Generic drugs may differ in color, size, or shape, but they have the same strength, purity, and quality as the brand-name alternatives. This is called "double coverage.". This is a website provided by the U.S. Department of Health and Human Services that provides up-to-date information on the Marketplace. Plus use our free tools to find new customers. In such cases, the hospitalized family members benefits under the new plan begin on the effective date of enrollment. Medical mistakes continue to be a significant cause of preventable deaths within the United States. Premiums for Tribal employees are shown under the Monthly Premium Rate column. We encourage you to contact the Plan to discuss specific services if you participate in a clinical trial. We will write to you with our decision. Note:If you change plans during open enrollment season and the effective date of the new plan is after January 1 of the next year, you do not have to start a new deductible under your prior plan between January 1 and the effective date of your new plan. In vitro fertilization benefits are not covered for Standard Option. Registered Dietitians- Save 25% on nutrition counseling from credentialed dietitians. Generic drugs contain the same active ingredients, in the same dosage form as their brand name counterparts, and are manufactured according to the same strict federal regulations. A range of voluntary family planningservices for women, limited to: Note: We cover oral contraceptives under the prescription drug benefit. If you or a covered family member moves outside of our service area, you can enroll in another plan. Medical services provided by physicians:Diagnostic and treatment services provided in the office, $10per visit for dependent children (under age 26), Services provided by a hospital: Inpatient. In extreme emergencies, if you are unable to contact your doctor, contact the local emergency system (e.g., the 911 telephone system) or go to the nearest hospital emergency room. You must get prior approval for certain services. breast prostheses and surgical bras and replacements (see Prosthetic devices). The Federal court will base its review on the record that was before OPM when OPM decided to uphold or overturn our decision. Failure to comply with pre - admission review or the concurrent review will result in the following reductions in health benefit reimbursment: $125 per day to a maximum of $250 per confinment as long as we determine thatthe inpatient admissionor service was medically necessary. EmblemHealth, Inc. complies with applicable Federal civil rights laws, Title VII of the Civil Rights Act of 1964. Please remember that we do not make decisions about plan eligibility issues. The Plan provides a large case management program that seeks to provide alternatives for improving the quality and cost effectiveness of care. The large case management program focuses on catastrophic illnesses for example, major head injury, high-risk infancy, stroke and severe amputations. The large case management process begins when we are notified that you or covered family member has experienced a specific illness or injury with potential long-term effects or changes in lifestyle. Case Managers evaluate individual needs, and the full range of treatment and financial exposures, from the onset of a condition or illness to recovery or stabilization. They review the efforts of the health care team and family with the goal of helping the patient return to pre-illness/injury functioning or of lessening the burden of a chronic or terminal condition. Case Managers provide the family with support and advice ranging from referral to family counseling. If it is determined that involvement of a Case Manager would be both care- and cost-effective, we will obtain the necessary authorization from the patient to proceed. Throughout the process, we will maintain strict confidentiality. Complete maternity (obstetrical) care, such as: Note: Here are some things to keep in mind: Note: When a newborn requires definitive treatment during or after the mother's confinement, the newborn is considered a patient in their own right. We will not cover care that you receive from non-network (non-participating) providers. Our right of reimbursement extends to any payment received by settlement, judgment, or otherwise. If you do not agree with our decision, you may ask OPM to review it. We may, at our option, choose to exercise our right of subrogation and pursue a recovery from any liable party as successor to your rights. You (or a covered family member) need because of a workplace-related illness or injury that the Office of Workers' Compensation Programs (OWCP) or a similar federal or state agency determines they must provide; or. It also helps prevent you from taking a medication to which you are allergic. Your coverage under TCC or the spouse equity law ends (If you canceled your coverage or did not pay your premium, you cannot convert); You decide not to receive coverage under TCC or the spouse equity law; or. 4. 