Page numbers referenced within this brochure apply only to the printed brochure

Medical Mutual of Ohio

www.MedMutual.com/feds
Customer Care 800-315-3144

2022



IMPORTANT:
  • Rates
  • Changes for 2022
  • Summary of Benefits
  • Accreditations
A Health Maintenance Organization (Standard and Basic Options)

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 12 for details.

Serving:  The Northeast Ohio Counties of Ashland, Ashtabula, Columbiana, Cuyahoga, Erie, Geauga, Huron, Lake, Lorain, Mahoning, Medina, Portage, Richland, Stark, Summit, Trumbull, and Wayne.

The Northwest Ohio counties of Allen, Auglaize, Defiance, Fulton, Henry, Lucas, Mercer, Ottawa, Putnam, Sandusky, Seneca, Williams and Wood.

Enrollment in this plan is limited.  You must live or work in our geographic service area to enroll.  See page 13 for the requirements.

Enrollment Codes for the Northeast Plan:                            Enrollment Codes for the Northwest Plan        

644 Standard Option - Self Only                                            X64 Standard Option - Self Only
646 Standard Option - Self Plus One                                     X66 Standard Option - Self Plus One
645 Standard Option - Self and Family                                 X65 Standard Option - Self and Family

UX1 Basic Option - Self Only                                                  X61 Basic Option - Self Only
UX3 Basic Option - Self Plus One                                           X63 Basic Option - Self Plus One
UX2 Basic Option - Self and Family                                       X62 Basic Option - Self and Family 

 

Federal Employees Health Benefits Program seal
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Important Notice

Important Notice from Medical Mutual About
 
Our Prescription Drug Coverage and Medicare

The Office of Personnel Management (OPM) has determined that the Medical Mutual 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.

  • 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 advised

    If 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. 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 Benefits

    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 www.socialsecurity.gov, 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 www.medicare.gov for personalized help.
    • Call 800-MEDICARE 800-633-4227, TTY 877-486-2048.



Table of Contents

(Page numbers solely appear in the printed brochure)




Introduction

This brochure describes the benefits of Medical Mutual of Ohio under our contract (CS 1182) between Medical Mutual of Ohio and the United States Office of Personnel Management, as authorized by the Federal Employees Health Benefits Law. Customer care may be reached at 800-315-3144TTY: 711) or through our website www.MedMutual.com/feds.  The address for Medical Mutual's administrative office is:

Medical Mutual of Ohio
2060 East Ninth Street 
Cleveland OH  44115-1355

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 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.  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. Benefit changes are effective January 1, 2022, and changes are summarized on page 14. 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 Medical Mutual.
  • 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 Health Care Fraud!

Fraud increases the cost of healthcare for everyone and increases your Federal Employees Health Benefits Program premium.

OPM’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 retired.

Protect 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 providers, authorized health benefits plan or OPM representative.
  • Let only the appropriate medical professionals review your medical record or recommend services.
  • Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to get it paid.
  • Carefully review explanations of benefits (EOB) statements that you receive from us.
  • Periodically review your claim history for accuracy to ensure we have not been billed for services you did not receive.
  • Do not ask your doctor to make false entries on certificates, bills, or records in order to get us to pay for an item or service.
  • If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following:
    • Call the provider and ask for an explanation. There may be an error.
    • If the provider does not resolve the matter, call us at 800-315-3144 (TTY 711) and explain the situation.
    • If we do not resolve the issue:

CALL - THE HEALTHCARE FRAUD HOTLINE 877-499-7295

OR go to www.opm.gov/our-inspector-general/hotline-to-report-fraud-waste-or-abuse/complaint-form/

The online reporting form is the desired method of reporting fraud in order to ensure accuracy, and a quicker response time.

You can also write to:

United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400
Washington, DC  20415-1100

  • Do not maintain as a family member on your policy:
    • Your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise)
    • Your child age 26 or over (unless they are disabled and incapable of self-support prior to age 26)

A carrier may request that an enrollee verify the eligibility of any or all members listed as covered under the enrollee's FEHB enrollment

  • If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed, with your retirement office (such as OPM) if you are retired, or with the National Finance Center if you are enrolled under Temporary Continuation of Coverage (TCC).
  • Fraud or intentional misrepresentation of material fact is prohibited under the Plan. You can be prosecuted for fraud and your agency may take action against you. 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.
  • If your enrollment continues after you are no longer eligible for coverage (i.e., you have separated from Federal service) and premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not paid. You may be billed by your provider for services received. You may be prosecuted for fraud for knowingly using health insurance benefits for which you have not paid premiums. It is your responsibility to know when you or a family member is no longer eligible to use your health insurance coverage.



Discrimination is Against the Law

Medical Mutual complies with applicable federal civil rights laws, including both Title VII of the Civil Rights Act of 1964.

You can also file a civil rights complaint with the Office of Personnel Management by mail at: Office of Personnel Management Healthcare and Insurance Federal Employee Insurance Operations,  Attention:  Assistant Director, FEIO, 1900 E Street NW, Suite 3400-S, Washington, D.C. 20415-3610.




Preventing Medical Mistakes

Medical mistakes continue to be a significant cause of preventable deaths within the Unites States. While death is the most tragic outcome, medical mistakes cause other problems such as permanent disabilities, extended hospital stays, longer recoveries, and even additional treatments. Medical mistakes and their consequences also add significantly to the overall cost of healthcare. Hospitals and healthcare providers are being held accountable for the quality of care and reduction in medical mistakes by their accrediting bodies. You can also improve the quality and safety of your own healthcare and that of you family members by learning more about and understanding your risks. Take these simple steps:

1. Ask questions if you have doubts or concerns.

  • Ask questions and make sure you understand the answers.
  • Choose a doctor with whom you feel comfortable talking.
  • Take a relative or friend with you to help you take notes, ask questions and understand answers.

2. Keep and bring a list of all the medications you take.

  • Bring the actual medication or give your doctor and pharmacist a list of all the medicines and dosage that you take, including non-prescription (over-the-counter) medications and nutritional supplements.
  • Tell your doctor and pharmacist about any drug, food, and other allergies you have, such as to latex.
  • Ask about any risks or side effects of the medication and what to avoid while taking it. Be sure to write down what your doctor or pharmacist says.
  • Make sure your medication is what the doctor ordered. Ask the pharmacist about your medicine if it looks different than you expected.
  • Read the label and patient package insert when you get your medication, including all warnings and instructions.
  • Know how to use your medication. Especially note the times and conditions when your medication should and should not be taken.
  • Contact your doctor or pharmacist if you have any questions.
  • Understand both the generic and brand names of your medication. This helps ensure you do not receive double dosing from taking both a generic and a brand. It also helps prevent you from taking a medication to which you are allergic.

3. Get the results of any test or procedure.

  • Ask when and how you will get the results of tests or procedures. Will it be in person, by phone, mail, through the Plan or Provider's portal? 
  • Don’t assume the results are fine if you do not get them when expected, Contact your healthcare provider and ask for your results.
  • Ask what the results mean for your care.

4. Talk to your doctor about which hospital or clinic is best for your health needs.

  • Ask your doctor about which hospital or clinic has the best care and results for your condition if you have more than one hospital or clinic to choose from to get the healthcare you need.
  • Be sure you understand the instructions you get about follow-up care when you leave the hospital or clinic.

5. Make sure you understand what will happen if you need surgery.

  • Make sure you, your doctor, and your surgeon all agree on exactly what will be done during the operation.
  • Ask your doctor, “Who will manage my care when I am in the hospital?”
  • Ask your surgeon:
    • "Exactly what will you be doing?"
    • "About how long will it take?"
    • "What will happen after surgery?"
    • "How can I expect to feel during recovery?"
  • Tell the surgeon, anesthesiologist, and nurses about any allergies, bad reactions to anesthesia, and any medications or nutritional supplements you are taking.

 Patient Safety Links

For more information on patient safety, please visit:

  • www.jointcommission.org/speakup.aspx.  The Joint Commission's Speak UPTM  patient safety program.
  • www.jointcommission.org/topics/patient_safety.aspx.  The Joint Commission helps healthcare organizations to improve the quality and safety of the care they deliver.
  • www.ahrq.gov/patients-consumers/. The Agency for Healthcare Research and Quality makes available a wide-ranging list of topics not only to inform consumers about patient safety but to help choose quality healthcare providers and improve the quality of care you receive.
  • www.bemedwise.org. The National Council on Patient Information and Education is dedicated to improving communication about the safe, appropriate use of medication.
  • www.leapfroggroup.org. The Leapfrog Group is active in promoting safe practices in hospital care.
  • www.ahqa.org. The American Health Quality Association represents organizations and healthcare professionals working to improve patient safety.

Preventable Healthcare Acquired Conditions ("Never Events")

When you enter the hospital for treatment of one medical problem, you do not expect to leave with additional injuries, infections or other serious conditions that occur during the course of your stay.  Although some of these complications may not be avoidable, patients do suffer from injuries or illnesses that could have been prevented if the doctors or the hospital had taken proper precautions. Errors in medical care that are clearly identifiable, preventable and serious in the consequences for patients, can indicate a significant problem in the safety and credibility of a healthcare facility.  These conditions and errors are sometimes called "Never Events" or "Serious Reportable Events."

We have a benefit payment policy that encourages hospitals to reduce the likelihood of hospital-acquired conditions such as certain infections, severe bedsores and fractures, and to reduce medical errors that should never happen.  When such an event occurs, neither you nor your FEHB plan will incur costs to correct the medical error.




FEHB Facts

Coverage information




TermDefinition
  • No pre-existing condition limitation
We will not refuse to cover the treatment of a condition you had before you enrolled in this Plan solely because you had the condition before you enrolled.
  • Minimum essential coverage (MEC)

Coverage under this plan qualifies as minimum essential coverage. Please visit the Internal Revenue Service (IRS) website at www.irs.gov/uac/Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision for more information on the individual requirement for MEC.

  • Minimum value standard
Our health coverage meets the minimum value standard of 60% established by the ACA.  This means that we provide benefits to cover at least 60% of the total allowed costs of essential health benefits.  The 60% standard is and actuarial value; your specific out-of-pocket costs are determined as explained in this brochure.
  • Where you can get information about enrolling in the FEHB Program

See www.opm.gov/healthcare-insurance for enrollment information as well as:

  • Information on the FEHB Program and plans available to you
  • A health plan comparison tool
  • A list of agencies that participate in Employee Express
  • A link to Employee Express
  • Information on and links to other electronic enrollment systems

Also, your employing or retirement office can answer your questions, and give you brochures for other plans and other materials you need to make an informed decision about your FEHB coverage. These materials tell you:

  • When you may change your enrollment
  • How you can cover your family members
  • What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire
  • What happens when your enrollment ends
  • When the next Open Season for enrollment begins

We do not determine who is eligible for coverage and, in most cases, cannot change your enrollment status without information from your employing or retirement office. For information on your premium deductions, disability leave, pensions, etc., you must also contact your employing or retirement office.

Once enrolled in your FEHB Program Plan, you should contact your carrier directly for address updates and questions about your benefit coverage.

  • Types of coverage available for you and your family

Self Only coverage is only for the enrollee. Self Plus One coverage is for the enrollee and one eligible family member. Self and Family coverage is for the enrollee and one or more eligible family members.  Family members include your spouse and your dependent children under age 26, including any foster children authorized for coverage by your employing agency or retirement office. Under certain circumstances, you may also continue coverage for a disabled child 26 years of age or older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self Plus One or Self and Family enrollment if you marry, give birth, or add a child to your family. You may change your enrollment 31 days before to 60 days after that event. The Self Plus one or Self and Family enrollment begins on the first day of the pay period in which the child is born or becomes an eligible family member. When you change to Self Plus One or Self and Family because you marry, the change is effective on the first day of the pay period that begins after your employing office receives your enrollment form.  Benefits will not be available to your spouse until you are married.  A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee's FEHB enrollment.

Contact your carrier to obtain a Certificate of Credible Coverage (COCC) or to add a dependent when there is already family Coverage.

Contact your employing or retirement office if you are changing from Self to Self Plus One or Self and Family or to add a newborn if you currently have a Self Only plan.

Your employing or retirement office will not notify you when a family member is no longer eligible to receive benefits, however, we will send you a letter notifying you when a dependent reaches the age limit. Please tell us immediately of changes in family member status, including your marriage, divorce, annulment, or when your child reaches age 26.

If you or one of your family members is enrolled in one FEHB plan, you or they cannot be enrolled in or covered as a family member by another enrollee in another FEHB plan.

If you have a qualifying life event (QLE) - such as marriage, divorce, or the birth of a child - outside of the Federal Benefits Open Season, you may be eligible to enroll in the FEHB Program, change your enrollment, or cancel coverage.  For a complete list of QLEs, visit the FEHB website at www.opm.gov/healthcare-insurance/life-events.  If you need assistance, please contact your employing agency, Tribal Benefits Officer, personnel/payroll office, or retirement office.

  • Family member coverage

Family members covered under your Self and Family enrollment are your spouse (including your spouse by a valid common-law marriage from a state that recognizes common-law marriages) and children as described below. A Self Plus One enrollment covers you and your spouse, or one other eligible family member as described below.

Natural children, adopted children, and stepchildren
Coverage: Natural children, adopted children, and stepchildren are covered until their 26th birthday.

Foster children
Coverage: Foster children are eligible for coverage until their 26th birthday if you provide documentation of your regular and substantial support of the child and sign a certification stating that your foster child meets all the requirements. Contact your human resources office or retirement system for additional information.

Children incapable of self-support
Coverage: Children who are incapable of self-support because of a mental or physical disability that began before age 26 are eligible to continue coverage. Contact your human resources office or retirement system for additional information.

Married children
Coverage: Married children (but NOT their spouse or their own children) are covered until their 26th birthday.

Children with or eligible for employer-provided health insurance
Coverage: Children who are eligible for or have their own employer-provided health insurance are covered until their 26th birthday.

Newborns of covered children are insured only for routine nursery care during the covered portion of the mother's maternity stay.

You can find additional information at www.opm.gov/healthcare-insurance.

  • Children’s Equity Act

OPM has implemented the Federal Employees Health Benefits Children’s Equity Act of 2000. This law mandates that you be enrolled for Self Plus One or Self and Family coverage in the FEHB Program, if you are an employee subject to a court or administrative order requiring you to provide health benefits for your child(ren).

