Otherwise, we pay the hospitals average charge for semiprivate accommodations. Note: For routine post-operative surgical care, see Section 5(b). We protect you against catastrophic out-of-pocket expenses for covered services. For more information or to make an inquiry about situations in which you are entitled to immediately appeal to OPM, including additional requirements not listed in Sections 3, 7 and 8 of this brochure, please call your plans customer service representative at the phone number found on your enrollment card, plan brochure, or plan website. And we offer many programs and tools to help you reach your personal health goals. Services Provided by a Hospital or Other Fa. Outpatient hospital or ambulatory surgical center. If you have Self Plus One orSelf and Family coverage with our Plan, when at least two family members complete the Health Assessment, we will enroll you and your covered family members in the CignaPlus Savingsdiscount dental program and pay the family CignaPlus Savingsdiscount dental premium for the remainder of the year in which both Health Assessments were completed, provided you remain enrolled in our Plan. Note: For initial examination of a newborn child covered under a family enrollment, see Preventive care, children in CDHP/Value Option Section 5. You should also see section Important Notice About Surprise Billing Know Your Rights below that describes your protections against surprise billing under the No Surprises Act. Preventive Care. Certain compounding chemicals (over-the-counter (OTC) products, bulk powders, bulk chemicals, and proprietary bases) are not covered through the prescription benefit and will be determined through preauthorization. See Wellness Incentive Programs in this section.
us if you or a covered family member has coverage under any otherhealth plan or has automobile insurance that pays healthcare ex, the healthcare program foractive duty service members,eligible dependents of military persons, and retirees of the military. Insertion of internal prosthetic devices. The 2020 grace period is extended through December 31, 2021, and the 2021 grace period is extended through December 31, 2022. an amount set by Medicare and called the Medicare approved amount, or. Each year, the Plan provides members $1,200 for a Self Only, $2,400 for a Self Plus Oneor $2,400 for a Self and Family who enroll in the CDHP during Open Seasonand $100 for a Self Only, $200 for a Self Plus One, or $200 for a Self and Family who enrollin the Value Option during Open Season. You will be going to a new website, operated on behalf of the Blue Cross and Blue Shield Service Benefit Plan by a third party. Professional services of physicians and urgent care centers: Emergency room physician care not related to Accidental injury or Medical emergency. We will cover other care of an infant who requires non-routine treatment if we cover the infant under Self Plus One orSelf and Family enrollment. Specialty prescriptions can be submitted to any local CVS Pharmacy or to our Specialty mail pharmacies. OPMs FEHB website (. You will receive educational information and support throughout your entire pregnancy and after. You can view the complete list of these rights and responsibilities in this section or by visiting our website at. When you use a non-network pharmacy, your cost-sharing will be higher. Please see Section 5(h). Effective in 2022, premium rates are the same for Non-Postal and Postal employees. FSAs are an excellent opportunity. Provider networks may be more extensive in some areas than others. Telehealth or virtual visits are available through MDLive. Blood or marrow stem cell transplants covered only in a National Cancer Institute (NCI) or National Institutes of Health (NIH) approved clinical trial at a Plan-designated center of excellence and if approved by the Plans medical director in accordance with the Plans protocols, such as: Note: If you are a participant in a clinical trial, the Plan will provide benefits for related routine care that is medically necessary (such as doctor visits, lab tests, X-rays and scans, and hospitalization related to treating the patients condition) if it is not provided by the clinical trial. However, we will process charges for radiology, laboratory, electrocardiogram (ECG/EKG), electroenceph. Due to the pandemic, FSAFEDS has added flexibilities to the 2020 and 2021 