A Fee-for-Service Plan (Elevate Plus and Elevate Options ...

1 GEHA Indemnity Benefit Customer Service: 800-821-6136 2022 A Fee-for-Service Plan ( Elevate Plus and Elevate Options ) with a Preferred Provider Network IMPORTANT Rates: Back Cover Changes for 2022: Page 14 Summary of Benefits: Page 122 This plan's health coverage qualifies as minimum essential coverage and meets the minimum value standard for the benefits it provides. See page 7 for details. This plan is accredited. See page and administered by: Government Employees health Association, may enroll in this Plan: All Federal employees and annuitants who are eligible to enroll in the Federal Employees health Benefits Program may become members of Government Employees health Association, Inc. (GEHA). You must be, or must become a member of GEHA. To become a member: You join simply by signing a completed Standard Form 2809, health Benefits Registration Form, evidencing your enrollment in the Plan. Membership dues: There are no membership dues for the Year 2022.

2 Enrollment codes for this Plan: 251 Elevate Plus Option - Self Only 253 Elevate Plus Option - Self Plus One 252 Elevate Plus Option - Self and Family 254 Elevate Option - Self Only 256 Elevate Option - Self Plus One 255 Elevate Option - Self and Family Special Notice: This brochure was updated on 5/5 71-018 Important Notice from Government Employees health Association, Inc. About Our Prescription Drug Coverage and MedicareThe Office of Personnel Management (OPM) has determined that the Government Employees health Association, Inc. prescription drug coverage is, on average, expected to pay out as much as the standard Medicare prescription drug coverage will pay for all plan participants and is considered Creditable Coverage. This means you do not need to enroll in Medicare Part D and pay extra for prescription drug coverage. If you decide to enroll in Medicare Part D later, you will not have to pay a penalty for late enrollment as long as you keep your FEHB coverage.

3 However, if you choose to enroll in Medicare Part D, you can keep your FEHB coverage and your FEHB plan will coordinate benefits with 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 as Medicare s prescription drug coverage, your monthly Medicare Part D premium will go up at least 1% per month for every month 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 as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the next Annual Coordinated Election Period (October 15 through December 7) to enroll in Medicare Part D.

4 For people with limited income and resources, extra help paying for a Medicare prescription drug plan is available. Information regarding this program is available through the Social Security Administration (SSA) online at , or call the SSA at 800-772-1213, TTY: s Low Income BenefitsYou can get more information about Medicare prescription drug plans and the coverage offered in your area from these places: Visit for personalized help. Call 800-MEDICARE (1-800-633-4227), (TTY: 1-877-486-2048).Table of Contents Table of Contents ..1 Introduction ..3 Plain Language ..3 Stop Healthcare Fraud! ..3 Discrimination is Against the Law ..4 Preventing Medical Mistakes ..5 FEHB Facts ..7 Coverage Information ..7 No pre-existing condition limitation ..7 Minimum essential coverage (MEC) ..7 Minimum value standard (MVS) ..7 Where you can get information about enrolling in the FEHB Program ..7 Types of coverage available for you and your family.

5 7 Family member coverage ..8 Children s Equity Act ..9 When benefits and premiums start ..9 When you retire ..10 When you lose benefits ..10 When FEHB coverage ends ..10 Upon divorce ..10 Temporary Continuation of Coverage (TCC) ..10 Converting to individual coverage ..11 health Insurance Marketplace ..11 Section 1. How This Plan Works ..12 General features of our Elevate Plus and Elevate Options ..12 How we pay providers ..12 health education resources ..13 Your rights and responsibilities ..13 Your medical and claims records are confidential ..13 Section 2. Changes for 2022 ..14 Section 3. How You Get Care ..16 Identification cards ..16 Where you get covered care ..16 Balance Billing Protection ..16 Plan providers ..16 Plan facilities ..17 Transitional care ..19 If you are hospitalized when your enrollment begins ..19 You need prior Plan approval for certain services ..19 Inpatient facility admission.

