Identification cards | We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation letter (for annuitants), or your electronic enrollment system (such as Employee Express) confirmation letter.
If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 313-664-8757 or 800-556-9765 or write to us at HAP, 1414 E. Maple Rd. Troy MI 48083.. If you know your HAP ID Number, you may also request replacement cards through our website at www.hap.org. ID cards may also be viewed at any time on the MyHAPCard mobile app (available for iTunes and Android). |
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When you get care | You can receive coverage under this plan on your effective enrollment date. Your effective enrollment date is the first day of your first pay period that starts on or after January 1st. For a few days at the beginning of the year, you may be under your prior plan. Please check with your employing office if you have questions about your effective enrollment date or if you are a new employee. |
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Where you get covered care | HMO members need to choose a PCP. HAP’s HMO network includes thousands of doctors and leading hospitals. Your PCP will provide your preventive care, keep your medical history updated and help you choose a specialist if you need one.
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Plan providers | Plan providers are physicians and other healthcare professionals in our service area that we employ or contract with to provide covered services to our members. Services by Plan Providers are covered when acting within the scope of their license or certification under applicable state law. We credential Plan providers according to national standards.
Benefits are provided under this Plan for the services of covered providers, in accordance with Section 2706(a) of the Public Health Service Act. Coverage of practitioners is not determined by your state’s designation as a medically underserved area. We list Plan providers in the provider directory, which we update periodically. For the most up-to-date list, visit our website at www.hap.org/providers.
This plan recognizes that transgender, non-binary, and other gender diverse members require health care delivered by healthcare providers experienced in gender affirming health. Benefits described in this brochure are available to all members meeting medical necessity guidelines regardless of race, color, national origin, age, disability, religion, sex or gender.
This plan provides Care Coordinators for complex conditions and can be reached 800-556-9765 for assistance. |
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| Plan facilities | Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these in the provider directory, which we update periodically. The list is also on our website. |
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Balance Billing Protection | FEHB Carriers must have clauses in their in-network (participating) providers agreements. These clauses provide that, for a service that is a covered benefit in the plan brochure or for services determined not medically necessary, the in-network provider agrees to hold the covered individual harmless (and may not bill) for the difference between the billed charge and the in network contracted amount. If an in-network provider bills you for covered services over your normal cost share (deductible, copay, co-insurance) contact your Carrier to enforce the terms of its provider contract. |
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What you must do to get covered care | It depends on the type of care you need. First, you and each family member must choose a primary care provider.. Each covered member on your plan may choose their own primary care provider.. This decision is important since your primary care provider. provides or arranges for most of your health care. See "Primary Care" section below for information about how to choose a primary care provider..
HMO members need to choose a PCP. Our HMO network includes thousands of doctors and leading hospitals. To find doctors within your HMO plan, visit hap.org/hmo doctors. You can also call a PCP selection specialist at (888) 742-2727 With this plan, your care is coordinated through your primary care provider.. Your PCP will provide your preventive care, keep your medical history updated and help you choose a specialist if you need one. When you need to see a specialist for an initial consultation, you don’t need to get a referral from HAP.
No matter what network and doctor you choose, you're going to get the care you need
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Primary care | Your primary care provider. can be a family practitioner, internist, general practitioner, or pediatrician. Your primary care provider. will provide most of your healthcare, or give you a referral to see a specialist.
You may change your primary care provider. at any time for any reason. If you would like to change your primary care provider., please call us. If your primary care provider. leaves the plan, we will contact you and help you select a new one. Simply call our primary care provider. Select line at 888-PIC-A-PCP or 888-742-2727. You may also select a primary care provider. online. Log in at www.hap.org and select the tab: Find a Doctor/Facility |
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Specialty care | Your primary care provider. (PCP) will refer you to a specialist for needed care.HAP doesn’t require you to get a referral to see a specialist in your network for an initial consultation. However, the specialist you visit may require a referral from your PCP. The schedules for certain specialists get filled months in advance. They may only accept patients whose PCP believes the patient needs specialty care. You can get behavioral health services without a referral from your PCP, by calling 800-444-5755.
Here are some other things you should know about specialty care:
Chronic/serious ongoing conditions:
- If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your PCP will provide a recommendation for you to see a specialist for care, HAP does not require a referral.
