FEP Blue Focus Brochure - Home - Blue Cross And Blue .
Blue Cross and Blue Shield Service Benefit PlanFEP Blue Focuswww.fepblue.org2021A Fee-For-Service Plan (FEP Blue Focus) with a Preferred ProviderOrganizationThis Plan’s health coverage qualifies as minimum essential coverageand meets the minimum value standard for the benefits it provides. Seepage 8 for details. This Plan is accredited. See page 12.Sponsored and administered by: The Blue Cross and Blue ShieldAssociation and participating Blue Cross and Blue Shield PlansIMPORTANT Rates: Back Cover Changes for 2021: Page 14 Summary of Benefits: Page 137Who may enroll in this Plan: All Federal employees, Tribalemployees, and annuitants who are eligible to enroll in the FederalEmployees Health Benefits ProgramEnrollment codes for this Plan:131 FEP Blue Focus - Self Only133 FEP Blue Focus - Self Plus One132 FEP Blue Focus - Self and FamilyRI 71-017
Important Notice from the Blue Cross and Blue Shield Service Benefit Plan AboutOur Prescription Drug Coverage and MedicareThe Office of Personnel Management (OPM) has determined that the Blue Cross and Blue Shield Service Benefit Plan’s prescriptiondrug coverage is, on average, expected to pay out as much as the standard Medicare prescription drug coverage will pay for all planparticipants and is considered Creditable Coverage. This means you do not need to enroll in Medicare Part D and pay extra forprescription drug coverage. If you decide to enroll in Medicare Part D later, you will not have to pay a penalty for late enrollment aslong as you keep your FEHB coverage.However, if you choose to enroll in Medicare Part D, you can keep your FEHB coverage and your FEHB plan will coordinate benefitswith Medicare.Remember: If you are an annuitant and you cancel your FEHB coverage, you may not re-enroll in the FEHB Program.Please be advisedIf you lose or drop your FEHB coverage and go 63 days or longer without prescription drug coverage that is at least as good asMedicare’s prescription drug coverage, your monthly Medicare Part D premium will go up at least 1 percent per month for everymonth that you did not have that coverage. For example, if you go 19 months without Medicare Part D prescription drug coverage,your premium will always be at least 19 percent higher than what many other people pay. You will have to pay this higher premium aslong as you have Medicare prescription drug coverage. In addition, you may have to wait until the next Annual Coordinated ElectionPeriod (October 15 through December 7) to enroll in Medicare Part D.Medicare’s Low Income BenefitsFor people with limited income and resources, extra help paying for a Medicare prescription drug plan is available. Informationregarding this program is available through the Social Security Administration (SSA) online at www.socialsecurity.gov, or call theSSA at 800-772-1213, TTY 800-325-0778.You can get more information about Medicare prescription drug plans and the coverage offered in your area from these places: Visit www.medicare.gov for personalized help. Call 800-MEDICARE 800-633-4227, TTY 877-486-2048.RI 71-017
Table of ContentsIntroduction .3Plain Language .3Stop Health Care Fraud! .3Discrimination is Against the Law .4Preventing Medical Mistakes .5FEHB Facts .8Coverage information .8 No pre-existing condition limitation.8 Minimum essential coverage (MEC) .8 Minimum value standard .8 Where you can get information about enrolling in the FEHB Program .8 Types of coverage available for you and your family .8 Family member coverage .9 Children’s Equity Act .9 When benefits and premiums start .10 When you retire .10When you lose benefits .10 When FEHB coverage ends .10 Upon divorce.11 Temporary Continuation of Coverage (TCC) .11 Finding replacement coverage .11 Health Insurance Marketplace .11Section 1. How This Plan Works .12General features of FEP Blue Focus .12We have a Preferred Provider Organization (PPO).12How we pay professional and facility providers .12Your rights and responsibilities .13Your medical and claims records are confidential .13Section 2. Changes for 2021 .14Section 3. How You Get Care .15Identification cards .15Where you get covered care .15 Covered professional providers .15 Covered facility providers .15What you must do to get covered care .17 Transitional care .17 If you are hospitalized when your enrollment begins.17You need prior Plan approval for certain services .18 Inpatient hospital admission, inpatient residential treatment center admission .18 Other services .18 Special prior authorization situations related to coordination of benefits (COB) .22 Prior notification – Maternity care .23How to request precertification for an admission or get prior approval for Other services .23 Non-urgent care claims .24 Urgent care claims .24 Concurrent care claims .25 Emergency inpatient admission .25 Maternity care .252021 Blue Cross and Blue Shield Service Benefit PlanFEP Blue Focus1Table of Contents