If this law applies to you, you must enroll in Self Plus One or Self and Family coverage in a health plan that provides full benefits in the area where your children live or provide documentation to your employing office that you have obtained other health benefits coverage for your children. If you do not do so, your employing office will enroll you involuntarily as follows:

  • If you have no FEHB coverage, your employing office will enroll you for Self Plus One or Self and Family coverage, as appropriate, in the lowest-cost nationwide plan option as determined by OPM
  • If you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the same option of the same plan; or
  • If you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the lowest-cost nationwide plan option as determined by OPM

As long as the court/administrative order is in effect, and you have at least one child identified in the order who is still eligible under the FEHB Program, you cannot cancel your enrollment, change to Self Only, or change to a plan that does not serve the area in which your children live, unless you provide documentation that you have other coverage for the children.

If the court/administrative order is still in effect when you retire, and you have at least one child still eligible for FEHB coverage, you must continue your FEHB coverage into retirement (if eligible) and cannot cancel your coverage, change to Self Only, or change to a plan that does not serve the area in which your children live as long as the court/administrative order is in effect.  Similarly, you cannot change to Self Plus One if the court/administrative order identifies more than one child.  Contact your employing office for further information.

  • When benefits and premiums start

The benefits in this brochure are effective January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be processed according to the 2022 benefits of your prior plan or option.  If you have met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of your coverage under your new plan or option. However, if your prior plan left the FEHB Program at the end of the year, you are covered under that plan’s 2021 benefits until the effective date of your coverage with your new plan. Annuitants’ coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective date of coverage.

If your enrollment continues after you are no longer eligible for coverage (i.e. you have separated from Federal service) and premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not paid. You may be billed for services received directly from your provider. You may be prosecuted for fraud for knowingly using health insurance benefits for which you have not paid premiums. It is your responsibility to know when you, or a family member, are no longer eligible to use your health insurance coverage.

  • When you retire

When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the last five years of your Federal service. If you do not meet this requirement, you may be eligible for other forms of coverage, such as Temporary Continuation of Coverage (TCC).




When you lose benefits




TermDefinition
  • When FEHB coverage ends

You will receive an additional 31 days of coverage, for no additional premium, when:

  • Your enrollment ends, unless you cancel your enrollment, or
  • You are a family member no longer eligible for coverage.

Any person covered under the 31 day extension of coverage who is confined in a hospital or other institution for care or treatment on the 31st day of the temporary extension is entitled to continuation of the benefits of the Plan during the continuance of the confinement but not beyond the 60th day after the end of the 31 day temporary extension.

You may be eligible for spouse equity coverage or assistance with enrolling in a conversion policy (a non-FEHB individual policy).

  • Upon divorce

If you are divorced from a Federal employee, or annuitant, you may not continue to get benefits under your former spouse’s enrollment. This is the case even when the court has ordered your former spouse to provide health coverage for you. However, you may be eligible for your own FEHB coverage under either the spouse equity law or Temporary Continuation of Coverage (TCC). If you are recently divorced or are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get additional information about your coverage choices. You can also visit OPM's website at www.opm.gov/healthcare-insurance/healthcare/plan-information/.  A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee's FEHB enrollment.

  • Temporary Continuation of Coverage (TCC)

If you leave Federal service, Tribal employment, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC).  The Affordable Care Act (ACA) did not eliminate TCC or change the TCC rule.   For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if you lose your Federal or Tribal job, if you are a covered dependent child and you turn 26, etc.

You may not elect TCC if you are fired from your Federal or Tribal job due to gross misconduct.

Enrolling in TCC. Get the RI 79-27, which describes TCC, from your employing or retirement office or from www.opm.gov/healthcare-insurance. It explains what you have to do to enroll.

Alternatively, you can buy coverage through the Health Insurance Marketplace where, depending on your income, you could be eligible for a new kind of tax credit that lowers your monthly premiums.  Visit www.HealthCare.gov to compare plans and see what your premium, deductible, and out-of-pocket costs would be before you make a decision to enroll.  Finally, if you qualify for coverage under another group health plan ( such as your spouse's plan) you may be able to enroll in that plan, as long as you apply within 30 days of losing FEHB Program coverage.

  • Converting to individual coverage

If you leave Federal or Tribal service, your employing office will notify you of your right to convert.  You must contact us in writing within 31 days after you receive this notice.  However, if you are a family member who is losing coverage, the employing or retirement office will not notify you.  You must contact us in writing within 31 days after you are no longer eligible for coverage.

Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, a waiting period will not be imposed and your coverage will not be limited due to pre-existing conditions.  When you contact us, we will assist you in obtaining information about health benefits coverage inside or outside the Affordable Care Act's Health Insurance Marketplace in your state.  For assistance in finding coverage, please contact us at 800-315-3144 or visit our website at www.MedMutual.com/feds

  • Health Insurance Marketplace

If you would like to purchase health insurance through the ACA’s Health Insurance Marketplace, please visit www.HealthCare.gov. This is a website provided by the U.S. Department of Health and Human Services that provides up-to-date information on the Marketplace.




Section 1. How This Plan Works

This Plan is a health maintenance organization (HMO) plan. OPM requires that FEHB plans be accredited to validate that plan operations and/or care management meet nationally recognized standards.  Medical Mutual holds the following accreditations: National Committee for Quality Assurance (www.ncqa.org).  To learn more about this plans accreditation(s), please visit the following website:  www.MedMutual.com/feds.  

We require you to see specific physicians, and use hospitals and other providers that contract with us. These Plan providers coordinate your health care services. We are solely responsible for the selection of these providers in your area. Contact us for a copy of our most recent Provider Directory. We give you a choice of enrollment in a Standard Option or a Basic Option Plan.

HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any course of treatment.

When you receive services from Plan providers, you will not have to submit claims or pay bills. You pay only the copayments and coinsurance described in this brochure. When you receive emergency services, or services related to accidental injury to teeth from non-Plan providers, you may have to submit claims.

You should join an HMO because you prefer the plan’s benefits, not because a particular provider is available. You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician, hospital, or other provider will be available and/or remain under contract with us.

Questions regarding what protections apply may be directed to us at 800-315-3144. You can also read additional information from the U.S. Department of Health and Human Services at www.HealthCare.gov.

General features of our  Standard  and Basic Options

How we pay providers

We contract with physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan providers accept a negotiated payment from us, and you will only be responsible for your cost-sharing (copayments, coinsurance, deductibles, and non-covered services and supplies).

Preventive care services

Preventive care services are generally covered with no cost sharing and are not subject to copayments, deductibles or annual limits when received from a network provider.

Your rights and responsibilities

OPM requires that all FEHB plans provide certain information to their FEHB members. You may get information about us, our networks, and our providers, and our facilities. OPM’s FEHB Website www.opm.gov/healthcare-insure/ lists the specific types of information that we must make available to you. Some of the required information is listed below.

  • Your Medical Mutual plan is underwritten and insured by Medical Mutual of Ohio. A trusted insurer for more than 80 years, Medical Mutual is the oldest and largest health insurance company headquartered in the state of Ohio. We are a mutual health insurance company, owned by its policyholders and directed by a Board of Trustees and corporate officers.
  • This medical benefit Plan is provided by Medical Mutual of Ohio.  Medical and hospital services are provided by the Medical Mutual MedFlex Network of providers.  

You are also entitled to a wide range of consumer protections and have specific responsibilities as a member of this Plan. You can view the complete list of these rights and responsibilities by visiting our website, Medical Mutual of Ohio at www.MedMutual.com/feds.  You can also contact us to request that we mail a copy to you.

If you want more information about us, call 800-315-3144 (TTY: 711) or write to Medical Mutual of Ohio, Customer Care, PO Box 6018, Cleveland, OH 44101-1018. You may also visit our website at www.MedMutual.com/feds.

By law, you have the right to access your protected health information (PHI). For more information regarding  access to PHI, visit our website at www.MedMutual.com/feds to obtain our Notice of Privacy Practices.  You can also contact us to request that we mail you a copy of that Notice.

Your medical and claims records are confidential

We will keep your medical and claims records confidential. Please note that we may disclose your medical and claims information (including your prescription drug utilization) to any of your treating physicians or dispensing pharmacies.

Language interpretation services

Language interpretation services are available to non-English speaking members. Please ask an English speaking friend or relative to call Customer Care at 800-315-3144 (TTY: 711).

Service Area

To enroll in this Plan, you must live or work in our service area. This is where our providers practice. 

Our Northeast service area includes the following counties:

Ashland, Ashtabula, Columbiana, Cuyahoga, Erie, Geauga, Huron, Lake, Lorain, Mahoning, Medina, Portage, Richland, Stark, Summit, Trumbull, and Wayne.

Our Northwest service area includes the following counties:

Allen, Auglaize, Defiance, Fulton, Henry, Lucas, Mercer, Ottawa, Putnam, Sandusky, Seneca, Williams and Wood.

Ordinarily, you must receive your care from physicians, hospitals, and other providers who contract with us. If you receive care outside our service area, we will pay only for emergency care benefits.  We will not pay for any other healthcare services out of our service area unless the services have prior plan approval.

If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live out of the area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service plan or an HMO that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait until Open Season to change plans. Contact your employing or retirement office.




Section 2. Changes for 2022

Do not rely only on these change descriptions; this Section is not an official statement of benefits. For that, go to Section 5 Benefits.  Also, we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not change benefits.

Program-wide changes

  • Effective in 2022, premium rates are the same for Non-Postal and Postal employees.

Changes to the Standard and Basic Option:

  • The Standard and Basic Options will now include coverage for iatrogenic infertility services. (see page  31) 
  • The plan will add coverage for two anti-obesity drugs, Qsymia and Imcivree on the FEHB drug formulary.

Changes to Standard Option:

  • Your share of the premium rate will increase for Self Only, Self Plus One and for Self and Family. See page 82.

Changes to Basic Option:

  • Your share of the premium rate will increase for Self Only, Self Plus One and for Self and Family. See page 82.



Section 3. How You Get Care

TermDefinition

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. Providers may request photo identification together with your ID card to verify identity. 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 Customer Care at 800-315-3144 (TTY: 711) or write to us at: Customer Care, Medical Mutual of Ohio, PO Box 6018, Cleveland, OH 44101-1018. After registering on our Website at www.MedMutual.com/feds, you may also request replacement cards electronically.

Where you get covered care

You get care from “Plan providers” and “Plan facilities.”  You will only pay cost-sharing as defined in Section 10, Definitions of terms we use in this brochure.

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. 

Plan providers

Plan providers are physicians and other healthcare professionals in our service area that we contract with to provide covered services to our members. We contract with the MedFlex provider network to provide or arrange covered services for our members. Medical care is provided through physicians, nurse practitioners, physician assistants, and other skilled medical personnel. Specialists in most major specialties are available as part of the medical teams for consultation and treatment. Other necessary medical care, such as physical therapy, laboratory and X-ray services, is also available. We credential Plan providers according to national standards.

We list Plan providers in the Provider Directory, which we update periodically. Directories are available at the time of enrollment or upon request by calling Customer Care at 800-315-3144 (TTY: 711). The list is also on our Website at www.MedMutual.com/feds.

This plan recognizes that transsexual, transgender, and gender-nonconforming members require health care delivered by healthcare providers experienced in transgender health. While gender reassignment surgeons (benefit details found in Section 5(b)) and hormone therapy providers (benefit details found in Section 5(f)) play important roles in preventive care, you should see a primary care provider familiar with your overall health care needs. Benefits described in this brochure are available to all members meeting medical necessity guidelines. 

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 Plan facilities in our Provider Directory, with their locations and phone numbers. Directories are updated on a regular basis and are available at the time of enrollment or upon request by calling Customer Care at 800-315-3144  (TTY:711). The list is also on our Website at www.MedMutual.com/feds.

What you must do to get covered care

It depends on the type of care you need. First, you and each covered family member should choose a primary care physician. This decision is important since your primary care physician provides or arranges for most of your health care.

To choose or change your primary care physician, you can either select one from our Provider Directory, from our Website, www.MedMutual.com/feds, or you can call Customer Care at 800-315-3144  (TTY: 711).

  • Primary care

We encourage you to choose a primary care physician when you enroll. You may choose any primary care Plan physician who is available to accept you. Parents may choose a pediatrician as the Plan physician for their child. Your primary care physician will provide most of your healthcare, or give you a referral to see a specialist.

Please notify us of the primary care physician you choose. If you need help choosing a primary care physician, call us. You may change your primary care physician at any time. You are free to see other Plan physicians if your primary care physician is not available, and to receive care at other MedFlex facilities.

Specialty care

Here are some other things you should know about specialty care:

Specialty care is care you receive from providers other than a primary care physician. You may pay different cost-sharing for your specialty care. A referral is not required to see a specialist that is participating in your network. You may make appointments directly with these providers.

You generally must receive your care from a participating Network provider. However, if your Network provider determines that covered services are not available from participating In Network providers, they will need to obtain authorization in advance for a referral, you may seek the initial consultation from the specialist to whom you are referred. You must then return to your Network physician after the consultation, unless your referral authorizes a certain number of additional visits without the need to obtain another referral. In order to receive covered follow up care from an Out of Network specialist, the provider must first obtain authorization from us. Do not go to an Out of Network provider for return visits until you have received written authorization from us for additional services. Services, drugs and supplies related to a covered abortion (see Section 6. General exclusions - services, drugs and supplies we do not cover), are covered. Please contact Medical Mutual for information on how to access this coverage including claims related issues at 800-315-3144.

  • If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide what treatment you need. If they decide to refer you to a specialist, ask if you can see your current specialist. If your current specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.
  • If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will work with you to identify another specialist for you to see.
  • If you have a chronic and disabling condition and lose access to your specialist because we:

- terminate our contract with your specialist for a reason other than cause;

- drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB plan; or

- reduce our service area and you enroll in another FEHB plan you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us, or if we drop out of the Program, contact your new 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.

Hospital care

Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of facility.

  • 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 Customer Care immediately at 800-315-3144  (TTY: 711). 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.

You need prior Plan approval for certain services

For certain services your Plan provider must obtain approval from us. Before giving approval, we may consider if the service or item is medically necessary and meets other coverage requirements. We call this review and approval process “precertification.”