- If you are seeing a specialist when you enroll in HAP’s plan, and your current specialist does not participate with HAP, you must receive treatment from a specialist who does. Generally, HAP will not pay for you to see a specialist who does not participate with our Plan.
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. |
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Hospital care | Your Plan primary care provider. or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of facility. |
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- If you are hospitalized when your enrollment begins
| We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 313-664-8757 or 800-556-9765. If you are new to the FEHB Program, we will arrange for you to receive care and provide benefits for your covered services while you are in the hospital beginning on the effective date of your coverage. If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until: - you are discharged, not merely moved to an alternative care center;
- the day your benefits from your former plan run out, or
- the 92nd day after you become a member of this Plan, whichever happens first.
These provisions apply only to the benefits of the hospitalized person. If your plan terminates participation in the FEHB Program in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply. In such cases, the hospitalized family member’s benefits under the new plan begin on the effective date of enrollment. |
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You need prior Plan approval for certain services | Since your primary care provider. arranges most referrals to specialists and inpatient hospitalization, the pre-service claim approval process only applies to care shown under Other services. |
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| Inpatient hospital admission | Prior authorization/precertification is a review process that ensures you meet the criteria for elective or emergency admissions before going into the hospital. All elective admissions need prior authorization/precertification before you receive inpatient services such as hospital, skilled nursing facility, hospice and behavioral health. If you are admitted to a hospital that isn’t affiliated with us, we may call the doctor treating you to check your status and your care plan. When it is safe, you may be transferred to an affiliated hospital. If you refuse to be transferred, your care at the non-affiliated hospital will not be covered or may be covered at a reduced benefit level. If services such as inpatient care and treatment are needed, you can notify us by calling the number on the back of your ID card. |
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Other Services that need approval | Your primary care provider. has authority to refer you for most services. For certain services, however, your physician must obtain prior approval from us. Before giving approval, we consider if the service is covered, medically necessary, and follows generally accepted medical practice. Your doctor must obtain prior authorization for some services, such as:
- Diagnostic tests such as a MRI or CT Scan
- Durable medical equipment
- Growth hormone therapy (GHT)
- Home care services
- Inpatient care
- Non-emergency ambulance services
- Select outpatient procedures
- Transplants
- Specialty drugs
- Genetic Testing
Physicians may contact us by phone, fax or electronically to submit new requests or to seek a renewal or extension of an existing referral.
You do not need a referral from your doctor to obtain behavioral health care (mental health and substance abuse services). You may directly access services by contacting Coordinated Behavioral Health Management at 800-444-5755. |
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| How to request precertification/prior authorization for an inpatient admission or for Other services | First, your physician, your hospital or your representative, must call us at 800-422-4641 before admission or services requiring prior authorization are rendered. Next, provide the following information: - enrollee’s name and Plan identification number;
- patient’s name, birth date, identification number and phone number;
- reason for hospitalization, proposed treatment, or surgery;
- name and phone number of admitting physician;
- name of hospital or facility; and
- number of days requested for hospital stay.
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Non-urgent care claims | For non-urgent care claims, we will tell the physician and/or hospital the number of approved inpatient days, or the care that we approve for other services that must have prior authorization. We will make our decision within 15 days of receipt of the pre-service claim. 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 notice will include the circumstances underlying the request for the extension and the date when a decision is expected.
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 to 60 days from the receipt of the notice to provide the information.
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Urgent care claims | If you have an urgent care claim (i.e., when waiting for the regular time limit for your medical care or treatment could seriously jeopardize your life, health, or ability to regain maximum function, or in the opinion of a physician with knowledge of your medical condition, would subject you to severe pain that cannot be adequately managed without this care or treatment), we will expedite our review and notify you of our decision within 72 hours. If you request that we review your claim as an urgent care claim, we will review the documentation you provide and our experts decide whether or not it is an urgent care claim by applying the judgment of a prudent layperson that possesses an average knowledge of health and medication.
If you fail to provide sufficient information, we will contact you within 24 hours after we receive the claim to let you know what information we need to complete our review of the claim. You will then have up to 48 hours to provide the required information. We will make our decision on the claim within 48 hours of (1) the time we received the additional information or (2) the end of the time frame, whichever is earlier.
We may provide our decision verbally within these time frames, but we will follow up with written or electronic notification within three days of the verbal notification.