0000007359 00000 n Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals, Section 5(b). The out-of-pocket limits for these Plans may differ from the IRS limit, but cannot exceed that amount. PPO benefits apply only when you use a PPO provider. For information on suspending your FEHB enrollment, contact your retirement office. Fluoride tablets, solution (not toothpaste, rinses) for children age 0-6 years. However, if at the time we make a decision regarding alternative benefits, we also decide that regular contract benefits are not payable, than you may dispute our regular contract benefits decision under the OPM disputed claim process (see section 8). You may be prosecuted for fraud for knowingly using health insurance benefits for which you have not paid premiums. Coordinating Benefits with Medicare and Other Coverage, Section 10. Your facility will file on the UB-04 form. Professional ambulanceservice to or from a hospitalfor medically necessaryservices. Any notice of an adverse benefit determination or correspondence from us confirming an adverse benefit determination will include information sufficient to identify the claim involved (including the date of service, the healthcare provider, and the claim amount, if applicable), and a statement describing the availability, upon request, of the diagnosis and procedure codes and its corresponding meaning, and the treatment code and its corresponding meaning). $500 per day inpatient admission up to a maximum of $1,000 per admission. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment. Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation (for annuitants), or your electronic enrollment system (such as Employee Express) confirmation letter. Examples of fraud include, falsifying a claim to obtain FEHB benefits, trying to or obtaining service or coverage for yourself or for someone else who is not eligible for coverage, or enrolling in the Plan when you are no longer eligible. Part-time or intermittent nursing care by a registered professional nurse(R.N.) Clinic for urgent healthcare. We pay for covered services from the effective date of your enrollment. If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, contact us at (877) 842-3625 or EmblemHealth 55 Water Street, New York, NY 10041. Be sure you understand the instructions you get about follow-up care when you leave the hospital or clinic. The list is also on our website. The following preventive services are covered at the time interval recommended at each of the links below. With the exception of durable medical equipment, thereis no calendar year deductible. We may reduce subsequent benefit payments to offset overpayments. Coverage that offers a network(s) of providers and uses provider selection standards, utilization management, and quality assessment techniques to complete negotiated fee reductions as an effective strategy for long-term health care cost savings. Although some of these complications may not be avoidable, too often patients suffer from injuries or illnesses that could have been prevented if the hospital had taken proper precautions. Members must make sure their prescribers obtain prior approval/authorizations for certain prescription drugs and supplies before coverage applies. This helps ensure you do not receive double dosing from taking both a generic anda brand. Contact your employing or retirement office if you are changing from Selfto Self Plus One or Self and Family or to add a newborn if you currently have a Self Only plan. You can also contact us to request that we mail you a copy of that notice. The need for these services must result from an accidental injury caused by external means and services must be completed within one year. Note: For information on the professional charges for the surgery to insert an implant, see Section 5(b) Surgical procedures. You must raise eligibility issues with your Agency personnel/payroll office if you are an employee, your retirement system if you are an annuitant or the Office of Worker's Compensation Programs if you are receiving Worker's Compensation benefits. If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist until the end of your postpartum care, even if it is beyond the 90 days, If you are hospitalized when your enrollment begins. If you enroll in Medicare Part D and we are the secondary payor, we will review claims for your prescription drug costs that are not covered by Medicare Part D and consider them for payment under the FEHB plan. hb``b``mg`a`R Bl@q +Z0 KFe|592 GGXQ^+ ie 312(,``esz@xC?cWl The 60% standard is an actuarial value; your specific out-of-pocket costs are determined as explained in this brochure. Your employing or retirement office will not notify you when a family member is no longer eligible to receive benefits, nor will we. You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM. Mini-transplants performed in a clinical trial setting (non-myeloablative, reduced intensity conditioning or RIC) for members with a diagnosis listed below are subject to medical necessity review by the Plan. $50 copay forfirstvisitonly (for all prenatal and postnatal care). Grce la carte interactive retrouvez des lieux d'exception, les bons plans de nos partenaires 2 pas des gares TER. 0000012403 00000 n Failure to do so will result in a $125 per day up$250penalty for hospital admissions. Members that do not receive prior approvalfor certain medical services will be responsible forall charges. You will be able to choose from pharmacies in the Express Advantage Network (EAN), provided by Express Scripts. EmblemHealth will determine reimbursement for emergency services from non-participating providers based on a lesser of 100% of the 90th percentile of FAIR Health Prevailing Healthcare Charges System for Emergency Professional charges and Emergency Admission Professional Charges or the provider's billed charge. Check with the provider. 