•
are age 65 or over; and•
do not have Medicare Part A, Part B, or both; and•
have this Plan as an annuitant or as a former spouse, or as a family member of an annuitant or former spouse; and•
are not employed in a position that gives FEHB coverage. (Your employing office can tell you if this applies.) Then, for your inpatient hospital care:•
The law requires us to base our payment on an amount – the "equivalent Medicare amount" – set by Medicare’s rules for what Medicare would pay, not on the actual charge.•
You are responsible for your deductible (Standard Option only), coinsurance, or copayments under this Plan.•
You are not responsible for any charges greater than the equivalent Medicare amount; we will show that amount on the explanation of benefits (EOB) form that we send you.•
The law prohibits a hospital from collecting more than the equivalent Medicare amount.And, for your physician care, the law requires us to base our payment and your applicable coinsurance or copayment on:
•
an amount set by Medicare and called the "Medicare approved amount," or•
the actual charge if it is lower than the Medicare approved amount.If you physician Then you are responsible for:
If your physician Standard Option Basic Option
Participates with Medicare or accepts Medicare
assignment for the claim and is in our Preferred network
Your deductibles, coinsurance, and copayments.
Your deductibles, coinsurance, and copayments.
Participates with Medicare or accepts Medicare assignment and is not in our Preferred network
Your deductibles, coinsurance, and copayments, and any balance up to the Medicare approved amount.
All charges
Does not participate with Medicare, and is in our Preferred network
Note: In many cases, your payment will be less because of our Preferred agreements. Contact your Local Plan for information about what your specific Preferred provider can collect from you.
Your deductibles, coinsurance, and copayments, and any balance up to 115% of the Medicare approved amount.
Your copayments and
coinsurance, and any balance up to 115% of the Medicare approved amount.
Does not participate with Medicare and is not in our Preferred network
Your deductibles, coinsurance, copayments, and any balance up to 115% of the Medicare approved amount.
All charges
Then you are responsible for:
If your physician:
Standard Option: your deductibles, coinsurance, and copayments.
Basic Option: your copayments and coinsurance.
Participates with Medicare or accepts Medicare assignment for the claim and is in our Preferred network
Standard Option: your deductibles, coinsurance, and copayments, and any balance up to 115% of the Medicare approved amount.
Basic Option: your copayments and coinsurance, and any balance up to 115% of the Medicare approved amount.
Note: In many cases, your payment will be less because of our Preferred agreements. Contact your Local Plan for information about what your specific Preferred provider can collect from you.
Does not participate with Medicare, and is in our Preferred network
Standard Option: your deductibles, coinsurance, and copayments, and any balance up to 115% of the Medicare approved amount.
Basic Option: all charges.
Does not participate with Medicare and is not in our Preferred network
It is generally to your financial advantage to use a physician who participates with Medicare. Such physicians are permitted to collect only up to the Medicare approved amount.
Our explanation of benefits (EOB) form will tell you how much the physician or hospital can collect from you. If your physician or hospital tries to collect more than allowed by law, ask the physician or hospital to reduce the charges. If you have paid more than allowed, ask for a refund. If you need further assistance, call us.
We limit our payment to an amount that supplements the benefits that Medicare would pay under Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance), regardless of whether Medicare pays.
Note: We pay our regular benefits for emergency services to a facility provider, such as a hospital, that does not participate with Medicare and is not reimbursed by Medicare.
We use the Department of Veterans Affairs (VA) Medicare-equivalent Remittance Advice (MRA) when the MRA statement is submitted to determine our payment for covered services provided to you if Medicare is primary, when Medicare does not pay the VA facility.
If you are covered by Medicare Part B and it is primary, your out-of-pocket costs for services that both Medicare Part B and we cover depend on whether your physician accepts Medicare assignment for the claim.
• If your physician accepts Medicare assignment, then you pay nothing for covered charges (see note below for Basic Option).
• If your physician does not accept Medicare assignment, then you pay the difference between the "limiting charge" or the physician’s charge (whichever is less) and our payment combined with Medicare’s payment (see note below for Basic Option).
Note: Under Basic Option, you must see Preferred providers in order to receive benefits. See page 14 for the exceptions to this requirement.
It is important to know that a physician who does not accept Medicare assignment may not bill you for more than 115% of the amount Medicare bases its payment on, called the "limiting charge." The Medicare Summary Notice (MSN) form that you receive from Medicare will have more information about the limiting charge. If your physician tries to collect more than allowed by law, ask the physician to reduce the charges. If the physician does not, report the physician to the Medicare carrier that sent you the MSN form. Call us if you need further assistance.