plan years, allowing unlimited carryover for re-enrolled HCFSA and LEX HCFSA participants for the 2020 and 2021 plan years. Call 855-511-1893 to receive precertification for an inpatient hospital staywhen we are your primary payor. Enrollees who wish to cover one eligible family member are free to elect either the Self and Family or Self Plus One . See Section 7. Emergency Services/Accidents. FEHB Carriers must have clauses in their in-network (participating) providers agreements. Please keep your card for future use even if you use all your health account dollars; you may be eligible for wellness incentives in subsequent benefit years. See pages 45, 48, 115, and 117. Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term, or when the pregnancy is the result of an act of rape or incest. We determine our allowance as follows: High Option PPO benefits:For services rendered by a covered provider that participates in the Plans PPO network, our allowance is based on a negotiated rate agreed to under the provider's network agreement. Note: If you have questions about the Program, wish to locate anNALC CareSelect Network retail pharmacy, or need additional claim forms, call 800-933-NALC (6252) 24 hours a day, 7 days a week. Enrolling in TCC. Your Health Assessment profile provides information to put you on a path to good physical health. Non-routine sonograms are payable under diagnostic testing. Each fullyear the Plan adds to your account: ncy, mental health and substance use disorder, and prescription drug services and supplies covered under t. n (CDHP) during Open Season, we will give you a Personal Care Account (PCA) credit in the amount of $1,200 for Self Only, $2,400 for Self Plus One, or$2,400 for Self and Family. Note: Exclusions that apply to other benefits apply to these mental health and substance use disorder benefits. Emergency room physician care not related to Accidental injury or Medical emergency. It is your responsibility to be informed about your health benefits. You can view the complete list of these rights and responsibilities in this section or by visiting our website atwww.nalchbp.org. See Section 4. However, if you are a family member who is losing coverage, the employing or retirement office will not notify you. Genetic testing requires prior authorization. However, we will process charges for the laboratory, the administration of anesthesia and the emergency room visit billed by Out-of-Network providers at the In-Network benefit level, based on the Plan allowance, if the services are rendered at an In-Network hospital or In-Network ambulatory surgical center. Reversal of a gender reassignment surgery is covered only when determined to be medically necessary or a complication occurs. We will write to you with our decision. Your Costs for Covered Services, Section 5(a). Examples of common conditions include allergies, cold and flu symptoms, sinus problems, skin disturbances, and minor wounds and abrasions. How You Get Care. In other words, a pre-service claim for benefits (1) requires precertification, preauthorization, or prior approvaland (2) will result in a reduction of benefits if you do not obtain precertification, preauthorization, or prior approval. Note: We cover internal and external breast prostheses, surgical bras and replacements. Complete maternity (obstetrical) care,limited to: Note: We cover services related to pregnancy that result in a miscarriage under the Maternity care benefit. Benefits are available for fertility preservation for medical reasons that cause irreversible infertility such as chemotherapy or radiation treatment. Call 855-511-1893 to find a covered provider and to obtain prior authorization. Next is our Consumer Option, which offers comprehensive medical coverage and a health savings account. We will notify you of our decision within 30 days after we receive your post-service claim. FAILURE TO DO SO WILL RESULT IN A DENIAL OF BENEFITS. Find every plan available to you ranked by estimated out-of-pocket costs and more. You dont have to enroll in a MHBP medical plan to participate in these programs. Medications for anti-narcolepsy, ADD/ADHD, certain analgesics,and certain opioids, 510K dermatological products, and artificial saliva will require PA. The Checkbook's Guide to Health Plans for Federal Employeessummarizes thousands of facts about the plans to simplify your choice.
