2023 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Table of Contents
Page 2
Table of Contents
Page 2
• Maternity care - 26
• If your facility stay needs to be extended - 26
• If your treatment needs to be extended - 26
• If your facility stay needs to be extended - 26
• If your treatment needs to be extended - 26
If you disagree with our pre-service claim decision - 26
• To reconsider a non-urgent care claim - 27
• To reconsider an urgent care claim - 27
• To file an appeal with OPM - 27
Section 4. Your Costs for Covered Services - 28• To reconsider an urgent care claim - 27
• To file an appeal with OPM - 27
Cost-share/Cost-sharing - 28
Copayment - 28
Deductible - 28
Coinsurance - 28
If your provider routinely waives your cost - 28
Waivers - 29
Differences between our allowance and the bill - 29
Important Notice About Surprise Billing – Know Your Rights - 29
Your costs for other care - 30
Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments - 30
Carryover - 30
If we overpay you - 31
When Government facilities bill us - 31
The Federal Flexible Spending Account Program - FSAFEDS - 31
Section 5. FEP Blue Focus Benefits - 32Section 6. General Exclusions – Services, Drugs, and Supplies We Do Not Cover - 111Copayment - 28
Deductible - 28
Coinsurance - 28
If your provider routinely waives your cost - 28
Waivers - 29
Differences between our allowance and the bill - 29
Important Notice About Surprise Billing – Know Your Rights - 29
Your costs for other care - 30
Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments - 30
Carryover - 30
If we overpay you - 31
When Government facilities bill us - 31
The Federal Flexible Spending Account Program - FSAFEDS - 31
Section 7. Filing a Claim for Covered Services - 113
Section 8. The Disputed Claims Process - 116
Section 9. Coordinating Benefits With Medicare and Other Coverage - 119
When you have other health coverage - 119
• TRICARE and CHAMPVA - 119
• Workers’ Compensation - 120
• Medicaid - 120
When other Government agencies are responsible for your care - 120
When others are responsible for injuries - 120
When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) - 121
Clinical trials - 121
When you have Medicare - 122
• The Original Medicare Plan (Part A or Part B) - 122
• Tell us about your Medicare coverage - 123
• Private contract with your physician - 123
• Medicare Advantage (Part C) - 123
• Medicare prescription drug coverage (Part D) - 123
• Medicare prescription drug coverage (Part B) - 123
When you are age 65 or over and do not have Medicare - 125
Physicians Who Opt-Out of Medicare - 126
When you have the Original Medicare Plan (Part A, Part B, or both) - 126
Section 10. Definitions of Terms We Use in This Brochure - 128• TRICARE and CHAMPVA - 119
• Workers’ Compensation - 120
• Medicaid - 120
When other Government agencies are responsible for your care - 120
When others are responsible for injuries - 120
When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) - 121
Clinical trials - 121
When you have Medicare - 122
• The Original Medicare Plan (Part A or Part B) - 122
• Tell us about your Medicare coverage - 123
• Private contract with your physician - 123
• Medicare Advantage (Part C) - 123
• Medicare prescription drug coverage (Part D) - 123
• Medicare prescription drug coverage (Part B) - 123
When you are age 65 or over and do not have Medicare - 125
Physicians Who Opt-Out of Medicare - 126
When you have the Original Medicare Plan (Part A, Part B, or both) - 126
Index - 137
Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan FEP Blue Focus – 2023 - 139