Your Plan provider must obtain precertification for:

  • Inpatient hospital care services, surgery and procedures
  • Certain Outpatient surgeries, call customer service for information 
  • Non-emergency Ambulance transport, including air ambulance
  • Bariatric surgery and related services
  • Chemotherapy
  • Clinical trials
  • Cosmetic, reconstructive and plastic surgery
  • Durable medical equipment (DME) and orthopedic and prosthetic devices
  • Home health services
  • Inpatient services for behavioral health and alcohol and chemical dependency
  • Injections/infusions
  • Organ/tissue transplants and related services 
  • Skilled Nursing Facility 
  • Hyperbaric oxygen  
  • Dental Related Procedures due to accident or injury
  • Genetic Testing (including but not limited to BRCA1 and BRCA2)
  • Services or items from a non-Plan Provider or at non-Plan facilities
  • Gender Reassignment surgery and related services

When you receive medical services for which you do not have precertification or that you receive from non-Plan providers or from non-Plan facilities that have not been referred by a Plan provider and approved by us, we will not pay for them except in an emergency. Charges for these medical services will be your financial responsibility.

To confirm if your service or item requires precertification, please call Customer Care at 800-315-3144  (TTY: 711).

Your Plan provider submits the request for the services above with supporting documentation. You should call your Plan provider’s office if you have not been notified of the outcome of the review within 5 working days. If your request is not approved, you have the right to ask us in writing to reconsider our initial decision (see Section 8,The disputed claims process).

Precertification determinations are made based on the information available at the time the service or item is requested. We will not cover the service or item unless you are a Plan member on the date you receive the service or item.

Inpatient Hospital Admission

Precertification 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.

How to request precertification for an admission or get prior authorization for other services

First, your physician, your hospital, you, or your representative, must call us at 800-315-3144 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.

 

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.

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 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 medicine.

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 orally within these time frames, but we will follow up with written or electronic notification within three days of oral 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  800-315-3144 (TTY: 711).  You may also call OPM's Health Insurance  at 202 606-0755 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 800-315-3144 (TTY: 711).  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).

  • Concurrent care claims

A concurrent care claim involves care provided over a period of time or over a number of treatments. We will treat any reduction or termination of our pre-approved course of treatment before the end of the approved period of  time or number of treatments as 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.

The Federal Flexible Spending Account Program –FSAFEDS

  • HealthCare FSA (HCFSA)–Reimburses you for eligible out-of-pocket healthcare expenses (such as copayments, deductibles, 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.
Emergency services/accidents and post-stabilization care

Emergency services do not require precertification. However, if you are admitted to a non-Plan facility, you or your family member must notify the Plan as soon as reasonably possible, or your claims may be denied.

You must obtain precertification from us for post-stabilization care you receive from non-Plan providers.

See Section 5(d), Emergency services/accidents for more information.

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 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.

What happens when you do not follow the precertification rules If you or your Plan physician do not obtain prior authorization from us for services or items that require prior authorization, we will not pay any amount for those services or items and you may be liable for the full price of those services or items. This also includes any residual amounts, such as deductibles, copayments or coinsurance, that are not covered or not paid by any other insurance plan you use to pay for those services or items.
Circumstances beyond our control

Under 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.

If you disagree with our pre-service claim decision

If you have a pre-service claim and you do not agree with our prior approval decision, you may request a review in accord with the procedures detailed below.

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.

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 do one of the following:

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.

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.

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.

Unless we request 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 request for appeals and the exchange of information by telephone, electronic mail, facsimile, or other expeditious methods.

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.




Section 4. Your Cost for Covered Services

This is what you will pay out-of-pocket for covered care:




TermDefinition
Cost-sharingCost-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.

Copayments

A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive certain services. The amount of copayment will depend upon whether you are enrolled in the Standard or Basic Option, the type of provider, and the service or supply that you receive.

You pay a primary care provider copayment when you visit any primary care provider as described in Section 3, How you get care. You pay a specialist copayment when you receive care from a specialist as described in Section 3.

For example, for diagnostic and treatment services as described in Section 5(a):

  • Under the Standard Option, you pay a $25 copayment when you receive diagnostic and treatment services from a primary care provider and a $45 copayment when you receive these services from a specialty care provider.
  • Under the Basic Option, you pay a $30 copayment when you receive diagnostic and treatment services from a primary care provider and a $60 copayment when you receive these services from a specialty care provider.

Deductible

A deductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for them.  Copayments do not count toward any deductible.

  • We do not have a calendar year deductible for the Standard Option.
  • The Basic Option calendar year deductible is $750 per person.  Under a Self Only enrollment, the deductible is considered satisfied and benefits are payable for you when your covered expenses applied to the calendar year deductible for your enrollment reach $750 under Basic Option.  Under a Self Plus One enrollment, the deductible is considered satisfied and benefits are payable for you and one other eligible family member when the combined covered expenses applied to the calendar year deductible for your enrollment reach $1,500 under Basic Option.  Under a Self and Family enrollment, the deductible is considered satisfied and benefits are payable for all family members when the combined covered expenses applied to the calendar year deductible for family members reach $1,500 under Basic Option.
  • Financial assistance programs also known as “Patient Assistance Programs,” “Fee Forgiveness,” “Not Out-of-Pocket,” “Manufacturers Coupons,”, “Discount programs,” for Specialty Drugs will not count towards the member’s out-of-pocket maximum or deductible, if you have one. (See page 63)

Coinsurance

Coinsurance is the percentage of our allowance that you must pay for certain services you receive.  Coinsurance does not begin until you have met your calendar year deductible.

Example: In our Plan, you pay 30% of our allowance for infertility services.

Differences between our Plan allowance and the bill

You should also see section Important Notice About Surprise Billing - Know Your Rights below that describes your protections against surprise billing under the No Surprises Act.

Your catastrophic protection out-of-pocket maximum

After your out-of-pocket expenses, including any applicable deductible, copayments and coinsurance total $6,000 for Self Only, or $12,000 for Self Plus One or Self and Family enrollment (for the Standard Option) or $6,500 for Self Only, or $13,000 for Self Plus One or Self and Family enrollment (for the Basic Option) in any calendar year, you do not have to pay any more for certain covered services. The maximum annual limitations on cost sharing listed under Self Only of $6,000 applies to each individual, regardless of whether the individual is enrolled in a Self Only, Self Plus One or a Self and Family.

Example Scenario (Standard Option): Your plan has a $6,000 Self Only Maximum out-of-pocket limit and a $12,000 Self Plus One or Self and Family maximum out-of-pocket limit.  If you or one of your eligible family members has out-of-pocket qualified medical expenses of $6,000 or more for the calendar year, any remaining qualified medical expenses for that individual will be covered fully by your health plan.  With a Self and Family or Self Plus One enrollment out-of-pocket maximum of $12,000, a second family member, or an aggregate of other eligible family members, will continue to accrue out-of-pocket qualified medical expenses up to a maximum of $12,000 for the calendar year before their qualified medical expenses will begin to be covered in full.

Be sure to keep accurate records and receipts of your copayments and coinsurance to ensure the plan's calculation of your out-of-pocket maximum is reflected accurately.

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 prior 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 prior 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 prior plan will first apply your covered out-of-pocket expenses until the prior year’s 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 prior 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.

When Government facilities bill us

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. They may not seek more than their governing laws allow. You may be responsible to pay for certain services and charges.  Contact the government facility directly for more information.

Important Notice About Surprise Billing - Know Your Rights

The No Surprises Act (NSA) is a federal law that provides you with protections against "surprise billing" and "balance billing" under certain circumstances.  A surprise bill is an unexpected bill you receive from a nonparticipating health care provider, facility, or air ambulance service for healthcare. Surprise bills can happen when you receive emergency care - when you have little or no say in the facility or provider from whom you receive care.  They can also happen when you receive non-emergency services at participating facilities, but you receive some care from nonparticipating providers.

Balance billing happens when you receive a bill from a nonparticipating provider, facility, or air ambulance service for the difference between the nonparticipating provider's charge and the amount payable by your health plan. 

Your health plan must comply with the NSA protections that hold you harmless from unexpected bills.  




Section 5. Standard and Basic Option Benefits (Standard and Basic Option)

See page 14 for how our benefits changed this year. Pages 80-81, and 82-83 are benefit summaries of each option. Make sure that you review the benefits that are available under the option in which you are enrolled.




(Page numbers solely appear in the printed brochure)




Section 5. Standard and Basic Option Benefits Overview (Standard and Basic Option)

This Plan offers a Standard and a Basic Option. The benefit packages are described in Section 5. Make sure that you review the benefits that are available under the option in which you are enrolled.

The Standard and Basic Options in Section 5 are divided into subsections. Please read Important things you should keep in mind at the beginning of the subsections. Also read the general exclusions in Section 6; they apply to the benefits in the following subsections. To obtain claims filing advice, or more information about Standard and Basic Option benefits, contact us at 800-315-3144 (TTY: 711) or on our Website at www.MedMutual.com/feds.

This Plan offers two options: the Standard and Basic Options. Both Options are designed to include preventive and acute care services provided by our Plan providers, but offer different levels of benefits and services for you to choose from to best fit your health care needs.

Each option offers unique features:

Standard Option

Specific benefits of our FEHB Standard Option include:

  • $25 per visit to your primary care physician (PCP) or $45 per visit to a specialist for diagnostic services
  • $650 per inpatient admission
  • $250 per visit for emergency services
  • $15 per prescription or refill for covered retail generic drugs up to a 30-day supply
  • $75 per prescription or refill for covered retail preferred  brand name drugs up to a 30-day supply
  • $180 per prescription or refill for covered retail non-preferred brand name drugs up to a 30-day supply.
  • 25% up to $500 per prescription or refill for covered Specialty Drugs up to a 30-day supply through a contracted specialty pharmacy.

Basic Option

Specific benefits of our FEHB Basic Option include:

  • $30 per visit to your primary care physician (PCP) or $60 per visit to a specialist for diagnostic services
  • 20% coinsurance after deductible per inpatient admission
  • $250 per visit for emergency services
  • $10 per prescription or refill for covered retail generic drugs up to a 30-day supply
  • 40% up to $250 per prescription or refill for covered retail preferred brand name drugs up to a 30-day supply
  • 60% up to $350 per prescription or refill for covered retail non-preferred brand name drugs up to a 30-day supply.
  • 30% up to $500 per prescription or refill for covered retail Specialty Drugs up to a 30 day supply through a contracted specialty pharmacy .

Please review this brochure carefully to learn which of our Medical FEHB options is best for you. If you would like more information about our benefits please contact us at 800-315-3144 (TTY: 711) or visit our Website: www.MedMutual.com/feds.




Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals (Standard and Basic Option)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • Plan physicians must provide or arrange your care.
  • The Standard Option has no calendar year deductible.  The calendar year deductible for the Basic Option is $750 per person ($1,500 per Self Plus One enrollment, or $1,500 per Self and Family enrollment).  We added "after deductible" when the deductible applies.
  • Be sure to read Section 4, Your cost for covered services, for valuable information about how cost-sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
  • YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR SOME MEDICAL PROCEDURES.  Please refer to the precertification information shown in Section 3 to be sure which services and supplies require precertification.



Benefit Description : Diagnostic and treatment servicesStandard Option (You pay )Basic Option (You pay )

Professional services of physicians and other health care professionals

  • In a physician’s office
  • Office medical consultations
  • Second surgical opinions
  • Advance care planning

$25 per primary care office visit

$45 per specialty care office visit

$30 per primary care office visit

$60 per specialty care office visit

Professional services of physicians and other health care professionals

  • In an urgent care center

$35 per visit

$45 per visit

Professional services of physicians and other health care professionals

  • In ambulatory surgical centers
  • At home by a physician
  • During a hospital stay
  • In a skilled nursing facility

Nothing

20% after deductible

Benefit Description : Telehealth servicesStandard Option (You pay )Basic Option (You pay )

Services not performed in-person

When performed by a Provider with whom Medical Mutual has an agreement to perform these services, your coverage will include:

  • Providers' charges for consulting by telephone, facsimile machine, electronic mail systems or online services.
  • Online covered services include a medical consultation using the internet via a webcam, chat or voice.

$25 per primary care office visit

$45 per specialty care office visit

$30 per primary care office visit

$60 per specialty care office visit

Not covered:

Non covered services include, but are not limited to, communications used for:

  • Reporting normal lab or other test results
  • Office appointment requests
  • Billing, insurance coverage or payment questions
  • Requests for referrals to doctors outside the online care panel
  • Benefit precertification
  • Physician-to-Physician consultation

All charges

All charges

Benefit Description : Lab, X-ray and other diagnostic testsStandard Option (You pay )Basic Option (You pay )

Tests, such as:

  • Blood tests
  • Urinalysis
  • Non-routine pap test
  • Pathology
  • X-ray
  • Non-routine mammogram
  • CT Scans/MRI
  • Ultrasound
  • Electrocardiogram and EEG
  • Nuclear medicine
  • PET scans

Note: Tests related to infertility are covered under the infertility services benefit. See Section 5(a), Infertility services.

Nothing

20% after deductible

Benefit Description : Preventive care, adultStandard Option (You pay )Basic Option (You pay )

Routine physical every year

Nothing

Nothing

The following preventive services are covered at the time interval recommended at each of the links below.

  • Immunizations such as Pneumococcal, influenza, shingles, tetanus/DTaP, and human papillomavirus (HPV).  For a complete list of immunizations go to the Centers for Disease Control (CDC) website at                              https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html
  • Screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer screening.  For a complete list of screenings go to the U.S. Preventive Services Task Force (USPSTF) website at                                                               https://www.uspreventiveservicestaskforce.org
  • Individual counseling on prevention and reducing health risks
Nothing

Nothing

  • Well woman care such as Pap smears, gonorrhea prophylactic medication to protect newborns, annual counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence.  For a complete list of Well Women preventive care services please visit the Health and Human Services (HHS) website at  https://www.healthcare.gov/preventive-care-women/
Nothing

Nothing

  • Routine mammogram - covered for women:

Nothing

Nothing

  • Adult immunizations-endorsed by the Centers for Disease Control and Prevention (CDC): based on the 
    Advisory Committee on Immunization Practices (ACIP) schedule.
  • To build your personalized list of preventive services go to https://health.gov/myhealthfinder

Note:  Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance, and deductible.

Nothing

Nothing

Not covered:

  • Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel.
  • Immunizations, boosters, and medications for travel or work-related exposure. 