PDF How to Use PostalEASE to Manage Your USPS Non-Career Employee Health Some FEHB plans already cover some dental and vision services. Please remember that we do not make decisions about plan eligibility issues. Under a Self Only enrollment, the deductible is considered satisfied and benefits are payable for you when your covered In-Network expenses applied to the calendar year deductible for your enrollment reach $2,000 ($4,000 for covered Out-of-Network expenses). Open Season. You are also entitled to a wide range of consumer protections and have specific responsibilities as a member of this Plan. The calendar yeardeductibledoes not apply to prescription drug benefits. When you use a combination of PPO and Non-PPO providers your out-of-pocket expense will not exceed $7,000. If you are a non-Postal employee, annuitant, survivor annuitant, or a Spouse Equity or TCC enrollee, you become an associate member of NALC when you enroll in the NALC Health Benefit Plan. Still need help? With low copayments for most services, you know what youre going to spend. Simply show your member ID card at the pharmacy. Occasionally, as part of regular review, we may recommend that the use of a drug is appropriate only with limits on its quantity, total dose, duration of therapy, age, gender or specific diagnoses. NALC is necessary to be an enrollee in the Plan. BENEFEDS is the benefits marketplace through which eligible members of the federal civilian workforce and uniformed services shop for, enroll in, and pay for voluntary benefits, including dental and vision plans under the Federal Employees Dental and Vision Insurance Program (FEDVIP). you receive a message in PostalEASE directing you to contact the HRSSC when attempting to make a change. re related to the delivery of a newborn. Note: We only cover the standard intraocular lens prosthesis for cataract surgery. In future years, the amount of your deductible may be lower if you rollover PCA dollars at the end of the year. Gene therapy products and services directly related to their administration are covered when medically necessary. In-Network Preventive Care is covered at 100% under CDHP/Value Option Section 5 and does not count against your PCA when you are enrolled in the CDHP/Value Option plan. PPO: Nothing (No deductible)Non-PPO: 30% of the Plan allowance and the difference, if any, between our allowance and the billed amount. for mail handlers to save money for health care and dependent care. Call Optum at 855-780-5955 to speak with a licensed clinician who can help guide you to an In-Network treatment provider or treatment center. When no PPO provider is available, non-PPO benefits apply, except as listed within this Section. If LabCorp or Quest Diagnostics performs your covered lab services, you will have no out-of-pocket expense and you will not have to file a claim. d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits(EOB) forms. The non-PPO benefits are the standard benefits of this option. Customer Service hours for our Dental and Vision plans are 8 a.m. to 6 p.m. Eastern. To enroll, you must be or become a member of the National Association of Letter Carriers. Ask us in writing to reconsider our initial decision. * You also have access to a registered pharmacist 24/7. For information on suspending your FEHB enrollment, contact your retirement office. Diagnostic and treatment services, Section 5(b). OptumHealth Behavioral Solutions In-Network providers are responsible for filing. Up to $120 for frames (every 24 months) or contact lenses (every 12 months) Discounted rates for laser vision correction. Preventive care, adult. Your enrollment in this programincludes a connected glucometer, unlimited test strips and lancets, medication therapy counseling from a pharmacist, two annual diabetes screenings at a CVS MinuteClinic and a suite of digital resources through the CVS mobile App, all at no cost. Our Musculoskeletal (MSK) Program through Hinge Health is an online exercise therapy program that provides a convenient virtual solution to help improve pain, avoid surgical procedures, and reduce medication usage. See your TRICARE or CHAMPVA Health Benefits Advisor if you have questions about these programs. A compound drug is a medication made by combining, mixing or altering ingredients in response to a prescription, to create a customized drug that is not otherwise commercially available. Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance, and deductible. OPM may disclose the information it collects during the review process to support their disputed claim decision. This information will become part of the court record. During Open Season, go to www.BENEFEDS.com to enroll or change enrollment in the Federal Employees Dental and Vision Insurance Program (FEDVIP). For example, if $50 of the Self and Family PCA had been used and you change to Value Option Self Only coverage, the PCA will be $100 minus $50 or $50 for the remainder of the year. You do not need to precertify your vaginal or cesareandelivery; see Section 3. Should you sign an agreement, Medicare will not pay any portion of the charges, and we will not increase our payment. In this Section, unlike Sections 5(a) and (b), the calendar year deductible applies to only a few benefits. When you change to Self Plus One or Self and Family because you marry, the change is effective on the first day of the pay period that begins after your employing office receives your enrollment form. We will need to know whether you are in the Original Medicare Plan or in a Medicare Advantage plan so we can correctly coordinate benefits with Medicare. Call Cigna at 877-220-NALC (6252) to obtain prior approval. See Wellness Incentive Programs in this section for more details. In-Network benefits apply only when you use an In-Network provider. Consumer Driven Health Plan and Value Option: Your deductible is your bridge between your Personal Care Account (PCA) and your Traditional Health Coverage. Note: Prior approval is required for gender reassignment surgery. In sharp contrast to regular health insurance benefits, there is no direct . Avoid usinghealthcareproviders who say that an item or service is not usually covered, but they know how to bill us to get it paid. Wellness and OtherSpecial Featuresfor information on theEnhancedCaremarkDirectRetailProgram where you may obtain non-covered medications at a discounted rate. Changes for 2022 for how our benefits changed this year and page 188,Summary of Benefits for the NALC Health Benefit Plan High Option - 2022for a benefits summary. You can purchase non-covered drugs through your local CVS network pharmacy and receive the convenience, safety, and confidentiality you already benefit from with covered prescriptions. The Out-of-Network benefits are the standard benefits of this option. Nov. 19, 2015 at midnight. See the official plan brochure on MHBP.com for full coverage details. You can contact MHBP whenever you need us.
Order the 2023 Guide to Health Plans for Federal Employees - Checkbook If we do not receive the information within 60 days,we will decide within 30 days of the datethe information was due. Copyright Center for the Study of Services. Note: To file a claim when Medicare is the primarypayor, see Section 9. Call CVS Specialtyat 800-237-2767 to obtain prior approval, more information, or a complete list. The Out-of-Network benefits are the standard benefits of this Plan. The amounts listed below are for charges billed by the facility (i.e., hospital or surgical center) or ambulance service for your surgery or care. If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to60 days from the receipt of the notice to provide the information. The consensus of opinion among experts is that further studies or clinical trials are necessary to determine its toxicity, safety, effectiveness, or effectiveness as compared with the standard means of treatment or diagnosis. patients confined to a nursing home that require less than a 90-day fill, patients who are in the process of having their medication regulated, or. Keep a separate record of the medical expenses of each covered family member as deductibles and maximum allowances apply separately to each person. Save copies of all medical bills, including those you accumulate to satisfy a deductible. In most instances they will serve as evidence of your claim. We will not provide duplicate or year-end statements. This plan is available to all qualified members regardless of their age. When you have the Original Medicare Plan (Part A, Part B, or both). Medications for anti-narcolepsy, ADD/ADHD, certain analgesics,certain opioids, 510K dermatological products, and artificial saliva will require PA. Please keep in mind that when you use an In-Network hospital or an In-Network physician, some of the professionals that provide related services may not all be preferred providers. This is a summary. When you enroll in the Value Option during Open Season, we will give you a Personal Care Account (PCA) credit in the amount of $100 for Self Only, $200 for Self Plus One, or$200 for Self and Family. This is different than a non-participating doctor, and we recommend you ask your physician if they haveopted out of Medicare. Go to, in regular physical activity, and adopt habits that will lead to a healthy weight for life. It also helps prevent you from taking a medication to which you are allergic. We require asigned copy of theprovider opt-out contract with Medicare. Note: If you have questions about the Program, wish to locate anNALC CareSelect Network retail pharmacy, or need additional claim forms, call 800-933-NALC (6252) 24 hours a day,7 days a week. We will then decide within 30 more days. Were available by phone and by email 24 hours a day, 7 days a week, except on major holidays, or you can write to us. If another health plan is your primary payor, you must send a copy of the explanation of benefits (EOB) form you received from your primary payor (such as the MedicareSummary Notice (MSN) with your claim). However, we will process charges for radiology, laboratory, electrocardiogram (ECG/EKG), electroencephalogram (EEG),the admi. 20% of the Plan allowance for