0000001565 00000 n You may contact EmblemHealth Customer Service toll-free at 1.800.447.9169, October 1 through March 31: 8 am to 8 pm, seven days a week. We willexpedite our review (if we have not yet responded to your claim); or we will inform OPM so they can quickly review your claim on appeal. If you have any questions, please call EmblemHealth Pharmacy Services toll free at 1.877.444.7097, Monday through Sunday, 8:00 a.m. to 8:00 p.m. (TTY/TDD: 711). Under Standard there is a $500 copay per day up to a maximum of $1000 per admission. When we are the primary payor, we will pay the benefits described in this brochure. Services, drugs, or supplies you receive while you are not enrolled in this Plan. If you are divorced from a Federal employee orannuitant, you may not continue to get benefits under your former spouses enrollment. Benefits described in this brochure are available to all members meeting medical necessity guidelines. These include: When you have to file a claim. If your claim is for the rental or purchase of durable medical equipment; private duty nursing; and physical therapy, occupational therapy, or speech therapy, you must provide awritten statement from theprovider specifying the medical necessity for the service or supply and the length of time needed. This is what you will pay out-of-pocket for covered care: Bring the actualmedication or give your doctor and pharmacist a list of all themedication and dosagethat you take, including non-prescription (over-the-counter) medications and nutritional supplements. Pre-certification is the process by which - prior to your inpatient hospital admission - we evaluate the medical necessity of your proposed stay and the number of days required to treat your condition. Contact your human resources office or retirement system for additional information. We do not cover the dental procedure unless it is described below. 5) Are a reemployed annuitant with the Federal government and your position is not excluded from the FEHB (your employing office will know if this is the case) and 6) Are a Federal judge who retired under title 28, U.S.C., or a Tax Court judge who retired under Section 7447 of title 26, U.S.C. The non-English languages meeting this threshold in certain counties are Spanish, Chinese, Navajo and Tagalog. Patients name, date of birth, address, phone number and relationship to enrollee, Name and address of person or company providing the service or supply, Dates that services or supplies were furnished. Dont assume the results are fine if you do not get them when expected. You may call OPM'sFEHB 2at (202) 606-3818 between 8 a.m. and 5 p.m. Eastern Time. Talk to your doctor about which hospital or clinic is best for your health needs. Benefits will not be available to your spouse until you are married. Facilities of the Department of Veterans Affairs, the Department of Defense and the Indian Health Services are entitled to seek reimbursement from us for certain services and supplies they provide to you or a family member. Rates are shown at the end of this brochure. Please note that by providing your email address, you may receive OPM's decision more quickly. We will ask you to submit information that establishes that the GHT is medically necessary.Ask us to authorize GHT before you begin treatment. Surprise Bills. We use the latest and greatest technology available to provide the best possible web experience.Please enable JavaScript in your browser settings to continue. It is the way everyone used to get Medicare benefits and is the way most people get their Medicare Part A and Part B benefits now. By law, you have the right to access your protected health information (PHI). To obtainmore information about the Standard Option benefits, contact us at 800-624-2414 or on our website at www.emblemhealth.com. We cover hospitalization for dentalprocedures only when a non-dental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient. This is true whether or not they accept Medicare. Suspended FEHB coverage to enroll in Medicaid or a similar State-sponsored program of medical assistance: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these state programs, eliminating your FEHB premium. When you enroll in a dental and/or vision plan on BENEFEDS.com or by phone 1-877-888-3337 (TTY 1-877-889-5680), you will be asked to provide information on your FEHB Plan so that your plans can coordinate benefits. family counseling under the direction of a doctor. Vision Affinity Discount Program -Receive discounts up to 20% at participating Davis Vision Centers. However, if you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at (877) 842-3625. We will base our decision on the information we already have. Mental health and substanceuse disordertreatment: Samecost-sharing as for other illnesses or conditions, Prescription drugs:Retail pharmacy - Up to a 30-day supply per prescription unit or refill (limit of two refills per prescription at a participating pharmacy). The treatment plan may include services, drugs, and supplies described elsewhere in this brochure. Take these simple steps: 1. 0000009863 00000 n You will not be billed for inpatient services related to treatment of specific hospital acquired conditions or for inpatient services needed to correct Never Events, if you use Emblemhealth providers. Claims process when you have The Original Medicare Plan You will probably not need to file a claim form when you have both our Plan and the Original Medicare Plan. Nothing for counseling for up to two quit attempts per year. For a complete list of QLEs, visit the FEHB website at, www.opm.gov/healthcare-insurance//lifeevents. All charges for non-participating providers. Balance billing happens when you receive a bill from the nonparticipating provider, facility, or air ambulance service for the difference between the nonparticipating provider's charge and the amount payable by your health plan. We will provide you with this information sufficiently in advance of the date that we are required to provide you with our reconsideration decision to allow you a reasonable opportunity to respond to us before that date. The No Surprises Act (NSA) is a federal law that provides you with protections against surprise billing and balance billing under certain circumstances.
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