2023 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Table of Contents
Table of Contents
Table of Contents
Introduction - 4
Plain Language - 4
Stop Healthcare Fraud! - 4
Discrimination is Against the Law - 5
Preventing Medical Mistakes - 6
FEHB Facts - 9
Section 3. How You Get Care - 16
Plain Language - 4
Stop Healthcare Fraud! - 4
Discrimination is Against the Law - 5
Preventing Medical Mistakes - 6
FEHB Facts - 9
Coverage information - 9
• No pre-existing condition limitation - 9
• Minimum essential coverage (MEC) - 9
• Minimum value standard - 9
• Where you can get information about enrolling in the FEHB Program - 9
• Types of coverage available for you and your family - 9
• Family member coverage - 10
• Children’s Equity Act - 10
• When benefits and premiums start - 11
• When you retire - 11
• Minimum essential coverage (MEC) - 9
• Minimum value standard - 9
• Where you can get information about enrolling in the FEHB Program - 9
• Types of coverage available for you and your family - 9
• Family member coverage - 10
• Children’s Equity Act - 10
• When benefits and premiums start - 11
• When you retire - 11
When you lose benefits - 11
• When FEHB coverage ends - 11
• Upon divorce - 12
• Temporary Continuation of Coverage (TCC) - 12
• Finding replacement coverage - 12
• Health Insurance Marketplace - 12
Section 1. How This Plan Works - 13• Upon divorce - 12
• Temporary Continuation of Coverage (TCC) - 12
• Finding replacement coverage - 12
• Health Insurance Marketplace - 12
General features of FEP Blue Focus - 13
We have a Preferred Provider Organization (PPO) - 13
How we pay professional and facility providers - 13
Your rights and responsibilities - 14
Your medical and claims records are confidential - 14
Section 2. Changes for 2023 - 15We have a Preferred Provider Organization (PPO) - 13
How we pay professional and facility providers - 13
Your rights and responsibilities - 14
Your medical and claims records are confidential - 14
Section 3. How You Get Care - 16
What you must do to get covered care - 18
You need prior Plan approval for certain services - 19
• Inpatient hospital admission, inpatient residential treatment center admission - 19
• Other services - 19
• Special prior authorization situations related to coordination of benefits (COB) - 23
• Prior notification – Maternity care - 24
• Other services - 19
• Special prior authorization situations related to coordination of benefits (COB) - 23
• Prior notification – Maternity care - 24
How to request precertification for an admission or get prior approval for Other services - 24
• Non-urgent care claims - 25
• Urgent care claims - 25
• Concurrent care claims - 26
• Emergency inpatient admission - 26
• Maternity care - 26
• If your facility stay needs to be extended - 26
• If your treatment needs to be extended - 26
• Urgent care claims - 25
• Concurrent care claims - 26
• Emergency inpatient admission - 26
• Maternity care - 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
• To reconsider an urgent care claim - 27
• To file an appeal with OPM - 27
Section 4. Your Costs for Covered Services - 28
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
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 - 32
Section 6. General Exclusions – Services, Drugs, and Supplies We Do Not Cover - 111
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
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
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
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
• 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