All charges



All charges

Benefit Description : Preventive care, childrenStandard Option (You pay )Basic Option (You pay )
  • Well-child visits, examinations, and other preventive services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics.  For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to                                                   https://brightfutures.aap.org
  • Immunizations such as DTaP, Polio, Measles, Mumps, and Rubella (MMR), and Varicella.  For a complete list of immunizations go to the Centers for Disease Control (CDC) website at                                         https://www.cdc.gov/vaccines/schedules/index.html
  • You can also find a complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) online at                                                                                                       https://www.uspreventiveservicestaskforce.org
  • To build your personalized list of preventive services go to https://health.gov/myhealthfinder

Note:  Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive listing of services will be subject to the applicable member copayments, coinsurance, and deductible.

Nothing

Nothing

Benefit Description : Maternity careStandard Option (You pay )Basic Option (You pay )

Routine maternity (obstetrical) care, such as:

  • Prenatal care
  • Screening for gestational diabetes for pregnant women.
  • Delivery
  • Postpartum Care

Note: Here are some things to keep in mind:  

  • Routine maternity care is covered after confirmation of pregnancy.
  • You need prior approval for your vaginal delivery. See Section 3, You need prior Plan approval for certain services, for prior approval guidelines.
  • You may remain in the hospital up to 48 hours after a vaginal delivery and 96 hours after a cesarean delivery. We will extend your inpatient stay if medically necessary.
  • We cover routine nursery care of the newborn child during the covered portion of the mother’s maternity stay and other non-routine treatment of an eligible infant for the first 31 days. We cover other care beyond the first 31 days only if we cover the infant under a Self Plus One or Self and Family enrollment.
  • Should you receive other service for illness, injury  or condition during a non-routine maternity care visit, you may be charge the cost share. We cover surgical services (delivery) and hospitalization the same as for illness and injury. See Section 5(b), Surgery benefits and Section 5(c), Hospital benefits.
  • For coverage of breastfeeding pumps, see Section 5(a), Durable medical equipment (DME).  
  • Hospital services are covered under Section 5(c) and Surgical benefits Section 5(b).

Note:  When a newborn requires definitive treatment during or after the mother's confinement, 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.

Nothing

Nothing

Benefit Description : Family planning Standard Option (You pay )Basic Option (You pay )

A range of family planning services for women, limited to:

  • Female voluntary sterilization (See Section 5(b), Surgical procedures)
  • Surgically implanted contraceptive drugs
  • Injectable contraceptive drugs (such as DePo Provera)
  • Family planning counseling  
  • Contraceptives counseling on an annual basis

Notes:

  • We cover contraceptive drugs and devices under Prescription drug benefits. See Section 5(f).
  • Male family planning services are covered in Primary and Specialty office visits.  See Section 5(a), Diagnostic and treatment services. 

Nothing

 

Nothing

Not covered:

  • Reversal of voluntary surgical sterilization

All charges

All charges

Benefit Description : Infertility servicesStandard Option (You pay )Basic Option (You pay )

Diagnosis and treatment of involuntary infertility, including Intrauterine insemination (IUI), a form of artificial insemination.

Coverage is provided for standard fertility preservation procedures for men and women as recognized by the American Society for Reproductive Medicine (ASRM) and/or American Society of Clinical Oncology (ASCO), for anyone facing the possibility of “iatrogenic infertility,” that is, infertility caused by a necessary medical intervention.  This type of coverage does not include:

  • "Elective fertility preservation, such as egg freezing sought due to natural aging;
  • Infertility treatments such as in vitro fertilization that might be needed after the necessary medical intervention, such as cancer treatment to achieve a pregnancy; or
  • Long-term storage costs

30% of our allowance per outpatient visit

Nothing for inpatient

50% after deductible

Infertility drugs administered in the office

Note: See Section 5(f), Prescription drug benefits, for coverage of fertility drugs.

All charges

All charges

Not covered:

These exclusions apply to fertile as well as infertile individuals or couples:

  • Assisted reproductive technology (ART) procedures, including related services and supplies, such as:
    • in vitro fertilization (IVF)
    • embryo transfer and gamete intra-fallopian transfer (GIFT) and zygote intra-fallopian transfer (ZIFT)
  • Sperm and eggs (whether from a member or from a donor) and services and supplies related to their procurement and storage, including freezing
  • Ovum transplants
  • Infertility services when either member of the family has been voluntarily surgically sterilized
  • Services to reverse voluntary, surgically induced infertility
  • Intravaginal insemination (IVI)
  • Intracervical insemination (ICI)
  • Services for surrogate mothers who are not Plan members
  • Preimplantation Genetic Diagnosis (PGD)
  • Services that are not FDA supported or supported by evidence based guidelines

All charges

All charges

Benefit Description : Allergy careStandard Option (You pay )Basic Option (You pay )
  • Testing

$25 per primary care office visit

$45 per specialty care office visit

20% after deductible

  • Treatment

Nothing

Nothing

  • Serum
Nothing

Nothing

Not covered:

  • Sublingual allergy desensitization

All charges

All charges

Benefit Description : Treatment therapiesStandard Option (You pay )Basic Option (You pay )
  • Cardiac rehabilitation

$25 per outpatient office visit

20% after deductible

  • Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Section 5(b), Organ/Tissue transplants.

$25 per office visit

20% after deductible

  • Dialysis – hemodialysis and peritoneal dialysis
  • Intravenous (IV)/Infusion Therapy - Home IV and antibiotic therapy

Note:  Intravenous (IV)/Infusion Therapy requires our prior approval.  See Section 3, You need prior Plan approval for certain benefits.

$25 per office visit, except Nothing if received in the home

20% after deductible

  • Growth hormone therapy

Note: Growth hormone requires our prior approval and is covered under the prescription drug benefit. See Section 3, You need prior Plan approval for certain benefits and Section 5(f), Prescription drug benefits.

$25 per office visit

20% after deductible

  • Respiration and inhalation therapy
Nothing

20% after deductible

  • Medical Nutrition Therapy - Behavioral Counseling for pregnant women to promote a healthy diet

  • Medical Nutrition Therapy - Behavioral Counseling for children with Phenylketonuria (PKU)

  • *Must meet specific medical criteria

First nine visits - Nothing

After initial nine preventive visits - Nothing

First nine visits - Nothing

After initial nine preventive visits- 20% after deductible

Not covered:

  • Chemotherapy supported by a bone marrow transplant or with stem cell support for any diagnosis not listed as covered under Section 5(b), Organ/Tissue transplants.

All charges

All charges

Benefit Description : Physical and occupational therapiesStandard Option (You pay )Basic Option (You pay )

60 visits per calendar year (combined benefit for Physical and Occupational Therapy):

  • Physical habilitative and rehabilitative therapy by qualified physical therapists to attain or restore bodily function when you have a total or partial loss of bodily function due to illness or injury
  • Occupational habilitative and rehabilitative therapy by occupational therapists to assist you in attaining or resuming self-care and improved functioning in other activities of daily life when you have a total or partial loss of bodily function due to illness or injury
  • ABA Therapy- Up to 20 hours a week of therapeutic intervention defined as therapies supported by empirical evidence, which includes but is not limited to Applied Behavioral Analysis, provided by or under the supervision of a professional who is licensed, certified, or registerd by an appropriate agency of the state of Ohio to perform the services in accordance with a treatment plan for persons with a diagnosis of Autism Spectrum Disorder.
 

$25 per outpatient office visit

Nothing for inpatient

20% after deductible

60 visits per calendar year (combined benefit for Physical and Occupational Therapy)

$25 per outpatient office visit

Nothing for inpatient

20% after deductible

Not covered:

  • Long-term therapy
  • Exercise programs
  • Maintenance therapy
  • Cognitive rehabilitation programs
  • Therapies done primarily for educational purposes
  • Services provided by local, state and federal government agencies, including schools

All charges

All charges

Benefit Description : Speech therapy Standard Option (You pay )Basic Option (You pay )

Habilitative and rehabilitative services for 60 visits per calendar year.

$25 per outpatient office visit

Nothing for inpatient

20% after deductible

Nothing for inpatient

Not covered:

  • Therapies done primarily for educational purposes
  • Therapy for tongue thrust in the absence of swallowing problems
  • Voice therapy for occupation or performing arts
  • Services provided by local, state, and federal government agencies including schools

All charges

All charges

Benefit Description : Hearing services (testing, treatment, and supplies)Standard Option (You pay )Basic Option (You pay )
  • Hearing aids for children through age 17, if the hearing aids are prescribed, fitted, and dispensed by a licensed Plan audiologist

Notes:

  • A single hearing aid providing hearing to both ears (binaural hearing aid) is considered two hearing aids for purposes of this benefit.
  • For coverage of:
    • Hearing screenings, see Section 5(a), Preventive care, children and, for any other hearing testing, see Section 5(a), Diagnostic and treatment services.
    • Audible prescription reading and speech generating devices, see Section 5(a), Durable medical equipment

All charges in excess of $1,000 for each hearing impaired ear every 36 months

All charges in excess if $1,000 for each hearing impaired ear every 36 months

Not covered:

  • All other hearing testing, except as may be covered in Section 5(a), Diagnostic and treatment services and Section 5(a), Preventive care, children
  • Hearing aids, including testing and examinations for them, for all persons age 18 and over.

All charges

All charges

Benefit Description : Vision services (testing, treatment, and supplies)Standard Option (You pay )Basic Option (You pay )
  • Diagnosis and treatment of diseases of the eye
  • Eye refractions to determine the need for vision correction and provide a prescription for eyeglasses or contact lenses

$25 per primary care office visit

$45 per specialty care office visit

$60 per office visit

Not covered:

  • Eyeglass lenses or frames
  • Contact lenses, examinations for contact lenses or the fitting of contact lenses
  • Eye surgery solely for the purpose of correcting refractive defects of the eye
  • Vision therapy, including orthoptics, visual training and eye exercises  

All charges

All charges

Benefit Description : Foot careStandard Option (You pay )Basic Option (You pay )
  • Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes

$25 per primary care office visit

$45 per specialty care office visit

$30 per primary care office visit

$60 per specialty care office visit

Not covered:

  • Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above
  • Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery)

All charges

All charges

Benefit Description : Orthopedic and prosthetic devices Standard Option (You pay )Basic Option (You pay )

External prosthetic and orthotic devices, such as:

  • Artificial limbs and appliances essential to the effective use of artificial limbs or braces
  • Prosthetic sleeve or sock
  • Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy
  • Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome
  • Braces
  • Lenses with frames or contact lenses following cataract removal or congenital absence of the organic lens of the eye
  • Terminal devices
  • External cardiac pacemakers
20% of our allowance

20% after deductible

Internal prosthetic devices, such as:

  • Pacemakers
  • Artificial joints
  • Surgically implanted breast implant following mastectomy
  • Intraocular lenses following cataract removal or congenital absence of the organic lens of the eye

Note: See Section 5(b), Surgery benefits, for coverage of the surgery to insert the device and Section 5(c), Hospital benefits, for inpatient hospital benefits.

Notes:

  • Orthopedic and prosthetic equipment or services must be prescribed by a Plan physician; obtained through sources designated by the Plan; consistent with our Plan DME formulary guidelines; and primarily and customarily used to serve a medical or therapeutic purpose in the treatment of an illness or injury.
  • We cover only those standard items that are adequate to meet the medical needs of the member.
  • For coverage of hearing aids, see Section 5(a), Hearing services.
Nothing

20% after deductible

Not covered:

  • Corrective shoes
  • Foot orthotics and podiatric use devices, such as arch supports, heel pad and heel cups
  • Corsets, trusses, elastic stockings, support hose, and other supportive devices
  • Comfort, convenience, or luxury equipment or features
  • Prosthetic devices, equipment, and supplies related to the treatment of sexual dysfunction
  • Educational training in the use of the prosthetic devices and orthotic appliances
  • Repairs, adjustments, or replacements due to misuse or loss

All charges

All charges

Benefit Description : Durable medical equipment (DME)Standard Option (You pay )Basic Option (You pay )

We cover rental or purchase, at our option, of durable medical equipment. Covered items include:

  • Oxygen
  • Hospital beds
  • Wheelchairs
  • Crutches
  • Walkers
  • Speech generating devices
  • Blood glucose monitors
  • Infant apnea monitors
  • Commodes
  • Apnea monitors
  • Bilirubin lights (for home photo therapy for infants)
  • Compression sleeves and gloves used in treatment of physical complications of mastectomy, including lymphedema

Notes:

  • Durable medical equipment (DME) is equipment that is prescribed by a Plan physician; obtained through sources designated by the Plan; consistent with Medicare guidelines; intended for repeated use; primarily and customarily used to serve a medical or therapeutic purpose in the treatment of an illness or injury; designed for prolonged use and appropriate for use in the home.
  • We cover only those standard items that are adequate to meet the medical needs of the member.
  • We may require you to return the equipment to us, or pay us the fair market price of the equipment, when it is no longer prescribed. 

25% of our allowance

30% after deductible

Breastfeeding pump, including any equipment required for pump functionality

Note:  We cover a 12 month rental.

Nothing

Nothing

Not covered:

  • Audible prescription reading devices
  • Comfort, convenience, or luxury equipment or features
  • Non medical items such as sauna baths or elevators
  • Exercise and hygiene equipment
  • Electronic monitors of the heart, lungs, or other bodily functions, except for infant apnea monitors
  • Devices to perform medical testing of bodily fluids, excretions, or substances, except blood glucose monitors for insulin dependent diabetics
  • Devices, equipment, supplies, and prosthetics related to the treatment of sexual dysfunction disorders
  • Modifications to the home or vehicle
  • Repairs, adjustments, or replacements due to misuse or loss

All charges

All charges

Benefit Description : Home health servicesStandard Option (You pay )Basic Option (You pay )
  • Home healthcare ordered by a Plan physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.), or home health aide
  • Services include oxygen therapy, intravenous therapy and medications

Notes:

  • We only provide these services in the Plan's service areas.
  • The services are covered only if you are homebound and a Plan physician determines that it is feasible to maintain effective supervision and control of your care in your home.
Nothing

20% after deductible

Not covered:

  • Nursing care requested by, or for the convenience of, the patient or the patient’s family
  • Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative
  • Custodial care
  • Private duty nursing
  • Personal care and hygiene items
  • Care that a Plan provider determines may be appropriately provided in a Plan facility, hospital, skilled nursing facility or other facility we designate and we provide, or offer to provide, that care in one of these facilities

All charges

All charges

Benefit Description : Chiropractic Standard Option (You pay )Basic Option (You pay )

Up to 20 chiropractic visits per calendar year. 