If your facility stay needs to be extended .25 If your treatment needs to be extended .25If you disagree with our pre-service claim decision .25 To reconsider a non-urgent care claim .26 To reconsider an urgent care claim .26 To file an appeal with OPM .26 The Federal Flexible Spending Account Program – FSAFEDS .26Section 4. Your Costs for Covered Services .27Cost-share/Cost-sharing .27Copayment .27Deductible .27Coinsurance .27If your provider routinely waives your cost .27Waivers .28Differences between our allowance and the bill .28Important notice about Non-participating providers! .28Your costs for other care .29Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments .29Carryover .29If we overpay you .30When Government facilities bill us .30Section 5. FEP Blue Focus Benefits.31FEP Blue Focus Overview .33Non-FEHB Benefits Available to Plan Members .108Section 6. General Exclusions – Services, Drugs, and Supplies We Do Not Cover .109Section 7. Filing a Claim for Covered Services .111Section 8. The Disputed Claims Process .114Section 9. Coordinating Benefits With Medicare and Other Coverage .117When you have other health coverage .117 TRICARE and CHAMPVA .117 Workers’ Compensation .118 Medicaid .118When other Government agencies are responsible for your care .118When others are responsible for injuries .118When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) .119Clinical trials .119When you have Medicare .120 The Original Medicare Plan (Part A or Part B).120 Tell us about your Medicare coverage .121 Private contract with your physician .121 Medicare Advantage (Part C) .121 Medicare prescription drug coverage (Part D) .121 Medicare prescription drug coverage (Part B) .121When you are age 65 or over and do not have Medicare .123Physicians Who Opt-Out of Medicare .124When you have the Original Medicare Plan (Part A, Part B, or both) .124Section 10. Definitions of Terms We Use in This Brochure .126Index.135Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan FEP Blue Focus – 2021 .1372021 Rate Information for the Blue Cross and Blue Shield Service Benefit Plan.1422021 Blue Cross and Blue Shield Service Benefit PlanFEP Blue Focus2Table of Contents
IntroductionThis brochure describes the benefits of the Blue Cross and Blue Shield Service Benefit Plan – FEP Blue Focus under contract (CS1039) with the United States Office of Personnel Management, as authorized by the Federal Employees Health Benefits law. This Planis underwritten by participating Blue Cross and Blue Shield Plans (Local Plans) that administer this Plan in their individual localities.For customer service assistance, visit our website, www.fepblue.org, or contact your Local Plan at the phone number appearing on theback of your FEP Blue Focus ID card.The Blue Cross and Blue Shield Association is the Carrier of the Plan. The address for the Blue Cross and Blue Shield Service BenefitPlan administrative office is:Blue Cross and Blue Shield Service Benefit Plan1310 G Street NW, Suite 900Washington, DC 20005This brochure is the official statement of benefits. No verbal statement can modify or otherwise affect the benefits, limitations, andexclusions of this brochure. It is your responsibility to be informed about your healthcare benefits.If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self Plus One or Selfand Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that wereavailable before January 1, 2021, unless those benefits are also shown in this brochure.OPM negotiates benefits and rates with each plan annually. Benefits are effective January 1, 2021, and are summarized on page 14.Rates are shown on the back cover of this brochure.Plain LanguageAll FEHB brochures are written in plain language to make them easy to understand. Here are some examples: Except for necessary technical terms, we use common words. For instance, “you” means the enrollee and each covered familymember; “we” means the Blue Cross and Blue Shield Service Benefit Plan. We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the United States Officeof Personnel Management. If we use others, we tell you what they mean. Our brochure and other FEHB plans’ brochures have the same format and similar descriptions to help you compare plans.Stop Health Care Fraud!Fraud increases the cost of healthcare for everyone and increases your Federal Employees Health Benefits Program premium.OPM’s Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of theagency that employs you or from which you retired.Protect Yourself From Fraud – Here are some things you can do to prevent fraud: Do not give your plan identification (ID) number over the phone or to people you do not know, except for your healthcare provider,authorized health benefits plan, or OPM representative. Let only the appropriate medical professionals review your medical record or recommend services. Avoid using healthcare providers who say that an item or service is not usually covered, but they know how to bill us to get it paid. Carefully review explanations of benefits (EOBs) statements that you receive from us. Periodically review your claim history for accuracy to ensure we have not been billed for services you did not receive. Do not ask your doctor to make false entries on certificates, bills, or records in order to get us to pay for an item or service.2021 Blue Cross and Blue Shield Service Benefit PlanFEP Blue Focus3Introduction/Plain Language/Advisory
