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Section
4. Your costs for covered services |
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This is what you will pay out-of-pocket for your covered
care
| Copayment |
A
copayment is a fixed amount of money you pay
to the provider, facility, pharmacy, etc.,
when you receive certain services.
Example: When you see your PPO physician you
pay a copayment of $20 per visit.
Note: If the billed amount (or the Plan
allowance that providers we contract with
have agreed to accept as payment in full) is
less than your copayment, you pay the lower
amount.
We also have a separate copayment for:
- Inpatient
hospital confinement; PPO: $200 per
confinement; non-PPO: $300 per
confinement under both High Option
and Standard Option
- High
Option outpatient services facility
charge; PPO: $100 per facility, per
day; non-PPO: $150 per facility, per
day
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| Cost-sharing |
Cost-sharing
is the general term used to refer to your
out-of-pocket costs (e.g., deductible,
coinsurance, and copayments) for the covered
care you receive.
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| Deductible |
A
deductible is a fixed amount of covered
expenses you must incur for certain covered
services and supplies before we start paying
benefits for them. Copayments and
coinsurance amounts do not count toward any
deductible. When a covered service or supply
is subject to a deductible, only the Plan
allowance for the service or supply counts
toward the deductible.
- The
calendar year deductible is $250 per
person under the High Option and
$300 per person under the Standard
Option. Under a family enrollment,
the deductible is satisfied for all
family members when the combined
covered expenses applied to the
calendar year deductible for family
members reach $500 under the High
Option and $600 under the Standard
Option.
- We also
have a separate deductible for
certain covered expenses for the
treatment of mental health and
substance abuse. The calendar year
deductible is $250 per person/$500
per family under the High Option and
$300 per person/$600 per family
under the Standard Option.
If the billed
amount (or Plan allowance that providers we
contract with have agreed to accept as
payment in full) is less than the remaining
portion of your deductible, you pay the
lower amount.
Example: If the billed amount is $100, the
provider has an agreement with us to accept
$80, and you have not paid any amount toward
meeting your calendar year deductible, you
must pay $80. We will apply $80 to your
deductible. We will begin paying benefits
once the remaining portion of your calendar
year deductible ($170) has been satisfied.
Note: If you change plans during open season
and the effective date of your new plan is
after January 1 of the next year, you do not
have to start a new deductible under your
old plan between January 1 and the effective
date of your new plan. If you change plans
at another time during the year, you must
begin a new deductible under your new plan.
If you change options in this Plan during
the year, we will credit the amount of
covered expenses already applied toward the
deductible of your old option to the
deductible of your new option.
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| Coinsurance |
Coinsurance
is the percentage of our allowance that you
must pay for your care. In most cases,
coinsurance doesnt begin until you meet your
deductible.
Example: You pay 10% of the Plan allowance
for in-network laboratory services under
High Option or 15% of the Plan allowance
under Standard Option.
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| If
your provider routinely waives your cost |
If
your provider routinely waives (does not
require you to pay) your copayments,
deductibles, or coinsurance, the provider is
misstating the fee and may be violating the
law. In this case, when we calculate our
share, we will reduce the providers fee by
the amount waived.
For example, if your physician ordinarily
charges $100 for a service but routinely
waives your 30% out-of-network coinsurance,
the actual charge is $70. We will pay $49
(70% of the actual charge of $70).
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| Waivers |
In
some instances, a provider may ask you to
sign a waiver prior to receiving care. This
waiver may state that you accept
responsibility for the total charge for any
care that is not covered by your health
plan. If you sign such a waiver, whether you
are responsible for the total charge depends
on the contracts that the Plan has with its
providers. If you are asked to sign this
type of waiver, please be aware that, if
benefits are denied for the services, you
could be legally liable for the related
expenses. If you would like more information
about waivers, please contact us at
1-800/638-6589 or 301/984-1440 (for TDD, use
301/984-4155).
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| Differences
between our allowance and the bill |
Our
"Plan allowance" is the amount we
use to calculate our payment for covered
services. Fee-for-service plans arrive at
their allowances in different ways, so their
allowances vary. For more information about
how we determine our Plan allowance, see the
definition of Plan allowance in Section 10.
Often, the providers bill is more than a
fee-for-service plans allowance. Whether or
not you have to pay the difference between
our allowance and the bill will depend on
the provider you use.
- PPO
providers agree to limit what
they will bill you. Because of that,
when you use a preferred provider,
your share of covered charges
consists only of your deductible and
coinsurance or copayment. Here is an
example about coinsurance: You see a
PPO surgeon who charges $150, but
our allowance is $100. If you have
met your deductible, you are only
responsible for your coinsurance.
That is, under High Option you pay
just 10% of our $100 allowance
($10). Because of the agreement,
your PPO physician will not bill you
for the $50 difference between our
allowance and his/her bill.
