A Fee-For-Service Plan (FEP Blue Focus) with a Preferred ...

1 Blue Cross and Blue Shield Service Benefit plan FEP Blue Focus 2022 A Fee-For-Service plan (FEP Blue Focus) with a Preferred provider Organization IMPORTANT Rates: Back Cover Changes for 2022: Page 15 Summary of Benefits: Page 139 This plan s health coverage qualifies as minimum essential coverage and meets the minimum value standard for the benefits it provides. See page 9 for details. This plan is accredited. See page 13. Sponsored and administered by: The Blue Cross and Blue Shield Association and participating Blue Cross and Blue Shield Plans Who may enroll in this plan : All Federal employees, Tribal employees, and annuitants who are eligible to enroll in the Federal Employees Health Benefits Program Enrollment codes for this plan : 131 FEP Blue Focus - Self Only 133 FEP Blue Focus - Self Plus One 132 FEP Blue Focus - Self and Family RI 71-017 Important Notice from the Blue Cross and Blue Shield Service Benefit plan About Our Prescription Drug Coverage and MedicareThe Office of Personnel Management (OPM) has determined that the Blue Cross and Blue Shield Service Benefit plan s 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.

2 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. 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 percent 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.

3 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. Medicare s Low Income BenefitsFor 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: 800-325-0778. You 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 800-633-4227, TTY 877-486-2048. RI 71-017 Table of Contents Introduction ..4 Plain Language ..4 Stop Healthcare Fraud! ..4 Discrimination is Against the Law ..5 Preventing Medical Mistakes.

4 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 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 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.

5 14 Section 2. Changes for 2022 ..15 Section 3. How You Get Care ..16 Identification cards ..16 Where you get covered care ..16 Balance Billing Protection ..16 Covered professional providers ..16 Covered facility providers ..17 What you must do to get covered care ..18 Transitional care ..18 If you are hospitalized when your enrollment begins ..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 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 1 2022 Blue Cross and Blue Shield Service Benefit plan FEP Blue Focus Table of Contents Maternity care.

6 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 The Federal Flexible Spending Account Program FSAFEDS ..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 Section 5. FEP Blue Focus Benefits.

7 32 Section 5. FEP Blue Focus Overview ..34 Non-FEHB Benefits Available to plan Members ..110 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 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).

8 123 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 Index ..137 Summary of Benefits for the Blue Cross and Blue Shield Service Benefit plan FEP Blue Focus 2022 ..139 2 2022 Blue Cross and Blue Shield Service Benefit plan FEP Blue Focus Table of Contents 2022 Rate Information for the Blue Cross and Blue Shield Service Benefit plan ..142 3 2022 Blue Cross and Blue Shield Service Benefit plan FEP Blue Focus Table of Contents Introduction This brochure describes the benefits of the Blue Cross and Blue Shield Service Benefit plan FEP Blue Focus under contract (CS 1039) between the Blue Cross and Blue Shield Association and the United States Office of Personnel Management, as authorized by the Federal Employees Health Benefits law.

9 This plan is 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, , or contact your Local plan at the phone number appearing on the back of your FEP Blue Focus ID card. The address for the Blue Cross and Blue Shield Service Benefit plan administrative office is: Blue Cross and Blue Shield Service Benefit Plan1310 G Street NW, Suite 900 Washington, DC 20005 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 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.

10 You do not have a right to benefits that were available before January 1, 2022, unless those benefits are also shown in this brochure. OPM negotiates benefits and rates with each plan annually. Benefits are effective January 1, 2022, and are summarized on page 15. Rates are shown on the back cover of this brochure. Plain 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 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 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.