You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM. Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at 800-422-4641. You may also call OPM’s Health Insurance at 202-606-0737 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review. We will cooperate with OPM so they can quickly review your claim on appeal. In addition, if you did not indicate that your claim was a claim for urgent care, call us at 800-422-4641. If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim). |
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| A concurrent care claim involves care provided over a period of time or over a number of treatments. Any reduction or termination of our pre-approved course of treatment before the end of the approved period of time or number of treatments is an appealable decision. This does not include reduction or termination due to benefit changes or if your enrollment ends. If we believe a reduction or termination is warranted, we will allow you sufficient time to appeal and obtain a decision from us before the reduction or termination takes effect.
If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim. |
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The Federal Flexible Spending Account Program – FSAFEDS
| Healthcare FSA (HCFSA) - Reimburses you for eligible out-of-pocket healthcare expenses (such as copayments, deductibles, prescriptions, physician prescribed over-the-counter drugs and medications, vision and dental expenses, and much more) for you and your tax dependents, including adult children (through the end of the calendar year in which they turn 26)
FSAFEDS offers paperless reimbursement for your HCFSA through a number of FEHB and FEDVIP plans. This means that when you or your provider files claims with your FEHB or FEDVIP plan, FSAFEDS will automatically reimburse your eligible out -of-pocket expenses based on the claim information it receives from your plan. |
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Emergency inpatient admission | If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your representative, the physician, or the hospital must phone us within two business days following the day of the emergency admission, even if you have been discharged from the hospital. If you are admitted to a hospital that isn’t affiliated with us, we may call the doctor treating you to check your status and your care plan. When it is safe, you may be transferred to an affiliated hospital. If you refuse to be transferred, your care at the non-affiliated hospital will not be covered or may be covered at a reduced benefit level. |
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| Referrals are not required for OB/GYN services. Complete maternity (obstetrical) care is covered, such as:
- Prenatal & Postpartum care
- Screening for gestational diabetes for pregnant women between 24-28 weeks gestation or first prenatal visit for women at a high risk
- Delivery
- Postnatal care
- Screening and counseling for prenatal and postpartum depression
You do not need precertification of a maternity admission for a routine delivery. However, if your medical condition requires you to stay more than 48 hours after a vaginal delivery or 96 hours after a cesarean section, then your physician or the hospital must contact us for precertification of additional days. Further, if your baby stays after you are discharged, your physician or the hospital must contact us for precertification of additional days for your baby.
Note: When a newborn requires definitive treatment during or after the mother’s hospital stay, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.
See page 30 for more information on maternity care. See page 29 for information on women's preventive care. |
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If your treatment needs to be extended | If you request an extension of an ongoing course of treatment at least 24 hours prior to the end of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim. |
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| What happens when you do not follow the precertification rules when using non-network facilities | Failure to follow the precertification rules for non-network facilities could result in denial of coverage for services and the member will be responsible for payment to non-network providers. |
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Circumstances beyond our control
| Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will make all reasonable efforts to provide you with the necessary care. |
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If you disagree with our pre-service claim decision | If you have a pre-service claim and you do not agree with our decision regarding precertification of an inpatient admission or prior approval of other services, you may request a review in accord with the procedures detailed below. If your claim is in reference to a contraceptive, call 800-556-9765
If you have already received the service, supply, or treatment, then you have a post-service claim and must follow the entire disputed claims process detailed in Section 8. |
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To reconsider a non-urgent care claim
| Within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure.
In the case of a pre-service claim and subject to a request for additional information, we have 30 days from the date we receive your written request for reconsideration to:
1. Precertify your hospital stay or, if applicable, arrange for the healthcare provider to give you the care or grant your request for prior approval for a service, drug, or supply; or
2. Ask you or your provider for more information.
You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days.
If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due. We will base our decision on the information we already have. We will write to you with our decision.
3. Write to you and maintain our denial.
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To reconsider an urgent care claim | In the case of an appeal of a pre-service urgent care claim, within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure.
Subject to a request for additional information, we will notify you of our decision within 72 hours after receipt of your reconsideration request. We will expedite the review process, which allows oral or written requests for appeals and the exchange of information by phone, electronic mail, facsimile, or other expeditious methods. |
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| To file an appeal with OPM | After we reconsider your pre-service claim, if you do not agree with our decision, you may ask OPM to review it by following Step 3 of the disputed claims process detailed in Section 8 of this brochure. |
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