- Non-PPO
providers, on the other hand,
have no agreement to limit what they
will bill you. When you use a
non-PPO provider, you will pay your
deductible and coinsurance plus any
difference between our allowance and
charges on the bill. Here is an
example: You see a non-PPO physician
who charges $150 and our allowance
is again $100. Because you've met
your deductible, you are responsible
for your coinsurance, so you pay 30%
of our $100 allowance ($30). Plus,
because there is no agreement
between the non-PPO physician and
us, the physician can bill you for
the $50 difference between our
allowance and his/her bill.
The
following table illustrates the examples of
how much you have to pay out-of-pocket under
High Option for services from a PPO
physician and a non-PPO physician. The table
uses our example of a service for which the
physician charges $150 and our allowance is
$100. The table shows the amount you pay if
you have met your calendar year deductible.
| EXAMPLE |
PPO
provider |
Non-PPO
provider |
| Surgical
charge |
$150 |
$150 |
| Our
allowance |
We
set it at: 100 |
We
set it at: 100 |
| We
pay |
90%
of our allowance: 90 |
70%
of our allowance: 70 |
| You
owe: Coinsurance |
10%
of our allowance: 10 |
30%
of our allowance: 30 |
| +Difference
up to charge? |
No:
0 |
Yes:
50 |
| TOTAL
YOU PAY |
$10 |
$80 |
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Your
catastrophic
protection out-of-pocket
maximum for deductibles,
coinsurance, and copayments |
For
those services with coinsurance, we pay 100%
of the plan allowance for the remainder of
the calendar year after out-of-pocket
expenses for you and your covered family
members for the expenses listed below in
that calendar year exceed:
- PPO:
$3,500 under High Option or $4,000
under Standard Option when PPO
providers are used.
- Non-PPO:
$5,000 under High Option or $6,000
under Standard Option. Eligible PPO
expenses will also count toward this
limit.
High Option:
Out-of-pocket expenses for the purposes of
this benefit are the:
- $250 per
person calendar year deductible
($500 family);
- $250 per
person mental health deductible
($500 family);
- $200 PPO
and $300 non-PPO per inpatient
hospital confinement copayment;
- $100 PPO
and $150 non-PPO outpatient facility
services copayment under the High
Option;
- $20
office visit copayment under PPO
benefits; and
- the
coinsurance you pay for:
- Medical
services and supplies
provided by physicians and
other health care
professionals;
- Surgical
and anesthesia services
provided by physicians and
other health care
professionals;
- Services
provided by a hospital or
other facility, and
ambulance services;
- Emergency
services/accidents (after 72
hours); and
- Mental
health and substance abuse
benefits.
The following
cannot be counted toward High Option
out-of-pocket expenses:
- expenses
in excess of the Plan allowance or
maximum benefit limitations;
- amounts
you pay for non-compliance with this
Plans preauthorization requirements;
- copayments
under prescription drug benefits;
and
- the cost
difference between a name brand drug
and its generic equivalent.
Standard
Option:
Out-of-pocket expenses for the purposes of
this benefit are:
- the
coinsurance you pay for:
- Medical
services and supplies
provided by physicians and
other health care
professionals;
- Surgical
and anesthesia services
provided by physicians and
other health care
professionals;
- Services
provided by a hospital or
other facility, and
ambulance services;
- Emergency
services/accidents (after 72
hours); and
- Mental
health and substance abuse
benefits.
The following
cannot be counted toward Standard Option
out-of-pocket expenses:
- the $300
per person ($600 family) calendar
year deductible;
- the $300
per person ($600 family) mental
health year deductible;
- the $200
PPO and $300 non-PPO per inpatient
hospital confinement copayment;
- the $20
office visit copayment under PPO
benefits;
- expenses
in excess of the Plan allowance or
maximum benefit limitations;
- amounts
you pay for non-compliance with this
Plans preauthorization requirements;
and
- the cost
difference between a name brand drug
and its generic equivalent.
Standard
Option (only) prescription drugs:
Copayments and coinsurance expenses for
prescription drugs obtained from a Network
retail pharmacy or through our Mail Order
program will count toward a separate $5,000
per person, per calendar year prescription
out-of-pocket limit. Note: Expenses you pay
for non-covered drugs and the difference in
cost between a name brand drug and its
generic equivalent do not count toward this
out-of-pocket limit.
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| Carryover |
If
you changed to this Plan during open season
from a plan with a catastrophic protection
benefit and the effective date of the change
was after January 1, any expenses that would
have applied to that plan's catastrophic
protection benefit during the prior year
will be covered by your old plan if they are
for care you received in January before your
effective date of coverage in this Plan. If
you have already met your old plan's
catastrophic protection benefit level in
full, it will continue to apply until the
effective date of your coverage in this
Plan. If you have not met this expense level
in full, your old plan will first apply your
covered out-of-pocket expenses until the
prior years catastrophic level is reached
and then apply the catastrophic protection
benefit to covered out-of-pocket expenses
incurred from that point until the effective
date of your coverage in this Plan. Your old
plan will pay these covered expenses
according to this year's benefits; benefit
changes are effective January 1.