Notes:

$25 per office visit

$30 per office visit

Chiropractic appliances

All charges

All charges

Benefit Description : Alternative treatmentsStandard Option (You pay )Basic Option (You pay )

No benefit

All charges

All charges

Benefit Description : Educational classes and programsStandard Option (You pay )Basic Option (You pay )

Health education classes, including:

  • Diabetes
  • Nutritional counseling

Nothing

20% after deductible

Tobacco cessation programs, including individual, group and telephone counseling

Nothing

20% after deductible

Childhood obesity education

Notes:

  • Please call Customer Care at 800-315-3144 (TTY: 711) for information on classes near you.
  • You pay nothing for over-the-counter (OTC) and prescription drugs approved by the FDA to treat tobacco dependence. See Section 5(f), Prescription drug benefits, for important information about coverage of tobacco cessation and other drugs.

Nothing

20% after deductible




Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals (Standard and Basic Option)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • Plan physicians must provide or arrange your care.
  • The Standard Option has no calendar year deductible.  The calendar year deductible for the Basic Option is $750 per person ($1,500 per Self Plus One enrollment, or $1,500 per Self and Family enrollment). We added "after deductible" when the deductible applies.
  • Be sure to read Section 4, Your cost for covered services, for valuable information about how cost-sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
  • The services  listed below are for the charges billed by a physician or other healthcare professional for your surgical care. See  Section 5(c) for charges associated with a facility (i.e. hospital, surgical center, etc.).
  • YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure which services require precertification.



Benefit Description : Surgical proceduresStandard Option (You pay )Basic Option (You pay )

A comprehensive range of services, such as:

  • Operative procedures
  • Treatment of fractures, including casting
  • Normal pre- and post-operative care by the surgeon
  • Corrections of amblyopia and strabismus
  • Endoscopy procedures
  • Biopsy procedures
  • Removal of tumors and cysts
  • Surgical treatment of morbid obesity (bariatric surgery). You must:

- be 18 years of age or older; and

- have either a Body Mass Index (BMI) of at least 40, or a BMI greater than 35 but less than 40 when one of the following severe or life threatening conditions is also present: diabetes, hypertension, hyperlipidemia, or obstructive sleep apnea with use of CPAP for at least two months immediately before surgery

Notes:

You will need to meet the above qualifications before your Plan provider will refer you to our bariatric surgery program. This program may refer you to other Plan providers to determine if you meet the additional criteria necessary for bariatric surgery, including nutritional, psychological, medical, and social readiness for surgery. Final approval for surgical treatment will be required from the Medical Mutual of Ohio designated physician.

See Section 3, You need prior Plan approval for certain services, for more information.

$25 per primary care office visit for outpatient services

$45 per specialty care office visit for outpatient services

Nothing for inpatient services

20% after deductible

  • Insertion of internal prosthetic devices.  See Section 5(a), Orthopedic and prosthetic devices, for device coverage information
  • Male voluntary sterilization (e.g., vasectomy)
  • Treatment of burns
  • Implanted time-release drugs except contraceptive drugs and devices

Note: We cover the cost of these surgically implanted time-release contraceptive drugs and intrauterine devices under the prescription drug benefit (see Section 5(f)).

$25 per primary care office visit for outpatient services

$45 per specialty care office visit for outpatient services

Nothing for inpatient services

20% after deductible

  • Female voluntary sterilization, including a hysterosalpingogram following tubal occlusion
  • Insertion of surgically implanted time-release contraceptive drugs and intrauterine devices (IUDs)

Note:  We cover the cost of these drugs and devices under the prescription drug benefit (see Section 5(f)).

Nothing

Nothing

Not covered:

  • Reversal of voluntary sterilization
  • Implants or devices related to the treatment of sexual dysfunction 

All charges

All charges

Benefit Description : Reconstructive surgery Standard Option (You pay )Basic Option (You pay )
  • Surgery to correct a functional defect
  • Surgery to correct a condition caused by injury or illness if:
    • the condition produced a major effect on the member’s appearance and
    • the condition can reasonably be expected to be corrected by such surgery
  • Surgery for treatment of a form of congenital hemangioma known as port wine stains on the face of members 18 years or younger
  • All stages of breast reconstruction surgery following a mastectomy, such as:
    • surgery and reconstruction on the other breast to produce a symmetrical appearance;
    • treatment of any physical complications, such as lymphedemas;
    • breast prostheses and surgical bras and replacements (see Prosthetic devices)

      Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure.
  • Gender Reassignment Surgery
    • Male-to-Female (MtF): penectomy, orchiectomy, vaginoplasty, clitoroplasty, vulvoplasty, labiaplasty, urethroplasty.
    • Female-to-Male (FtM): bilateral mastectomy or breast reduction, hysterectomy, salpingo-oophorectomy, urethroplasty, metoidioplasty, phalloplasty, vulvectomy, vaginectomy, scrotoplasty and implantation of penile and/or testicular prostheses.

      Your Plan provider must obtain precertification from the plan prior to obtaining any gender reassignment surgery.  Please see Section 3 for additional details regarding the "precertification" process.

$45 per office visit for outpatient services

Nothing for inpatient services

20% after deductible

Not covered:

  • Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except as otherwise specified above

All charges

All charges

Benefit Description : Oral and maxillofacial surgery Standard Option (You pay )Basic Option (You pay )

Not covered:

  • Oral implants and transplants 
  • Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingival, and alveolar bone), except for procedures related to accidental injury of teeth
  • Correction of any malocclusion not listed above 
  • Any dental care involved in treatment of temporomandibular joint (TMJ) pain dysfunction syndrome
  • Dental services associated with medical treatment such as surgery and radiation treatment, except for services related to accidental injury of teeth (See Section 5(g))

All charges

All charges

Oral surgical procedures, limited to:

  • Reduction of fractures of the jaws or facial bones;
  • Surgical correction of cleft lip, cleft palate, or severe functional malocclusion;
  • Removal of stones from salivary ducts;
  • Excision of leukoplakia or malignancies;
  • Excision of cysts and tumors;
  • Medical and surgical treatment of temporomandibular joint (TMJ) disorder (non-dental)
  • Other surgical procedures that do not involve the teeth or their supporting structures.

$45 per office visit for outpatient services

Nothing for inpatient services

20% after deductible

Benefit Description : Organ/tissue transplantsStandard Option (You pay )Basic Option (You pay )

These solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan.  Refer to Section 3, How you get care for precertification procedures. Solid organ tissue transplants are limited to:

  • Autologous pancreas islet cell transplant ( as an adjunct to total or near total  pancreatectomy ) only for patients with chronic  pancreatitis.
  • Cornea
  • Heart
  • Heart/lung
  • Intestinal transplants
    • Isolated small intestine
    • Small intestine with the liver
    • Small intestine with multiple organs, such as the liver, stomach, and pancreas
  • Kidney
  • Kidney/pancreas
  • Liver
  • Lung: Single/bilateral/lobar
  • Pancreas

$45 per office visit for outpatient services

Nothing for inpatient services

20% after deductible

Blood or marrow stem cell transplants

The Plan extends coverage for the diagnoses as indicated below:

  • Allogeneic transplants for:
    • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
    • Acute myeloid leukemia
    • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
    • Advanced Myeloproliferative Disorders (MPDs)
    • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
    • Amyloidosis
    • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
    • Hemoglobinopathy
    • Marrow Failure and Related Disorders (i.e. Fanconi's, Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia)
    • Myelodysplasia/Myelodysplastic syndromes
    • Paroxysmal Nocturnal Hemoglobinuria
    • Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiscott-Aldrich syndrome)
    • Severe combined immunodeficiency
    • Severe or very severe aplastic anemia
    • Sickle cell anemia
    • X-linked lymphoproliferative syndrome
  • Autologous transplants for:
    • Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
    • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
    • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
    • Amyloidosis
    • Breast Cancer
    • Ependymoblastoma
    • Epithelial ovarian cancer
    • Multiple myeloma
    • Neuroblastoma
    • Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell tumors

$45 per office visit for outpatient services

Nothing for inpatient services

20% after deductible

These blood or marrow stem cell transplants are covered only in a National Cancer Institute or National Institutes of health approved clinical trial or a Plan-designated center of excellence if approved by the Plan’s medical director in accordance with the Plan’s protocols.

If you are a participant in a clinical trial, the Plan will provide benefits for related routine care that is medically necessary (such as doctor visits, lab tests, x-rays and scans, and hospitalization related to treating the patient’s condition) if it is not provided by the clinical trial. Section 9 has additional information on costs related to clinical trials. We encourage you to contact the Plan to discuss specific services if you participate in a clinical trial.

  • Autologous Transplants for
    • Advanced childhood kidney cancers
    • Advanced Ewing sarcoma
    • Aggressive non-Hodgkin's lymphomas
    • Childhood rhabdomyosarcoma
    • Epithelial ovarian cancer
    • Mantle Cell (Non-Hodgkin's lymphoma)

$45 per office visit for outpatient services

Nothing for inpatient services

20% after deductible

The following blood or marrow stem cell transplants are not subject to medical necessity review. Blood or marrow stem cell transplants for:

  • Allogeneic transplants for:
    • Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome)
  • Autologous transplants for:
    • Multiple myeloma
    • Testicular, mediastinal, retroperitoneal, and ovarian germ cell tumors

$45 per office visit for outpatient services

Nothing for inpatient services

20% after deductible

Mini-transplants performed in a Clinical Trial Setting (non-myeloblative, reduced intensity conditioning for member over 60 years of age).

  • Allogeneic transplants for:
    • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
    • Acute myeloid leukemia
    • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
    • Advanced Myeloproliferative Disorders (MPDs)
    • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
    • Amyloidosis
    • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
    • Chronic myelogenous leukemia
    • Hemoglobinopathy
    • Marrow Failure and Related Disorders (i.e. Fanconi's, PNH, Pure Red Cell Aplasia)
    • Myelodysplasia/Myelodysplastic syndromes
    • Paroxysmal Nocturnal Hemoglobinuria
    • Severe combined immunodeficiency
    • Severe or very severe aplastic anemia
  • Autologous transplants for:
    • Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
    • Advanced Hodgkin’s lymphoma  with recurrence (relapsed)
    • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
    • Amyloidosis
    • Neuroblastoma

$45 per office visit for outpatient services

Nothing for inpatient services

20% after deductible

Not covered:

  • Donor screening tests and donor search expenses, except those listed above
  • Implants of non-human artificial organs
  • Transplants not listed as covered

All charges

All charges

Tandem transplants: Subject to medical necessity

  • Autologous tandem transplants for:
    • AL Amyloidosis
    • Multiple myeloma (de novo and treated)
    • Recurrent germ cell tumors (including testicular cancer)

Notes:

  • We cover related medical and hospital expenses of the donor when we cover the recipient.
  • We cover donor screening tests for potential donors for solid organ transplants. We cover human leukocyte antigen (HLA) typing for potential donors for a bone marrow/stem cell transplant only for parents, children and siblings of the recipient.
  • We cover computerized national and international search expenses for prospective unrelated bone marrow/stem cell transplant donors conducted through the National Marrow Donor Program, and the testing of blood relatives of the recipient.
  • Please refer to Section 5(h), Special features, for information on our Centers of Excellence.

$45 per office visit for outpatient services

Nothing for inpatient services

20% after deductible

Benefit Description : AnesthesiaStandard Option (You pay )Basic Option (You pay )

Professional services provided in –

  • Office

Nothing

20% after deductible

Professional services provided in –

  • Hospital (inpatient)

  • Hospital outpatient department

  • Skilled nursing facility

  • Ambulatory surgical center

Nothing

20% after deductible




Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services (Standard and Basic Option)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.
  • The Standard Option has no calendar year deductible.  The calendar year deductible for the Basic Option is $750 per person ($1,500 per Self Plus One enrollment, or $1,500 per Self and Family enrollment).  We added "after deductible" when the deductible applies.
  • Be sure to read Section 4, Your cost for covered services for valuable information about how cost-sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
  • The amounts listed below are for the charges billed by the facility (i.e., hospital or surgical center) or ambulance service for your surgery or care. Any costs associated with the professional charge    (i.e., physicians, etc.) are in Sections 5(a) or (b).
  • YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR HOSPITAL STAYS. Please refer to Section 3 to be sure which services require precertification. 



Benefit Description : Inpatient hospitalStandard Option (You pay)Basic Option (You pay)

Room and board, such as:

  • Ward, semiprivate, or intensive care accommodations
  • General nursing care
  • Meals and special diets

Notes:

  • If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate.

$650 per admission

20% after deductible

Other hospital services and supplies, such as:

  • Operating, recovery, maternity, and other treatment rooms
  • Prescribed drugs and medications
  • Diagnostic laboratory tests and x-rays
  • Blood and blood products
  • Dressings, splints, plaster casts, and sterile tray services
  • Medical supplies, appliances, and equipment, including oxygen
  • Anesthetics, including nurse anesthetist services
  • The collection and storage of autologous blood for elective surgery when authorized by a Plan physician.

Note: You may receive covered hospital services for certain dental procedures if a Plan physician determines you need to be hospitalized for reasons unrelated to the dental procedure. The need for anesthesia, by itself, is not such a condition.

Nothing

20% after deductible

Not covered:

  • Custodial care and care in an intermediate care facility
  • Non-covered facilities, such as nursing homes
  • Personal comfort items, such as telephone, television, barber services, and guest meals and beds
  • Private nursing care, except when medically necessary
  • Inpatient dental procedures
  • Cord blood procurement and storage for possible future need for a yet-to-be determined member recipient.

All charges

All charges

Benefit Description : Outpatient hospital or ambulatory surgical centerStandard Option (You pay)Basic Option (You pay)
  • Operating, recovery, and other treatment rooms
  • Prescribed drugs and medications
  • Lab, x-ray, and other diagnostic tests
  • Blood and blood products
  • The collection and storage of autologous blood for elective surgery, when authorized by a Plan physician
  • Pre-surgical testing
  • Dressing, casts, and sterile tray services
  • Medical supplies and equipment, including oxygen
  • Anesthetics and anesthesia service

 

$375 per outpatient surgery

20% after deductible

Not covered:

  • Cord blood procurement and storage for possible future need or for a yet-to-be determined member recipient.