If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, ormisrepresented any information, do the following:- Call the provider and ask for an explanation. There may be an error.- If the provider does not resolve the matter, call the FEP Fraud Hotline at 800-FEP-8440 (800-337-8440) and explain thesituation.- If we do not resolve the issue:CALL – THE HEALTH CARE FRAUD HOTLINE877-499-7295OR go to t-fraud-waste-or-abuse/complaint-formThe online form is the desired method of reporting fraud in order to ensure accuracy, and a quick response time.You can also write to:United States Office of Personnel ManagementOffice of the Inspector General Fraud Hotline1900 E Street NW Room 6400Washington, DC 20415-1100 Do not maintain as a family member on your policy:- Your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise); or- Your child age 26 or over (unless he/she was disabled and incapable of self-support prior to age 26).- A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee’sFEHB enrollment. If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed, with yourretirement office (such as OPM) if you are retired, or with the National Finance Center if you are enrolled under TemporaryContinuation of Coverage (TCC). Fraud or intentional misrepresentation of material fact is prohibited under the Plan. You can be prosecuted for fraud and youragency may take action against you. Examples of fraud include falsifying a claim to obtain FEHB benefits, trying to or obtainingservice or coverage for yourself or for someone who is not eligible for coverage, or enrolling in the Plan when you are no longereligible. If your enrollment continues after you are no longer eligible for coverage (i.e., you have separated from Federal service) andpremiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not paid. You may bebilled by your provider for services received. You may be prosecuted for fraud for knowingly using health insurance benefits forwhich you have not paid premiums. It is your responsibility to know when you or a family member is no longer eligible to use yourhealth insurance coverage.Discrimination is Against the LawThe Blue Cross and Blue Shield Service Benefit Plan complies with all applicable Federal civil rights laws, including Title VII of theCivil Rights Act of 1964.We: Provide free aids and services to people with disabilities to communicate effectively with us, such as:- Qualified sign language interpreters- Written information in other formats (large print, audio, accessible electronic formats, other formats)2021 Blue Cross and Blue Shield Service Benefit PlanFEP Blue Focus4Introduction/Plain Language/Advisory
Provide free language services to people whose primary language is not English, such as:- Qualified interpreters- Information written in other languagesIf you need these services, contact the Civil Rights Coordinator of your Local Plan by contacting your Local Plan at the phone numberappearing on the back of your ID card.If you believe that we have failed to provide these services or discriminated in another way on the basis of race, color, national origin,age, disability, or sex, you can file a grievance with the Civil Rights Coordinator of your Local Plan. You can file a grievance inperson or by mail, fax, or email. If you need help filing a grievance, your Local Plan’s Civil Rights Coordinator is available to helpyou.Members may file a complaint with the HHS Office of Civil Rights, OPM, or FEHB Program Carriers.You can also file a civil rights complaint with the Office of Personnel Management by mail at:Office of Personnel ManagementHealthcare and InsuranceFederal Employee Insurance OperationsAttention: Assistant Director, FEIO1900 E Street NW, Suite 3400-SWashington, D.C. 20415-3610For further information about how to file a civil rights complaint, go to www.fepblue.org/en/rights-and-responsibilities/, or call thecustomer service phone number on the back of your ID card. For TTY, dial 711.Preventing Medical MistakesMedical mistakes continue to be a significant cause of preventable deaths within the United States. While death is the most tragicoutcome, medical mistakes cause other problems such as permanent disabilities, extended hospital