Note: If you change options in this Plan
during the year, we will credit the amount
of covered expenses already accumulated
toward the catastrophic out-of-pocket limit
of your old option to the catastrophic
protection limit of your new option.
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| If
we overpay you |
We
will make diligent efforts to recover
benefit payments we made in error but in
good faith. We may reduce subsequent benefit
payments to offset overpayments.
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| When
Government facilities bill us |
Facilities
of the Department of Veteran Affairs, the
Department of Defense, and the Indian Health
Service are entitled to seek reimbursement
from us for certain services and supplies
they provide to you or a family member. They
may not seek more than their governing laws
allow. |
When you are age 65 or over and
do not have Medicare
Under the FEHB law, we must limit our payments for
inpatient hospital care and physician care to those
payments you would be entitled to if you had Medicare.
Your physician and hospital must follow Medicare rules
and cannot bill you for more than they could bill you if
you had Medicare. You and the FEHB benefit from these
payment limits. Outpatient hospital care and
non-physician based care are not covered by this law;
regular Plan benefits apply. The following chart has
more information about the limits.
If you...
- are age 65 or over,
and
- do not have Medicare
Part A, Part B, or both; and
- have this Plan as an
annuitant or as a former spouse, or as a family
member of an annuitant or former spouse; and
- are not employed in
a position that gives FEHB coverage. (Your
employing office can tell you if this applies.)
Then, for your inpatient hospital care,
- the law requires us
to base our payment on an amount - the
"equivalent Medicare amount" - set by
Medicare's rules for what Medicare would pay,
not on the actual charge;
- you are responsible
for your applicable deductibles, coinsurance, or
copayments under this Plan;
- you are not
responsible for any charges greater than the
equivalent Medicare amount; we will show that
amount on the explanation of benefits (EOB) form
that we send you; and
- the law prohibits a
hospital from collecting more than the
equivalent Medicare amount.
And, for your physician care, the law requires us
to base our payment and your coinsurance or copayment
on...
- an amount set by
Medicare and called the "Medicare approved
amount," or
- the actual charge if
it is lower than the Medicare approved amount.
| If your
physician... |
Then you are
responsible for... |
| Participates
with Medicare or accepts Medicare assignment
for the claim and is a member of our PPO
network, |
your
deductibles, coinsurance, and copayments; |
| Participates
with Medicare and is not in our PPO
network, |
your
deductibles, coinsurance, copayments, and
any balance up to the Medicare approved
amount; |
| Does not
participate with Medicare, |
your
deductibles, coinsurance, copayments, and
any balance up to 115% of the Medicare
approved amount |
It is generally to your financial advantage to use a
physician who participates with Medicare. Such
physicians are permitted to collect only up to the
Medicare approved amount.
Our explanation of benefits (EOB) form will tell you how
much the physician or hospital can collect from you. If
your physician or hospital tries to collect more than
allowed by law, ask the physician or hospital to reduce
the charges. If you have paid more than allowed, ask for
a refund. If you need further assistance, call us.
When
you have the
Original Medicare Plan
(Part A, Part B, or both)
|
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. Note: We pay our regular benefits for
emergency services to an institutional
provider, such as a hospital, that does not
participate with Medicare and is not
reimbursed by Medicare.
We use the Department of Veterans Affairs
(VA) Medicare-equivalent Remittance Advice (MRA)
when the statement is submitted to determine
our payment for covered services provided to
you if Medicare is primary, when Medicare
does not pay the VA facility.
If you are covered by Medicare Part B and it
is primary, your out-of-pocket costs for
services that both Medicare Part B and we
cover depend on whether your physician
accepts Medicare assignment for the claim.
If your physician accepts Medicare
assignment, then we waive some of your
deductibles, copayment and coinsurance for
covered charges.
If your physician does not accept
Medicare assignment, then you pay the
difference between the limiting charge or
the physicians charge (whichever is less)
and our payment combined with Medicare's
payment.
It is important to know that a physician who
does not accept Medicare assignment may not
bill you for more than 115% of the amount
Medicare bases its payment on, called the
limiting charge. The Medicare Summary Notice
(MSN) that Medicare will send you will have
more information about the limiting charge.
If your physician tries to collect more than
allowed by law, ask the physician to reduce
the charges. If the physician does not,
report the physician to the Medicare carrier
that sent you the MSN form. Call us if you
need further assistance.
Please see Section
9, Coordinating benefits with other
coverage, for more information about
how we coordinate benefits with Medicare. |
To print this entire
FEHB Brochure or a section of this Brochure, click
here.
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