All charges

All charges

Benefit Description : Skilled nursing care facility benefitsStandard Option (You pay)Basic Option (You pay)

Up to 100 days per calendar year

  • When you need full-time skilled nursing care

All necessary services are covered, including:

  • Room and board
  • General nursing care
  • Medical social services
  • Prescribed drugs, biologicals, supplies, and equipment, including oxygen, ordinarily provided or arranged by the skilled nursing facility
Nothing

20% after deductible

Not covered:

  • Custodial care and care in an intermediate care facility
  • Personal comfort items, such as telephone, television, barber services, and guest meals and beds.

All charges

All charges

Benefit Description : Hospice care/End of life careStandard Option (You pay)Basic Option (You pay)

Supportive and palliative care for a terminally ill member:

  • You must reside in the service area
  • Services are provided:
    • in the home, when a Plan physician determines that it is feasible to maintain effective supervision and control of your care in your home, or
    • in a Plan-approved hospice facility, if approved by a Plan physician

Services include inpatient care, outpatient care, and family counseling. A Plan physician must certify that you have a terminal illness, with a life expectancy of approximately six months or less.

Note:

Hospice is a program for caring for the terminally ill patient that emphasizes supportive services, such as home care and pain and symptom control, rather than curative care. A person who is terminally ill may elect to receive hospice benefits. These palliative and supportive services include nursing care, medical social services, therapy services for purposes of safety and symptom control, physician services, palliative drugs in accord with our drug formulary guidelines, medical supplies and equipment, and short-term inpatient care for pain control and acute and chronic symptom management. We also provide inpatient respite care, counseling, and bereavement services. If you make a hospice election, you are not entitled to receive other health care services that are related to the terminal illness. If you have made a hospice election, you may revoke that election at any time, and your standard health benefits will be covered.

Nothing

Nothing

Not covered:

  • Independent nursing (private duty nursing)
  • Homemaker services

All charges

All charges

Benefit Description : AmbulanceStandard Option (You pay)Basic Option (You pay)
  • Local licensed ambulance service when medically necessary

Note: See Section 5 (d) for emergency services

$350 per trip

20% after deductible

Not covered:

  • Transportation by car, taxi, bus, gurney van, wheelchair van, and any other type of transportation (other than a licensed ambulance), even if it is the only way to travel to a Plan Provider.

All charges

All charges




Section 5(d). Emergency Services/Accidents (Standard and Basic Option)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

  • The Standard Option has no calendar year deductible.  The calendar year deductible for the Basic Option is $750 per person ($1,500 per Self Plus One enrollment, or $1,500 per Self and Family enrollment).  We added "after deductible" when the deductible applies.
  • Be sure to read Section 4, Your cost for covered services, for valuable information about how cost-sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.




What is a medical emergency?

A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are emergencies because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are emergencies because they are potentially life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability to breathe. There are many other acute conditions that we may determine are medical emergencies – what they all have in common is the need for quick action.





What to do in case of emergency:

In a life-threatening emergency, call 911 or go to the nearest hospital emergency room. Be sure to tell the emergency room personnel that you are a Plan member so they can notify us. You or a family member must notify us within 24 hours unless it is not reasonable to do so. It is your responsibility to be sure we have been timely notified.

Emergencies within our service area:

If you are unsure whether you are experiencing an emergency, call your Primary Care Physician at the number listed in the Provider Directory, or call our 24/7 Nurse Line 888-912-0636 (TTY: 711) for assistance. To better coordinate your emergency care, if you are inside the Service Area, you should go to a Plan facility if possible. You must return to us for follow-up care after emergency services are received within our service area.

Emergency care may be received by calling 911 or by going to the nearest emergency room.

If you need to be hospitalized at a non-Plan facility, we must be notified as soon as reasonably possible. You can call us toll-free from anywhere in the United States at 800-338-4114. If you are hospitalized in a non-Plan facility and our physicians believe care can be better provided in a Plan designated hospital, you will be transferred when medically feasible. If you do not notify us, we will not cover any services you receive after transfer would have been possible. Benefits are available for care from non-Plan providers in a medical emergency only if delay in reaching us would result in death, disability, or significant jeopardy to your condition.

Emergencies outside our service area:

Emergency care may be received by calling 911, by going to the nearest emergency room or seeking care at any urgent care or physician’s office for medically necessary health service that is immediately required because of injury or unforeseen illness.

If you need to be hospitalized, you must notify us as soon as is reasonably possible. You can call us toll-free from anywhere in the United States at 800-338-4114. If a Plan provider believes care can be better provided in a Plan hospital, we will transfer you when medically feasible.  Any follow-up care recommended by non-Plan providers must be approved by the Plan or provided by Plan providers to be covered by this Plan.  With the MedFlex HMO, you will be responsible for the full cost of any services you receive from non-network providers. (excluding emergency services).

You may obtain emergency and urgent care from Med Flex medical facilities and providers when you are in the Medical Mutual service area. You may also call Customer Care at 800-315-3144 (TTY:711). 




Benefit Description : Emergency within our service areaStandard Option (You pay )Basic Option (You pay )
  • Urgent care center

$35 per visit

$45 per visit

  • Emergency care as an outpatient at an emergency facility, including physicians' services

Notes:

  • We waive your emergency room copayment if you are directly admitted to a hospital as an inpatient. Your inpatient admission copayment will still apply (see Section 5(c)).
  • Transfers to an observation bed or observation status do not qualify as an admission to a hospital and your emergency copayment will not be waived.

$250 per visit

$250 per visit

Not covered:

  • Elective care or non-emergency care
  • Urgent care at a non-Plan urgent care center

All charges

All charges

Benefit Description : Emergency outside our service areaStandard Option (You pay )Basic Option (You pay )
  • Urgent care center

$35 per visit

$45 per visit

  • Emergency care as an outpatient in a hospital, including physicians' services 

Notes:

  • We waive your emergency room copayment if you are directly admitted to a hospital as an inpatient. Your inpatient admission copayment will still apply (See Section 5(c)).
  • Transfers to an observation bed or observation status do not qualify as an admission to a hospital and your emergency copayment will not be waived.

$250 per visit

$250 per visit

Not covered:

  • Elective care or non-emergency care
  • Follow-up care recommended by non-Plan providers that has not been approved by the Plan or provided by Plan providers 
  • Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
  • Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area

All charges

All charges




Section 5(e). Mental Health and Substance Use Disorder Benefits (Standard and Basic Option)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and we cover them only when we determine they are clinically appropriate to treat your condition.
  • Plan physicians must provide or arrange your care.
  • The Standard Option has no calendar year deductible.  The calendar year deductible for the Basic Option is $750 per person ($1,500 per Self Plus One enrollment, or $1,500 per Self and Family enrollment).
  • We have no calendar year deductible.
  • Be sure to read Section 4, Your cost for covered services, for valuable information about how cost-sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare
  • As an additional benefit, all Covered Persons under the plan may take advantage of the option of seeing a MedFlex provider free of charge for up to three sessions. The MedFlex provider may offer up to three (3) sessions at no charge to provide the Covered Person(s) with brief consultation and referral sources, if warranted. This additional benefit  is provided as a service to Covered Persons to facilitate timely assessment and referral to a Participating Provider where delays might otherwise occur in getting timely, appropriate treatment.
  • YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR HOSPITAL STAYS.  Please refer to Section 3 to be sure which services require precertification.
  • OPM will base its review of disputes about treatment plans on the treatment plan's clinical appropriateness.  OPM will generally not order us to pay or provide one clinically appropriate treatment plan in favor of another.



Benefit Description : Professional servicesStandard Option (You pay )Basic Option (You pay )

We cover professional services recommended by a mental health or substance use disorder Plan provider and contained in a treatment plan that we approve. The treatment plan may include services, drugs, and supplies described elsewhere in this brochure.

Notes:

  • We cover the services only when we determine that the care is clinically appropriate to treat your condition, and only when you receive the care as part of a treatment plan developed by a mental health or substance use disorder Plan provider.
  • OPM will base its review of disputes about treatment plans on the treatment plan’s clinical appropriateness. OPM will generally not order us to pay or provide one clinically appropriate treatment in favor of another.
Your cost-sharing responsibilities are no greater than for other illnesses or conditions

Your cost-sharing responsibilities are no greater than for other illnesses or conditions

Diagnosis and treatment of mental illness. Services include:

  • Diagnostic evaluation
  • Treatment and counseling (including individual and group therapy visits)
  • Crisis intervention and stabilization for acute episodes
  • Psychological testing necessary to determine the appropriate psychiatric treatment

$25 per office visit for individual therapy

$12 per office visit for group therapy

$30 per office visit for individual therapy

$60 per office visit for group therapy

Diagnosis and treatment of substance use disorders. Services include:

  • Detoxification (medical management of withdrawal from the substance)
  • Treatment and counseling (including individual and group therapy visits)

Notes:

  • You may see an outpatient mental health or substance use disorder Plan provider for outpatient services without a referral from your primary care physician. See Section 3, How you get care, for information about services requiring our prior approval.
  • Your mental health or substance use disorder Plan provider will develop a treatment plan to assist you in improving or maintaining your condition and functional level, or to prevent relapse and will determine which diagnostic and treatment services are appropriate for you.
$25 per office visit for individual therapy

$5 per office visit for group therapy (maximum $5 per day for substance abuse benefit)

$30 per office visit for individual therapy

$60 per office visit for group therapy

  • Medication evaluation and management
$25 per office visit

$30 per office visit

Benefit Description : Inpatient hospital or other covered facilityStandard Option (You pay )Basic Option (You pay )
  • Inpatient psychiatric or substance use disorder care
  • Residential Treatment

Note: All inpatient admissions require approval by a mental health or substance use disorder Plan physician.

$650 per admission

Nothing limited to 100 days per calendar year

20% after deductible

Benefit Description : Outpatient hospital or other covered facilityStandard Option (You pay )Basic Option (You pay )
  • Hospital alternative services, such as partial hospitalization, day and night care
.
$25 per day

20% after deductible

Benefit Description : Not coveredStandard Option (You pay )Basic Option (You pay )

Not covered:

  • Care that is not clinically appropriate for the treatment of your condition
  • Inpatient services we have not approved
  • Intelligence, IQ, aptitude ability, learning disorders, or interest testing not necessary to determine the appropriate treatment of psychiatric condition
  • Evaluation or therapy on court order or as a condition of parole or probation, or otherwise required by the criminal justice system, unless determined by a Plan physician to be medically necessary and appropriate
  • Services that are custodial in nature
  • Services rendered or billed by a school or a member of its staff
  • Services provided under a federal, state, or local government program
  • Psychoanalysis or psychotherapy credited toward earning a degree or furtherance of education or training regardless of diagnosis or symptoms
  • Inpatient services that are not part of a preauthorized approved treatment plan

All charges

All charges




Section 5(f). Prescription Drug Benefits (Standard and Basic Option)

Important things you should keep in mind about these benefits:

  • We cover prescribed drugs and medications, as described in the chart in this section.
  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and we cover them only when we determine they are medically necessary.
  • Members must make sure their prescribers obtain prior approval/authorizations for certain prescription drugs and supplies before coverage applies.  Prior approval/authorizations must be renewed periodically.
  • Federal law prevents the pharmacy from accepting unused medications.
  • The Standard Option has no calendar year deductible.  The calendar year deductible for the Basic Option is $750 per person ($1,500 per Self Plus One enrollment, or $1,500 per Self and Family enrollment).  We added "after deductible" when the deductible applies.
  • Be sure to read Section 4, Your cost for covered services, for valuable information about how cost-sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.



     There are important features you should be aware of. These include:

  • Who can write your prescription. A licensed physician or dentist, and in states allowing it, licensed/certified providers with prescriptive authority prescribing within their scope of practice must prescribe your medication. We cover prescriptions filled at a non-Plan pharmacy only for covered out-of-area emergencies and out-of-area urgent care services as specified in Section 5(d), Emergency services/accidents.
  • Where you can obtain them. You may fill your prescriptions at any in-network pharmacy. To see what retail pharmacies are in the Walgreens Advantage Network, log in to our secure member website, My Health Plan,  at www.MedMutual.com/member.  Click Find a Provider then choose Pharmacy as the Provider Type.  You may also use Express Scripts Home Delivery pharmacy.  Plan members called to active military duty (or members in time of national emergency), should call a Plan pharmacy when they need to fill prescribed medications.
  • We use a formulary. A group of physicians, pharmacists, and other healthcare professionals choose the medications included in our drug formulary.  These providers meet regularly to consider adding and removing prescription drugs on the drug formulary based on new information or drugs that become available. If you would like information about whether a particular drug is included on our formulary, please call Express Scripts at 800-417-1961 (TTY: 711 - for hearing impaired) or view the formulary on our secure member website, My Health Plan.  Log in at www.MedMutual.com/member and click on Benefits and Coverage, then Prescription Drug Benefit.
  • These are the dispensing limitations. Prescription drugs will be provided for one copayment up to a 30-day supply or a 90-day supply sent to your home through our direct mail service. We provide up to a 30-day supply based on (a) the prescribed dosage, (b) the standard manufacturer’s package size, and (c) specified dispensing limits. Drugs to treat sexual dysfunction have dispensing limitations; contact Express Scripts at 800-417-1961 (TTY: 711 - for hearing impaired) for details. Drugs that have a significant potential for waste or misuse and those we determine are in limited supply in the market will be provided for up to a 30-day supply in any 30-day period.
  • The Generic Incentive Program - If members request a brand name drug when a generic equivalent is available they will pay the brand name drug copay (preferred or non-preferred) PLUS the difference in cost between the generic and the brand name drug. Please note:  For mail-order pharmacy maintenance, or long-term prescriptions (taken for three months or more), the generic equivalent will automatically be substituted unless you or your provider specifies the brand-name drug must be provided through a dispense-as-written (DAW) order.
  • Why use generic drugs? Typically generic drugs cost you and us less money than a brand-name drug. Under federal law, generic and brand-name drugs must meet the same standards for safety, purity, strength, and effectiveness.
  • When do you have to file a claim? You do not need to file a claim when you receive drugs from a Plan or affiliated pharmacy. You have to file a claim when you receive drugs from a non-Plan pharmacy for covered out-of-area emergency and out-of-area urgent care as specified in Section 5(d), Emergency services/accidents. For information about how to file a claim, see Section 7, Filing a claim for covered services.
  • Preventive Plus Generic Medication Program - You pay nothing for drugs on the Standard Plus Medication List.  The Prevention Plus Generic Medication Program medication list includes medication to treat asthma, diabetes, high blood pressure and high cholesterol. 