services obtained through the Cigna. Enrollees in the Plan must be members, or associate members, of the NALC. Under a Self and Family enrollment, the deductible is considered satisfied and benefits are payable for all family members when the combined covered expenses applied to the calendar year deductible for family members reach $600. Wellness Incentive Programs for more details. High Option: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. Hospitals and healthcare providers are being held accountable for the quality of care and reduction in medical mistakes by their accrediting bodies. Outpatient hospital or ambulatory surgical center. Whether its arranging transportation to doctors appointments, explaining insurance options, having safety equipment installed, or coordinating care with multiple providers, the Care Advocate will help ensure that your elderly relative or disabled dependent maintains a safe, healthy lifestyle. You will receive an additional 31 days of coverage, for no additional premium, when: Any person covered under the 31 day extension of coverage who is confined in a hospital or other institution for care or treatment on the 31st day of the temporary extension is entitled to continuation of the benefits of the Plan during the continuance of the confinement but not beyond the 60th day after the end of the 31 day temporary extension. DHP during Open Season, we will give you a Personal Care Account (PCA) in the amount of $1,200 for Self Only, $2,400 for Self Plus One, or$2,400 for Self and Family. Note: FDA-approved prescription medications and over-the-counter medications (when purchased with a prescription) for tobacco cessation are covered only under the Prescription drug benefit. When you enroll in the Value Option during Open Season, we will give you a PCA in the amount of $100 for Self Only, or $200 for Self Plus One, or$200 for Self and Family. If they are not, they will be paid as Out-of-Network providers. Finally, we offer the Value Plan. You must sign our subrogation/reimbursement agreement and provide us with any other relevant information about the claim if we ask you to do so. Non-PPO: 30% of the Plan allowance and the difference, if any, between our allowance and the billed amount (calendar year deductible applies). When an In-Network provider is not available, Out-of-Network benefits apply. Call CVS Specialty at 800-237-2767 to obtain prior approval, more information, or a complete list. Acupuncture, by a doctor of medicine or osteopathy, or a state licensed or certified acupuncturist. We will pay $49.00 (70% of the actual charge of $70). Unused PCA benefits are forfeited when leaving. Prescription Drug Benefits. Certain musculoskeletal procedures, such as orthopedic surgeries and injections. When our liability is equal to, or less than, the Medicare Part D payment, you will receive no benefit. You will receive discounts on weight management and nutrition services, fitness clubs, vision and hearing care, and healthy lifestyle products. Employees with additional questions should call the Human Resources Shared Service Center at 877-477-3273 and select Option 5. If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you of the need for an extension of time before the end of the original 15-day period. Our Personal Health Record allows you to create and maintain a complete, comprehensive, and confidential medical record containing information on allergies, immunizations, medical providers, medications, past medical procedures, and more. Lab, X-ray and other diagnostic tests. Telehealth professional servicesthrough NALCHBP Telehealth for: Note: For more information on NALCHBP Telehealth benefits, see Section 5(h). Clinical records support a body mass index (BMI) of 40 or greater, or 35 or greater with at least one clinically significant obesity-related co-morbidity including but not limited to type 2 diabetes, cardiovascular disease,hypertension, obstructive sleep apnea, hyperlipidemia, or debilitating arthritis. Note: Internal prosthetic devices billed by the hospital are paid as hospital benefits. Your PCA must be used first for eligible healthcare expenses when you are enrolled in the CDHP/Value Option plan. Note: You do not need to precertify treatment when Medicare covers your services. What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire, When the next Open Season for enrollment begins, Your enrollment ends, unless you cancel your enrollment; or. Eligibility will be determined by your Quit for Life Coach and you must have at least 5 coaching interactions. If your PCA has been exhausted, you must meet your deductible before your Traditional Health Coverage may begin. Benefit changes are effective January 1, 2022, and changes are summarized on page (Applies to printed brochure only). Open season adjustments may be made using PostalEASE, which can be accessed online at liteblue.usps.gov or by calling HRSSC 1-877-477-3273, option 1. If you have Medicare Part A as primary payor, we waive: The coinsurance for a hospital admission.
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