stays, longer recoveries, andadditional treatments. Medical mistakes and their consequences also add significantly to the overall cost of healthcare. Hospitals andhealthcare providers are being held accountable for the quality of care and reduction in medical mistakes by their accrediting bodies.You can also improve the quality and safety of your own healthcare and that of your family members by learning more about andunderstanding your risks. Take these simple steps:1. Ask questions if you have doubts or concerns. Ask questions and make sure you understand the answers. Choose a doctor with whom you feel comfortable talking. Take a relative or friend with you to help you take notes, ask questions and understand answers.2. Keep and bring a list of all the medications you take. Bring the actual medications or give your doctor and pharmacist a list of all the medications and dosages that you take, includingnon-prescription (over-the-counter) medications and nutritional supplements. Tell your doctor and pharmacist about any drug, food, and other allergies you have, such as to latex. Ask about any risks or side effects of the medication and what to avoid while taking it. Be sure to write down what your doctor orpharmacist says. Make sure your medication is what the doctor ordered. Ask the pharmacist about your medication if it looks different than youexpected. Read the label and patient package insert when you get your medication, including all warnings and instructions. Know how to use your medication. Especially note the times and conditions when your medication should and should not be taken. Contact your doctor or pharmacist if you have any questions.2021 Blue Cross and Blue Shield Service Benefit PlanFEP Blue Focus5Introduction/Plain Language/Advisory
Understand both the generic and brand names of your medication. This helps ensure you do not receive double dosing from takingboth a generic and a brand. It also helps prevent you from taking a medication to which you are allergic.3. Get the results of any test or procedure. Ask when and how you will get the results of tests or procedures. Will it be in person, by phone, mail, through the Plan orProvider’s portal? Do not assume the results are fine if you do not get them when expected. Contact your healthcare provider and ask for your result
This brochure is the official statement of benefits. No verbal statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure. It is your responsibility to be informed about your healthcare benefits. If you are enrolled in this Plan, you are
color, national origin, age, disability, or sex, you can file a grievance with BCBS FEP Dental by: Calling BCBS FEP Dental at 1-855-504-BLUE (2583) or 711 for TTY relay services. Sending a letter to BCBS FEP D
The drugs covered in each tier for Standard Option, Basic Option and FEP. Blue Focus vary. Both Standard and Basic Option cover Preferred and Non-preferred drugs, while FEP Blue Focus only covers Preferred drugs. If you currently take prescription drugs, you should check our approved drug lists
3-8 Gas permeability Gas permeability of NEOFLON FEP film is shown in Figure 13 and Table 9, and is compared with other plastic films in Figure 14. Table 9 Gas Permeability of NEOFLON FEP Film (Test method: ASTM D-1434, JIS Z0208) Gas Gas permeability* NEOFLON FEP PTFE Low densit
BCBS FEP Dental is responsible for the selection of in-network providers in your area. Contact us at 1-855-504-2583, Dial 711 (for TTY relay services) for the names of participating providers or to request a zip code based provider directory. You
Blue Shield 65 Plus Choice Plan (HMO) X Blue Shield of California Blue Shield Inspire (HMO) X Blue Shield of California Blue Shield Medicare (PPO) Blue Shield Promise X Blue Shield of California AdvantageOptimum Plan (HMO) Blue Shield Promise X Blue Shield of California AdvantageOpt
Blue Cross and Blue Shield of Alabama is an independent corporation operating under a license from the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. The Blue Cross and Blue Shield Association permits us to use the Blue Cross and Blue Shield service marks in the state of Alabama.
Form 4220 FEP-SO 02006554-A Effective 11/2021 Revised 10/2021 The Blue Cross and Blue Shield Service Benefit Plan maintains a list of specialty prescription drugs. Coverage of and out-of-pocket costs for drugs on this list may be different under Basic Option, Standard Option and FEP Blue Focus. Please se
ED-OIG/A02-D0023 . Honorable César Rey-Hernández Secretary of Education Puerto Rico Department of Education Calle Teniente González, Esq. Calle Calaf – 12. th. Floor Urb. Tres Monjitas Hato Rey, Puerto Rico 00919 Dear Secretary Rey-Hernández: This is our Final Audit Report entitled . Puerto Rico Department of Education’s (PRDE) Salaries for the Period July 1, 1999 to June 30, 2003. The .
