•
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 your 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 copayments and coinsurance.
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.
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.
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 18 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)
teeth while eating are not considered accidental injuries. Dental care for accidental injury is limited to dental treatment necessary to repair sound natural teeth.
The period from entry (admission) as an inpatient into a hospital (or other covered facility) until discharge. In counting days of inpatient care, the date of entry and the date of discharge count as the same day.
Admission
Medicines and other substances or products given by mouth, inhaled, placed on you, or injected in you to diagnose, evaluate, and/or treat your condition. Agents include
medicines and other substances or products necessary to perform tests such as bone scans, cardiac stress tests, CT Scans, MRIs, PET Scans, lung scans, and X-rays, as well as those injected into the joint.
Agents
An authorization by the enrollee or spouse for us to issue payment of benefits directly to the provider. We reserve the right to pay you, the enrollee, directly for all covered services.
Assignment
Fertility treatments in which both eggs and sperm are manipulated. In general, assisted reproductive technology (ART) procedures involve retrieval of eggs from a woman’s ovaries, combining them with sperm in the laboratory, and returning them to the woman’s body or donating them to another woman.
Assisted reproductive technology (ART)
January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of the same year.
Calendar year
The Blue Cross and Blue Shield Association, on behalf of the local Blue Cross and Blue Shield Plans.
Carrier
A collaborative process of assessment, planning, facilitation, and advocacy for options and services to meet an individual’s health needs through communication and available resources to promote quality, cost-effective outcomes (Case Management Society of America, 2002). Each Blue Cross and Blue Shield Plan administers a case management program to assist Service Benefit Plan members with certain complex and/or chronic health issues. Each program is staffed by licensed health care professionals (Case Managers) and is accredited by URAC or NCQA. For additional information regarding case management, call us at the telephone number listed on the back of your Service Benefit Plan ID card.
Case management
• Routine care costs – costs for medically necessary 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
Clinical trials cost categories
Coinsurance is the percentage of our allowance that you must pay for your care. You may also be responsible for additional amounts. See page 24.
Coinsurance
termination takes effect. See pages 21 and 22 in Section 3.
A copayment is a fixed amount of money you pay when you receive covered services. See page 24.
Copayment
Any surgical procedure or any portion of a procedure performed primarily to improve physical appearance through change in bodily form, except for repair of accidental injury, or to restore or correct a part of the body that has been altered as a result of disease or surgery or to correct a congenital anomaly.
Cosmetic surgery
Cost-sharing is the general term used to refer to your out-of-pocket costs (e.g., deductible, coinsurance, and copayments) for the covered care you receive.
Cost-sharing
Services we provide benefits for, as described in this brochure.
Covered services
Treatment or services, regardless of who recommends them or where they are provided, that a person not medically skilled could perform safely and reasonably, or that mainly assist the patient with daily living activities, such as:
1. Personal care, including help in walking, getting in and out of bed, bathing, eating (by spoon, tube, or gastrostomy), exercising, or dressing;
2. Homemaking, such as preparing meals or special diets;
3. Moving the patient;
4. Acting as companion or sitter;
5. Supervising medication that can usually be self-administered; or
6. Treatment or services that any person can perform with minimal instruction, such as recording pulse, temperature, and respiration; or administration and monitoring of feeding systems.
Custodial care that lasts 90 days or more is sometimes known as Long Term Care. The Carrier, its medical staff, and/or an independent medical review determine which services are custodial care.
Custodial care
A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies in a calendar year before we start paying benefits for those services.
See page 24.
Deductible
An examination or test of an individual with signs, symptoms, or a probability of having a specific disease to determine the presence of that disease; or an examination or test to evaluate the course of treatment for a specific disease.
Diagnostic service
Equipment and supplies that:
1. Are prescribed by your physician (i.e., the physician who is treating your illness or injury);
2. Are medically necessary;
3. Are primarily and customarily used only for a medical purpose;
4. Are generally useful only to a person with an illness or injury;
5. Are designed for prolonged use; and
6. Serve a specific therapeutic purpose in the treatment of an illness or injury.
Durable medical equipment
Experimental or investigational shall mean:
Experimental or investigational services
b. Reliable evidence shows that the health care service (e.g., procedure, treatment, supply, device, equipment, drug, biological product) is the subject of ongoing phase I, II, or III clinical trials or under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis; or
c. Reliable evidence shows that the consensus of opinion among experts regarding the health care service (e.g., procedure, treatment, supply, device, equipment, drug, biological product) is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis; or
d. Reliable evidence shows that the health care service (e.g., procedure, treatment, supply, device, equipment, drug, biological product) does not improve net health outcome, is not as beneficial as any established alternatives, or does not produce improvement outside of the research setting.
Reliable evidence shall mean only evidence published in peer-reviewed medical literature generally recognized by the relevant medical community and physician specialty society recommendations, such as:
a. Published reports and articles in the authoritative medical and scientific literature;
b. The written protocol or protocols used by the treating facility or the protocol(s) of another facility studying substantially the same drug, device, or biological product or medical treatment or procedure; or
c. The written informed consent used by the treating facility or by another facility
studying substantially the same drug, device, or biological product or medical treatment or procedure.
A generic alternative is an FDA-approved generic drug in the same class or group of drugs as your brand-name drug. The therapeutic effect and safety profile of a generic alternative are similar to your brand-name drug, but it has a different active ingredient.
Generic alternative
A generic equivalent is a drug whose active ingredients are identical in chemical composition to those of its brand-name counterpart. Inactive ingredients may not be the same. A generic drug is considered "equivalent," if it has been approved by the FDA as interchangeable with your brand-name drug.
