.
Please refer to Section 5(d) regarding your emergency care benefits inside and outside our service area.
If You Move Outside Our Service Area
If you or a covered family member moves outside of our service area, you can enroll in another plan; you do not have to wait until Open Season to change plans. Contact your employing or retirement office.
If you choose to remain enrolled in this plan when you and/or your family members move outside our service area, you and/or your family will only be covered for emergency services. See Section 5(d). The only exception to this is your dependent children living out of the service area while you remain in the service area (see below).
Dependent Child(ren) Living Out of The Service Area
If your dependent child(ren) lives out of the service area while you remain in the service area (for example, if your child resides in California and you reside in Guam), coverage is available for that child(ren).
However, to be covered, the following information must be provided to TakeCare prior to non-emergency services being received:
- The child’s name, address outside the service area, phone number
- Name and address of the child’s primary care physician*
TakeCare can be reached at 671-647-3526 or toll-free, 877-484-2411, or via email at customerservice@takecareasia.com.
In the absence of such information, non-emergency services will not be covered.
Your dependent child(ren) must receive prior approval before being treated by a specialist, receiving certain diagnostic tests, or is considering an elective outpatient or inpatient procedure.
*- for dependent child(ren) residing in Hawaii or the continental US, a primary care physician can be selected in advance by using the search tool available at www.multiplan.com. For all other locations, contact TakeCare.
In-Network Providers
We encourage you to access your benefits through our in-network providers to minimize higher out of pocket expenses for you and your dependents. In-network providers are physicians and medical professionals employed by TakeCare or any person, organization, health facility, institution or physician who has entered into a contract with TakeCare to provide services to our members. Please view or download the most current TakeCare Provider Directory at www.takecareasia.com for the most updated list of in-network providers.
Preferred In-Network Providers
These are in-network, directly contracted providers that have entered into a written agreement with TakeCare to provide care or treatment at preferential or better rates compared to other contracted or in-network providers and have demonstrated better outcomes based on a standard measurement set (HEDIS) by the National Committee for Quality Assurance (“NCQA”) . The participating providers which are identified herein as preferred in-network providers are subject to change. Please check with TakeCare to confirm the preferential status of contracted/in-network providers.
Out-of-Network Providers
For out-of-network care, covered members pay 30% of our allowance plus any difference between our allowance and billed charges. Some services may not be covered under your Plan. Members enrolled in the HDHP option must meet their deductible first before any benefits will be paid.
Because we do not have contracts with out-of-network providers, some of these providers may require upfront payment from you at the time of service. If this occurs, you will need to seek reimbursement from TakeCare for its portion of the eligible charges.
Please note that Medicare beneficiaries only have coverage for services received at Medicare-contracted facilities on Guam, CNMI, Hawaii, and the continental United States. However, TakeCare will act as the primary payor for PSHB members with Medicare for preauthorized services received in-network in the Philippines. Otherwise, Medicare-eligible care and services will not be covered if non-emergency care and services are received at a facility or physician not contracted with Medicare.