When you have the Original Medicare Plan (Part A, Part B, or both)
See pages 9-10 for how our benefits changed this year. Page 144 and page 145 are a benefits summary of each option. Make sure that you review the benefits that are available under the option in which you are enrolled.
Standard and Basic Option Overview ...30 Section 5(a). Medical services and supplies provided by physicians and other health care professionals ...31 Diagnostic and treatment services ...32 Lab, X-ray and other diagnostic tests ...33 Preventive care, adult ...34 Preventive care, children ...37 Maternity care ...39 Family Planning ...40 Infertility services ...41 Allergy care ...41 Treatment therapies ...42 Physical therapy, occupational therapy, speech therapy, and cognitive therapy ...43 Hearing services (testing, treatment, and supplies) ...44 Vision services (testing, treatment, and supplies) ...44 Foot care ...45 Orthopedic and prosthetic devices ...46 Durable medical equipment (DME) ...47 Medical supplies ...48 Home health services ...49 Chiropractic ...49 Manipulative treatment ...50 Alternative treatments ...50 Educational classes and programs ...51 Section 5(b). Surgical and anesthesia servicesprovided by physicians and other health care professionals ...52 Surgical procedures ...53 Reconstructive surgery ...55 Oral and maxillofacial surgery ...56 Organ/tissue transplants ...57 Anesthesia ...65 Section 5(c). Services provided by a hospital or other facility,and ambulance services ...66 Inpatient hospital ...67 Outpatient hospital or ambulatory surgical center ...69 Extended care benefits/Skilled nursing care facility benefits ...73 Hospice care ...73 Ambulance ...76 Section 5(d). Emergency services/accidents ...77 Accidental injury ...78 Medical emergency ...79 Ambulance ...80 Section 5(e). Mental health and substance abuse benefits ...81 Professional services ...81 Inpatient hospital or other covered facility ...82 Outpatient hospital or other covered facility ...83 Not covered ...83 Section 5(f). Prescription drug benefits ...84
Section 5(g). Dental benefits ...97 Accidental injury benefit ...97 Dental benefits ...101 Section 5(h). Special features ...104 Flexible benefits option ...104 Blue Health Connection ...106 Blue Health Assessment ...105 Diabetes Management Incentive Program ...105 MyBlue Customer eService ...108 National Provider Directory ...108 Care Management Programs ...108 Services for the deaf and hearing impaired ...106 Web accessibility for the visually impaired ...106 Travel benefit/services overseas ...107 Healthy Families Programs ...108 WalkingWorks® Wellness Program ...108 Section 5(i). Services, drugs, and supplies provided overseas ...108 Non-FEHB benefits available to Plan members ...110 Summary of benefits for the Blue Cross and Blue Shield Service Benefit Plan Standard Option – 2012 ...145 Summary of benefits for the Blue Cross and Blue Shield Service Benefit Plan Basic Option – 2012 ...147
This Plan offers both a Standard and Basic Option. Both benefit packages are described in Section 5. Make sure that you review the benefits that are available under the option in which you are enrolled.
The Standard and Basic Option Section 5 is divided into subsections. Please read Important things youshould keep in mind at the beginning of the subsections. Also read the General exclusions in Section 6; they apply to the benefits in the following subsections. To obtain claim forms, claims filing advice, or more information about Standard and Basic Option benefits, contact us at the customer service telephone number on the back of your Service Benefit Plan ID card or at our Web site at www.fepblue.org.
Each option offers unique features.
When you have Standard Option, you can use both Preferred and Non-preferred providers. However, your out-of-pocket expenses are lower when you use Preferred providers and Preferred providers will submit claims to us on your behalf. Standard Option has a calendar year deductible for some services and a $20 copayment for office visits to primary care providers ($30 for specialists). Standard Option also features a Preferred retail pharmacy program, a Preferred mail service drug program, and a Preferred specialty drug pharmacy program.
• Standard Option
Basic Option does not have a calendar year deductible. Most services are subject to copayments ($25 for primary care providers and $35 for specialists). Members do not need to have referrals to see specialists. You must use Preferred providers for your care to be eligible for benefits, except in certain circumstances, such as emergency care. Preferred providers will submit claims to us on your behalf.
Basic Option also offers a Preferred retail pharmacy program and a Preferred specialty drug pharmacy program.
• Basic Option