Generic equivalent
Health care coverage that you are eligible for based on your employment, or your membership in or connection with a particular organization or group, that provides payment for medical services or supplies, or that pays a specific amount of more than
$200 per day for hospitalization (including extension of any of these benefits through COBRA).
Group health coverage
A physician or other health care professional licensed, accredited, or certified to perform specified health services consistent with state law.
Health care professional
A questionnaire designed to assess your overall health and identify potential health risks.
Service Benefit Plan members have access to the Blue Cross and Blue Shield HRA (called the "Blue Health Assessment") which is supported by a computerized program that analyzes your health and lifestyle information and provides you with a personal and confidential health action plan that is protected by HIPAA privacy and security provisions.
Results from the Blue Health Assessment include practical suggestions for making healthy changes and important health information you may want to discuss with your health care provider. For more information, visit our Web site, www.fepblue.org.
Health Risk Assessment (HRA)
or outpatient professional office setting. Program sessions may occur more than one day per week. Timeframes and frequency will vary based upon diagnosis and severity of illness.
A Blue Cross and/or Blue Shield Plan that serves a specific geographic area.
Local Plan
The term medical food, as defined in Section 5(b) of the Orphan Drug Act (21 U.S.C.
360ee (b) (3)) is “a food which is formulated to be consumed or administered enterally under the supervision of a physician and which is intended for the specific dietary management of a disease or condition for which distinctive nutritional requirements, based on recognized scientific principles, are established by medical evaluation.” In general, to be considered a medical food, a product must, at a minimum, meet the
following criteria: the product must be a food for oral or tube feeding; the product must be labeled for the dietary management of a specific medical disorder, disease, or condition for which there are distinctive nutritional requirements; and the product must be intended to be used under medical supervision.
Medical foods
All benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine that the criteria for medical necessity are met.
Medical necessity shall mean health care services that a physician, hospital, or other covered professional or facility provider, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms, and that are:
a. In accordance with generally accepted standards of medical practice in the United States; and
b. Clinically appropriate, in terms of type, frequency, extent, site, and duration; and considered effective for the patient’s illness, injury, disease, or its symptoms; and c. Not primarily for the convenience of the patient, physician, or other health care
provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results for the diagnosis or treatment of that patient’s illness, injury, or disease, or its symptoms; and
d. Not part of or associated with scholastic education or vocational training of the patient;
and
e. In the case of inpatient care, only provided safely in the acute inpatient hospital setting.
For these purposes, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical
literature generally recognized by the relevant medical community and physician specialty society recommendations.
The fact that one of our covered physicians, hospitals, or other professional or facility providers has prescribed, recommended, or approved a service or supply does not, in itself, make it medically necessary or covered under this Plan.
Medical necessity
Conditions and diseases listed in the most recent edition of the International Classification of Diseases (ICD) as psychoses, neurotic disorders, or personality disorders; other nonpsychotic mental disorders listed in the ICD; or disorders listed in the ICD requiring treatment for abuse of, or dependence upon, substances such as alcohol, narcotics, or hallucinogens.
Mental conditions/
substance abuse
Hospital outpatient services ordered by the physician to assess whether the member needs to be admitted as an inpatient or can be discharged. If you are in the hospital more than a few hours, always ask your physician or the hospital staff if your stay is considered inpatient or outpatient. Although you may stay overnight in a hospital room and receive meals and other hospital services, some hospital services – including “observation services” – are actually outpatient care. Since observation services are billed as outpatient care, outpatient facility benefit levels apply and your out-of-pocket expenses may be higher as a result.
Observation services
An intensive facility-based treatment program during which an interdisciplinary team provides care related to mental health and/or substance abuse conditions. Program sessions may occur more than one day per week and may be full or half days, evenings, and/or weekends. The duration of care per session is less than 24 hours. Timeframes and frequency will vary based upon diagnosis and severity of illness.
Partial hospitalization
Our Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Fee-for-service plans determine their allowances in different ways. If the amount your provider bills for covered services is less than our allowance, we base our payment, and your share (coinsurance, deductible, and/or copayments), on the billed amount. We determine our allowance as follows:
• PPO providers - Our allowance (which we may refer to as the "PPA" for "Preferred Provider Allowance") is the negotiated amount that Preferred providers (hospitals and other facilities, physicians, and other covered health care professionals that contract with each local Blue Cross and Blue Shield Plan, and retail and internet pharmacies that contract with CVS Caremark) have agreed to accept as payment in full, when we pay primary benefits.
Our PPO allowance includes any known discounts that can be accurately calculated at the time your claim is processed. For PPO facilities, we sometimes refer to our allowance as the "Preferred rate." The Preferred rate may be subject to a periodic adjustment after your claim is processed that may decrease or increase the amount of our payment that is due to the facility. However, your cost sharing (if any) does not change. If our payment amount is decreased, we credit the amount of the decrease to the reserves of this Plan. If our
payment amount is increased, we pay that cost on your behalf. (See page 108 for special information about limits on the amounts Preferred dentists can charge you under Standard Option.)
• Participating providers - Our allowance (which we may refer to as the "PAR" for
"Participating Provider Allowance") is the negotiated amount that these providers (hospitals and other facilities, physicians, and other covered health care professionals that contract with some local Blue Cross and Blue Shield Plans) have agreed to accept as payment in full, when we pay primary benefits. For facilities, we sometimes refer to
"Participating Provider Allowance") is the negotiated amount that these providers (hospitals and other facilities, physicians, and other covered health care professionals that contract with some local Blue Cross and Blue Shield Plans) have agreed to accept as payment in full, when we pay primary benefits. For facilities, we sometimes refer to