6 19 Other services that require preauthorization ..20 How to request precertification for an admission or get preauthorization for Other Services ..21 Non-urgent care claims ..22 Urgent care claims ..22 Concurrent care claims ..22 The Federal Flexible Spending Account Program FSAFEDS ..23 Emergency inpatient admission ..23 1 2022 GEHA Indemnity Benefit Plan Table of Contents Maternity care ..23 If your hospital stay needs to be extended ..23 If your treatment needs to be extended ..23 If you disagree with our pre-service claims decision ..23 To reconsider a non-urgent care claim ..24 To reconsider an urgent care claim ..24 To file an appeal with OPM ..24 Overseas claims ..24 Section 4. Your Costs for Covered Services ..25 Coinsurance ..25 Copayments ..25 Cost-sharing ..25 Deductible ..25 If your provider routinely waives your cost ..26 Waivers ..26 Differences between our allowance and the bill ..26 Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments.

7 27 Carryover ..28 If we overpay you ..28 When Government facilities bill us ..28 Important Notice About Surprise Billing - Know Your Rights ..28 Section 5. Elevate Plus and Elevate Benefits ..29 Elevate Plus and Elevate Overview ..31 Non-FEHB Benefits Available to Plan Members ..95 Section 6. General Exclusions - Services, Drugs and Supplies We Do Not Cover ..96 Section 7. Filing a Claim for Covered Services ..97 Section 8. The Disputed Claims Process ..100 Section 9. Coordinating Benefits with Medicare and Other Coverage ..103 When you have other health coverage or auto insurance ..103 TRICARE and CHAMPVA ..103 Workers Compensation ..103 Medicaid ..104 When other Government agencies are responsible for your care ..104 When others are responsible for injuries ..104 When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) ..105 Clinical trials ..105 When you have Medicare ..106 The Original Medicare Plan (Part A or Part B).

8 106 Tell us about your Medicare coverage ..107 Private contract with your physician ..108 Medicare Advantage (Part C) ..108 Medicare prescription drug coverage (Part D) ..108 When you have the Original Medicare Plan (Part A, Part B, or both) ..111 Section 10. Definitions of Terms We Use in This Brochure ..112 Index ..120 Summary of Benefits for the Elevate Plus Option of the Government Employees health Association, Inc. 2022 ..122 Summary of Benefits for the Elevate Option of the Government Employees health Association, Inc. 2022 ..123 2022 Rate Information for Government Employees health Association, Inc. (GEHA) Benefit Plan ..126 2 2022 GEHA Indemnity Benefit Plan Table of Contents Introduction This brochure describes the benefits of GEHA Indemnity Benefit Plan under contract (CS 2962) between Government Employees health Association, Inc. and the United States Office of Personnel Management, as authorized by the Federal Employees health Benefits law.

9 This Plan is underwritten by Government Employees health Association, Inc. (GEHA, Inc.) and Surety Life Insurance Company and administered by GEHA, Inc. The Carrier of the Plan is a voluntary association comprised of GEHA, Inc. and Surety Life Insurance Company. Customer service may be reached at 800-821-6136 or through our website: The address for GEHA s administrative office is:Government Employees health Association, NE Mulberry St. Lee's Summit, MO 64086 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 health 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 Self and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that were available before January 1, 2022, unless those benefits are also shown in this negotiates benefits and rates with each plan annually.

10 Benefit changes are effective January 1, 2022, and changes are summarized in Section 2, Changes for 2022. Rates are shown at the end of this Language All 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 family member, we means Government Employees health Association, Inc. We limit acronyms to ones you know. FEHB is the Federal Employees health Benefits Program. OPM is the United States Office of 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 Healthcare Fraud! Fraud increases the cost of healthcare for everyone and increases your Federal Employees health Benefits Program s Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of the agency that employs you or from which you Yourself From Fraud Here are some things that 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.