Benefit Description : Covered medications and suppliesStandard Option (You pay )Basic Option (You pay )

We cover the following medications and supplies prescribed by a licensed health care professional and obtained from a Plan pharmacy or through our direct mail services:

  • Drugs and medicines that, by federal law, require a prescription for their purchase, except those listed as Not covered
  • Certain over-the-counter medications prescribed by a provider and listed on the Plan’s formulary
  • Insulin
  • Disposable needles and syringes for the administration of covered medications
  • Growth hormone
  • Compound drugs
  • Drugs to treat gender dysphoria
  • Two Anti-Obesity Drugs: Qsymia and Imcivree

Notes:

  • For compound drugs you will be charged your applicable generic or brand name drug copayment depending on the compound drug’s main ingredient, whether the main ingredient is a generic or brand name drug.
  • A compound drug is one in which two or more drugs or pharmaceutical agents are combined together to meet the requirements of a prescription.
  • The Carrier does not cover compounded prescriptions unless all the ingredients are FDA approved and determined to be medically necessary
  • Growth hormone requires our prior approval. See Section 3, Services requiring our prior approval.
  • Drug treatment for gender dysphoria is individualized and varies. Examples of covered drugs are included below and may require prior authorization.  Drug coverage is subject to change. Please consult the formulary for more information:
    • Feminizing hormone therapy: estradiol tablets or patches, estradiol valerate injection
    • Masculinizing hormone therapy: testosterone cypionate injection, testosterone enanthate injections
  • Financial assistance programs also known as "Patient Assistance Programs," "Fee Forgiveness," "Nor Out-of-Pocket," 'Manufacturers Coupons," "Discount programs," for Specialty Drugs will not count toward your out-of-pocket maximum or deductible, if you have one.

Retail Pharmacy

Tier 1 - $15 per prescription or refill for retail generic drugs for up to 30-day supply

Tier 2 - $75 per prescription or refill for retail preferred brand-name drugs for up to 30-day supply

Tier 3 - $180 per prescription or refill for  retail non-preferred brand-name drugs for up to 30-day supply

Tier 4 - 25% up to $500 per prescription or refill for a 30-day supply of covered Specialty Drugs filled through a contracted specialty pharmacy

Mail Order

Tier 1 - $30 per prescription or refill for mail-order generic drugs for up to 90-day supply

Tier 2 - $150 per prescription or refill for mail-order preferred brand-name drugs for up to 90-day supply

Tier 3 - $360 per prescription or refill for mail-order non-preferred brand-name drugs for up to 90-day supply

Tier 4 - Mail order not available for specialty medications

Retail Pharmacy

Tier 1 - $10 per prescription or refill for retail generic drugs for up to 30-day supply

Tier 2 - 40% up to $250 per prescription or refill for retail preferred brand-name drugs for up to 30-day supply

Tier 3 - 60% up to $350 per prescription or refill for retail non-preferred brand-name drugs for up to 30-day supply

Tier 4 - 30% up to $500 per prescription or refill for a 30-day supply of covered Specialty Drugs filled through a contracted specialty pharmacy

Mail Order

Tier 1 - $20 per prescription or refill for mail order generic drugs for up to a 90-day supply

Tier 2 - 40% coinsurance up to $500 maximum for mail order preferred brand for up to a 90-day supply

Tier 3 - 60% up to $700 maximum for mail order for non-preferred brand-name drugs for up to a 90-day supply

Tier 4 - Mail order not available for specialty medications

 

Women's contraceptive drugs and devices:

  • Diaphragms and cervical caps
  • Intrauterine devices (IUDs)
  • Injectable contraceptive drugs
  • Implanted time-release contraceptive drugs
  • Oral contraceptive drugs
  • Prescribed FDA approved over-the-counter women's contraceptives and devices
  • Women's breast cancer preventative medications
Nothing

Nothing

  • Fertility drugs for covered infertility treatments

All charges

All charges

  • Sexual dysfunction drugs
50% of our allowance

50% of our allowance

  • Prescription and over-the-counter tobacco cessation drugs approved by the FDA to treat tobacco dependence
Nothing

Nothing

Not covered:

  • Drugs and supplies for cosmetic purposes
  • Drugs to enhance athletic performance
  • Prescriptions filled at out-of-network pharmacies, except for out-of-area emergencies or out of area urgent care services
  • Vitamins, nutrients and food supplements not listed as a covered benefit even if a physician prescribes or administers them   
  • Nonprescription drugs, unless they are included in our drug formulary or listed as covered above
  • Medical supplies such as dressings and antiseptics, except as listed above
  • Drugs used to shorten the duration of the common cold
  • Any requested packaging of drugs other than the dispensing pharmacy’s standard packaging Replacement of lost, stolen or damaged prescription drugs or accessories
  • Drugs related to non-covered services
  • Drugs for the promotion, prevention, or other treatment of hair loss or growth 

All charges

All charges

Benefit Description : Preventive care medicationsStandard Option (You pay )Basic Option (You pay )

Medications to promote better health as recommended by ACA.

Note: Preventive Medications with a USPSTF recommendation of A or B are covered without cost-share when prescribed by a healthcare professional and filled by a network pharmacy.  These may include some over-the-counter vitamins, nicotine replacement medications, and low dose aspirin for certain patients.  For current recommendations go to

www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations 

Nothing

Nothing




Section 5(g). Dental Benefits (Standard and Basic Option)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and we pay them only when we determine they are medically necessary.
  • If you are enrolled in a Federal Employees Dental/Vision Insurance Program (FEDVIP) Dental Plan, your FEHB Plan will be First/Primary payor of any Benefit payments and your FEDVIP Plan is secondary to your FEHB Plan. See Section 9, Coordinating benefits with other coverage.
  • The Standard Option has no calendar year deductible.  The calendar year deductible for the Basic Option is $750 per person ($1,500 per Self Plus One enrollment, or $1,500 per Self and Family enrollment).
  • We cover hospitalization for dental procedures at Plan facilities only when a non-dental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient. See Section 5(c), Hospital benefits, for inpatient hospital benefits. We do not cover dental procedures except as described below.
  • Be sure to read Section 4, Your cost for covered services, for valuable information about how cost-sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
  • No precertification is required for accidental injury to teeth. Accidental injury to teeth services may be obtained from a licensed dentist. Please submit claims for services related to accidental injury to teeth according to Section 7, Filing a claim for covered services, of this brochure.



Benefit Description : Accidental injury benefitStandard Option (You Pay)Basic Option (You Pay)

We cover services to promptly repair (but not replace) a sound, natural tooth, if:

  • damage is due to an accidental injury from trauma to the mouth from violent contact with an external object,
  • the tooth has not been restored previously, except in a proper manner, and
  • the tooth has not been weakened by decay, periodontal disease or other existing dental pathology.

Note: Services will be covered only when provided within 72 hours following the accidental injury.

Nothing

Nothing

Not covered:

  • Services for conditions caused by an accidental injury occurring before your eligibility date

We have no other dental benefits.

All charges

All charges




Section 5(h). Wellness and Other Special Features (Standard and Basic Option)

Feature : FeatureStandard and Basic Option (Description)
Wellness Program

The Carrier's wellness programs provide plan members with core initiatives designed to help them understand overall health, identify health risks and participate in a programs to improve your total well-being.

The following programs and services are available to all Medical Mutual covered plan members:

  • Health Assessment
  • QuitLine Tobacco Cessation Program
  • Nurse Line
  • Weight Watchers discount
  • Fitness discounts
  • Hearing discounts
  • Wellness portal
  • Online educational tools
  • Online wellness challenges

The Health Assessment

Begin a focus on your health by completing the Health Assessment which allows you to assess you current health status.  The Health Assessment is a confidential questionnaire that compiles information about your health status, current medical conditions and daily health habits to give you an overall picture of your health.

The results show current health status, potential risk for chronic health conditions, and suggestions for improving health going forward.  It offers the following advantages:

  • Helps you make more informed decisions about healthcare and lifestyle.
  • Helps you take control of your own health.
  • Prepares you for doctor's visits, including knowing what questions to ask.
  • Tailors educational materials to your health status and risks.

The Health Assessment allows the Carrier to provide you with additional information on helpful programs Medical Mutual offers that can help you in the following areas:

  • Nutrition
  • Physical Activity
  • Seat belt usage
  • Stress
  • Tobacco use
  • Weight management

QuitLine Tobacco Cessation Program - Program participants have access to professional telephone counseling, educational materials and a supply of nicotine replacement therapy (gum or patches) at no cost.

Weight Watchers Discount - Plan members can participate in an online, at work or local meeting series and obtain a discount on the registration fees each calendar year.

Fitness Discounts - We partner with local and national fitness clubs to offer discounts on club membership fees.                                

Wellness Portal - Medical Mutual plan members will have access to a wellness portal providing health and wellness education, program enrollment information.

24/7 Nurse Line

You may call 888-912-0636 (TTY:771) 24 hours a day, 7 days a week for any of your health concerns.  You may talk with a registered nurse who can help assess medical symptoms and provide advice over the phone, when appropriate, including directing you to urgent care.

Services for the deaf, hard of hearing or speech impaired

We provide a TTY/text telephone number at :711.  Sign language services are also available.

Disease and Maternity Management

Whether you live with a chronic condition or just found out you're pregnant, having a health coach to guide you can help improve your overall well-being.  You can trust the Carrier's Disease and Maternity Programs to support you.  Medical Mutual programs, available at no additional cost to qualified members, help members who are pregnant or diagnosed with one or more of the following conditions:

  • Asthma
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Congestive Heart Failure
  • Coronary Artery Disease
  • Diabetes

These programs help you learn more about your conditions, with a plan designed for your individual needs.  You receive personal attention and education based on your condition, as well as support from a trained health coach.

Your health coach plays a key role in empowering you to self-manage your condition and works with you to achieve your healthcare goals.  Your doctor and healthcare team will continue to treat you, and you health coach will offer guidance to complement your doctor's treatment plan.  If you are actively enrolled in the Diabetes program, you will receive certain diabetic supplies for no copay.

Our disease management program includes several incentives for qualified members designed to enhance participation and improve clinical outcomes.

  • Active diabetes program participants receive essential diabetic testing supplies, if needed.
  • Diabetic participants receive an electronic tablet and glucometer to monitor and report symptoms and track blood sugar levels.
  • Heart failure participants receive an electronic tablet, if needed, to monitor and report symptoms and weight.
  • COPD participants receive an electronic tablet and scale, if needed, to monitor and report symptoms
  • Coronary artery disease participants receive an electronic tablet and home blood pressure monitor to report symptoms and track daily readings.
Centers of Excellence

The Carrier's Care Management staff includes nurse care managers who work closely with the plan member and family members to help choose the most appropriate facility based on the individual's specific needs.  For transplant needs, our dedicated transplant team of specialized registered nurses work proactively with plan members and their health care providers to direct them to the Carrier's network transplant center based on the member's health care needs.  These Medicare Certified Transplant centers provide solid and tissue transplant procedures throughout the State of Ohio.  If it is determined that the plan member requires services that are not available within the State of Ohio, the transplant team coordinates out of state transplants utilizing a Transplant network.




Section 6. General Exclusions – Services, Drugs and Supplies We Do Not Cover

The exclusions in this section apply to all benefits. There may be other exclusions and limitations listed in Section 5 of this brochure. Although we may list a specific service as a benefit, we will not cover it unless it is medically necessary to prevent, diagnose, or treat your illness, disease, injury, or condition. For information on obtaining prior approval for specific services, such as transplants, see Section 3, You need prior Plan approval for certain services.

We do not cover the following:

  • When a service is not covered, all services, drugs, or supplies related to the non-covered service are excluded from coverage, except services we would otherwise cover to treat complications of the non-covered service
  • Care by non-Plan providers, except for authorized referrals, emergencies,  (see Emergency services/accidents and Special features)
  • Services, drugs, or supplies you receive while you are not enrolled in this Plan
  • Services, drugs, or supplies not medically necessary
  • Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice
  • Experimental or investigational procedures, treatments, drugs, or devices (see specifics regarding transplants)
  • Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term, or when the pregnancy is the result of an act of rape or incest
  • Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program
  • Services required for (a) obtaining or maintaining employment or participation in employee programs or (b) insurance or governmental licensing
  • Services, drugs, or supplies you receive without charge while in active military service
  • Services provided or arranged by criminal justice institutions for members confined therein
  • Services or supplies we are prohibited from covering under the Federal Law.



Section 7. Filing a Claim for Covered Services

This section primarily deals with post-service claims (claims for services, drugs, or supplies you have already received).  See Section 3 for information on prior Plan approval and pre-service claims procedures (services, drugs, or supplies requiring prior Plan approval), including urgent care claims procedures.  

When you see Plan providers, receive services at Plan hospitals and facilities, or fill your prescription drugs at Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment or coinsurance.

You may need to file a claim when you receive a service or item from a non-Plan provider or at a non-Plan facility. This includes services such as out-of-network emergency services, out-of-area urgent care.  Check with the provider to determine if they can bill us directly. Filing a claim does not guarantee payment. If you need to file the claim, here is the process:




TermDefinition

Medical, hospital and drug benefits

In most cases, providers and facilities file claims for you. Providers must file on the form CMS-1500, Health Insurance Claim Form. Your facility will file on the UB-04 form. For claims questions and assistance, call us at 800-315-3144 (TTY :711) or visit or website at https://MedMutual.com/feds.

When you must file a claim – such as for services you received outside of the Plan’s service area – submit it on the CMS-1500 or an invoice or billing statement from the provider that includes the information shown below. Bills and receipts should be itemized and show:

  • Covered member’s name, date of birth, address, phone number and ID number
  • Name and address of the provider or facility that provided the service or supply
  • Dates you received the services or supplies
  • Diagnosis
  • Type of each service or supply
  • The charge for each service or supply
  • Follow up services rendered out-of-area
  • A copy of the explanation of benefits, payments, or denial from any primary payor – such as the Medicare Summary Notice (MSN)
  • Receipts, if you paid for your services

Note: Canceled checks, cash register receipts, or balance due statements are not acceptable substitutes for itemized bills.

Submit your claims to:

Claims Administration
Medical Mutual of Ohio
PO Box 6018
Cleveland, OH 44101-1018

If your pharmacy will not file your prescription claim electronically, you can complete and submit a Prescription Drug Claim Form.  To get a claim form, log in to My Health Plan at medmutual.com/member and select Resources & Tools, then Forms.  You can also call Customer care at the number on your member ID card and ask for a form to be mailed to you.  Please follow the instructions on the form.  Your must submit receipts/labels when sending in a claim.  Your pharmacist at the pharmacy where you filled the prescription can help you fill out information.  A separate claim form must be submitted for each person or pharmacy.  After completing the form, send it to the address on the form: Express Scripts Inc.; P.O. Box 14711; Lexington, KY 40512.

Deadline for filing your claim

Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you received the service, unless timely filing was prevented by administrative operations of Government or legal incapacity, provided the claim was submitted as soon as reasonably possible.

Post-Service Claims

We will notify you of our decision within 30 days after we receive your post-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 before the expiration of the original 30-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.

If you do not agree with our initial decision, you may ask us to review it by following the disputed claims process detailed in Section 8 of this brochure.

Authorized Representative

You may designate an authorized representative to act on your behalf for filing a claim or to appeal claims decisions to us.  For urgent care claims, we will permit a healthcare professional with knowledge of your medical condition to act as your authorized representative without your express consent. For the purposes of this section, we are also referring to your authorized representative when we refer to you.

Notice Requirements

If you live in a county where at least 10 percent of the population is literate only in a non-English language (as determined by the Secretary of Health and Human Services), we will provide language assistance in that non-English language. You can request a copy of your Explanation of Benefits (EOB) statement, related correspondence, oral language services (such as telephone customer assistance), and help with filing claims and appeals (including external reviews) in the applicable non-English language. The English versions of your EOBs and related correspondence will include information in the non-English language about how to access language services in that non-English language.

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.




Section 8. The Disputed Claims Process

You may be able to appeal directly to the Office of Personnel Management (OPM) if we do not follow required claims processes. For more information about situations in which you are entitled to immediately appeal to OPM, including additional requirements not listed in Sections 3, 7 and 8 of this brochure, please call your plan's customer service representative at the phone number found on your enrollment card, plan brochure, or plan website.

Please follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your post-service claim (a claim where services, drugs or supplies have already been provided). In Section 3 If you disagree with our pre-service claim decision, we describe the process you need to follow if you have a claim for services, referrals, drugs or supplies that must have prior Plan approval, such as inpatient hospital admissions.

To help you prepare your appeal, you may arrange with us to review and copy, free of charge, all relevant materials and Plan documents under our control relating to your claim, including those that involve any expert review(s) of your claim.  To make your request, please contact our Customer Care by writing Customer Care, PO Box 6018, Cleveland, OH 44101-1018 or calling 800-315-3144 (TTY: 711).

Our reconsideration will take into account all comments, documents, records, and other information submitted by you relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination.

When our initial decision is based (in whole or in part) on a medical judgment (i.e., medical necessity, experimental/investigational), we will consult with a healthcare professional who has appropriate training and experience in the field of medicine involved in the medical judgment and who was not involved in making the initial decision.

Our reconsideration will not take into account the initial decision. The review will not be conducted by the same person, or their subordinate, who made the initial decision.

We will not make our decisions regarding hiring, compensation, termination, promotion, or other similar matters with respect to any individual (such as a claims adjudicator or medical expert) based upon the likelihood that the individual will support the denial of benefits.




StepDescription

1

Ask us in writing to reconsider our initial decision. You must:

a) Write to us within 6 months from the date of our decision; and

b) Send your request to us at: Member Appeal, Medical Mutual, P.O. Box 94580, Cleveland, OH 44101-4580; and

c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and

d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms.

We will provide you, free of charge and in a timely manner, with any new or additional evidence considered, relied upon, or generated by us or at our direction in connection with your claim and any new rationale for our claim decision. 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. However, our failure to provide you with new evidence or rationale in sufficient time to allow you to timely respond shall not invalidate our decision on reconsideration. You may respond to that new evidence or rationale at the OPM review stage described in step 4.

2

In the case of a post-service claim, we have 30 days from the date we receive your request to:

a) Pay the claim or

b) Write to you and maintain our denial or

c) 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

If you do not agree with our decision, you may ask OPM to review it.

You must write to OPM within:

  • 90 days after the date of our letter upholding our initial decision; or
  • 120 days after you first wrote to us - if we did not answer that request in some way within 30 days; or
  • 120 days after we asked for additional information.

Write to OPM at: United States Office of Personnel Management, Healthcare and Insurance, Federal Employee Insurance Operations, FEHB 3, 1900 E Street NW, Washington, DC 20415-3630.

Send OPM the following information:

  • A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
  • Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;
  • Copies of all letters you sent to us about the claim;
  • Copies of all letters we sent to you about the claim;
  • Your daytime phone number and the best time to call; and
  • Your email address, if you would like to receive OPM's decision via email. Please note that by providing your email address, you may receive OPM's decision more quickly.

Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to which claim.

Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review request. However, for urgent care claims, a healthcare professional with knowledge of your medical condition may act as your authorized representative without your express consent.

Note: The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control.

4

OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other administrative appeals.

If you do not agree with OPM’s decision, your only recourse is to sue. If you decide to file a lawsuit, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or supplies or from the year in which you were denied precertification or prior approval. This is the only deadline that may not be extended.

OPM may disclose the information it collects during the review process to support their disputed claim decision. This information will become part of the court record.

You may not file a lawsuit until you have completed the disputed claims process. Further, Federal law governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was before OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of benefits in dispute.




Note: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and you did not indicate that your claim was a claim for urgent care, then call us at 800-315-3144. We will expedite 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. You may call OPM’s FEHB 3 at 202-606-0755 between 8 a.m. and 5 p.m. Eastern Time.

Please remember that we do not make decisions about plan eligibility issues.  For example, we do not determine whether you or a dependent is covered under this Plan.  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 Workers' Compensation Programs if you are receiving Workers' Compensation benefits.




Section 9. Coordinating Benefits with Medicare and Other Coverage

TermDefinition

When you have other health coverage

You must tell us if you or a covered family member has coverage under any other health plan or has automobile insurance that pays healthcare expenses without regard to fault. This is called “double coverage.”

When you have double coverage, one plan normally pays its benefits in full as the primary payor and the other plan pays a reduced benefit as the secondary payor. We, like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners’ (NAIC) guidelines. For more information on NAIC rules regarding the coordinating of benefits, visit our website at www.MedMutual.com/feds.

When we are the primary payor, we will pay the benefits described in this brochure.

When we are the secondary payor, we will determine our allowance. After the primary plan pays, we will pay what is left of our allowance, up to our regular benefit. We will not pay more than our allowance. If we are the secondary payor, and you received your services from Plan providers, we may bill the primary carrier.

  • TRICARE and CHAMPVA

TRICARE is the healthcare program for eligible dependents of military persons, and retirees of the military. TRICARE includes the CHAMPUS program. CHAMPVA provides health coverage to disabled Veterans and their eligible dependents. If TRICARE or CHAMPVA and this Plan cover you, we pay first. See your TRICARE or CHAMPVA Health Benefits Advisor if you have questions about these programs.

Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these programs, eliminating your FEHB premium. (OPM does not contribute to any applicable plan premiums.) For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under TRICARE or CHAMPVA.

  • Workers’ Compensation

We do not cover services that:

  • 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
  • OWCP or a similar agency pays for through a third-party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws.

Once OWCP or similar agency pays its maximum benefits for your treatment, we will cover your care.

  • Medicaid

When you have this Plan and Medicaid, we pay first.

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. For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under the state program.

When other Government agencies are responsible for your care

We do not cover services and supplies when a local, state, or federal government agency directly or indirectly pays for them.

When others are responsible for injuries

When you receive money to compensate you for medical or hospital care for injuries or illness caused by another person, you must reimburse us for any expenses we paid. However, we will cover the cost of treatment that exceeds the amount you received in the settlement.

If you do not seek damages you must agree to let us try. This is called subrogation. If you need more information, contact us for our subrogation procedures.

If you obtain a judgment or settlement from or on behalf of a third party who allegedly caused or is responsible for an injury or illness for which you received covered health care services or benefits (“Services”), you must pay us Charges for those Services. “Charges” are: 1) for Services that we pay the provider on a fee-for-service basis, the payments that we made for the Services; and 2) for all other Services, the charges in the provider’s schedule of charges for Services provided to Members less any cost share payments that you made to the provider. Our payments for Services in these circumstances are expressly conditioned on your agreement to comply with this paragraph.

You must also pay us Charges for such Services if you receive or are entitled to receive a recovery from any insurance for an injury or illness alleged to be based on a third party’s fault, such as from uninsured or underinsured motorist coverage. You must also pay us Charges for such Services if you receive or are entitled to receive recovery from any Workers' Compensation benefits.

To secure our rights, we will have a lien on the proceeds of any judgment or settlement you or we obtain against a third party. The proceeds of any judgment or settlement that you or we obtain shall first be applied to satisfy our lien, regardless of whether the total amount of the proceeds is less than the actual losses and damages you incurred. We are entitled under our first-priority lien to be paid Charges for Services even if you are not "made whole" for all of your damages in the recoveries that you receive.

In order for us to determine the existence of any rights we may have and to satisfy those rights, you must complete and send us all consents, releases, authorizations, assignments, and other documents, including lien forms directing your attorney, the third party, and the third party's liability insurer to pay us directly. You may not agree to waive, release, or reduce our rights under this provision without our prior, written consent. You must cooperate in doing what is reasonably necessary to assist us with our right of recovery.  You must notify us within 30 days of the date you or someone acting on your behalf notifies anyone, including an insurer or attorney, of your intention to pursue or investigate a claim to recover damages or obtain compensation due to your injury or illness. You must not take any action that may prejudice our right of recovery.

If your estate, parent, guardian, or conservator asserts a claim against a third party based on your injury or illness, that person or entity and any settlement or judgment recovered by that person or entity shall be subject to our liens and other rights to the same extent as if you had asserted the claim against the third party. We may assign our rights to enforce our liens and other rights.

We have the option of becoming subrogated to all claims, causes of action, and other rights you may have against a third party or an insurer, government program, or other source of coverage for monetary damages, compensation, or indemnification on account of the injury or illness allegedly caused by the third party. We will be so subrogated as of the time we mail or deliver a written notice of our exercise of this option to you or your attorney, but we will be subrogated only to the extent of the total of Charges for the relevant Services.

We will reduce our lien pro rata to share in your legal fees and costs under the common fund doctrine. This net lien will not be more than (1) one-third of your total gross recovery from all third-party sources if you engaged an attorney to obtain that recovery; or (2) one-half of such recovery if you did not.

Contact us if you need more information about recovery or subrogation.

When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) coverage

Some FEHB plans already cover some dental and vision services. When you are covered by more than one vision/dental plan, coverage provided under your FEHB plan remains as your primary coverage. FEDVIP coverage pays secondary to that coverage. When you enroll in a dental and/or vision plan on BENEFEDS.com, or by phone at 877-888-3337.(TTY 877-889-5680), you will be asked to provide information on your FEHB plan so that your plans can coordinate benefits. Providing your FEHB information may reduce your out-of-pocket cost.

Clinical trials

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is either Federally funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration; or is a drug trial that is exempt from the requirement of an investigational new drug application.

We will cover routine care costs not provided by the clinical trial in accordance with Section 5 when Plan physicians provide or arrange for your care.

  • Routine care costs are costs for routine services, such as doctor visits, lab tests, x-rays and scans, and hospitalizations related to treating the patient’s condition whether the patient is in a clinical trial or is receiving standard therapy. We cover routine care costs not provided by the clinical trial.

The Plan does not cover extra care costs and research costs.

  • Extra care costs are costs related to taking part in a clinical trial, such as additional tests that a patient may need as part of the trial, but not as part of the patient’s routine care. We do not cover these costs.
  • Research costs are costs related to conducting the clinical trial, such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes. These costs are generally covered by the clinical trials. This plan does not cover these costs.



TermDefinition
When you have Medicare

What is Medicare?

For more detailed information on "What is Medicare?" and "Should I enroll in Medicare?" please contact Medicare at 1-800-MEDICARE (1-800-633-4227) (TTY 1-877-486-2048) or at www.medicare.gov 

  • The Original Medicare Plan (Part A or Part B)

The Original Medicare Plan (Original Medicare) is available everywhere in the United States. 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. You may go to any doctor, specialist, or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay your share.

All physicians and other providers are required by law to file claims directly to Medicare for members with Medicare Part B, when Medicare is primary.  This is true whether or not they accept Medicare.

When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care.

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.

When we are the primary payor, we process the claim first.

When Original Medicare is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. To find out if you need to do something to file your claim, call us at 800-315-3144 (TTY:711), 7:30 a.m. to 7:30 p.m. (EST), Friday 7:30 a.m. to 6:00 p.m. (EST), Saturday 9:0 a.m. to 1:00 p.m. (EST), or visit our Website at www.MedMutual.com/feds.

We do not waive any costs if the Original Medicare Plan is your primary payor.

Please review the following table. It illustrates your cost share if you are enrolled in Medicare Part B.  Medicare will be primary for all Medicare eligible services.  Members must use providers who accept Medicare's assignment.

Compare for STANDARD and BASIC Option

Benefit: Out of Pocket Maximum
Member Cost STANDARD Option without Medicare: $6,000/$12,000
Member Cost STANDARD Option with Medicare parts A and B: $6,000/$12,000
Member Cost BASIC Option without Medicare: $6,500/$13,000
Member Cost BASIC Option with Medicare parts A and B: $6,500/$13,000

Benefit: Primary Care
Member Cost STANDARD Option without Medicare: $25
Member Cost STANDARD Option with Medicare parts A and B: $25
Member Cost BASIC Option without Medicare: $30
Member Cost BASIC Option with Medicare parts A and B: $30

Benefit: Specialist
Member Cost STANDARD Option without Medicare: $45
Member Cost STANDARD Option with Medicare parts A and B: $45
Member Cost BASIC Option without Medicare: $60
Member Cost BASIC Option with Medicare parts A and B: $60

Benefit: Inpatient Hospital
Member Cost STANDARD Option without Medicare: $650
Member Cost STANDARD Option with Medicare parts A and B: $650
Member Cost BASIC Option without Medicare: 20% after deductible
Member Cost BASIC Option with Medicare parts A and B: 20% after deductible

Benefit: Outpatient Surgery
Member Cost STANDARD Option without Medicare: $375
Member Cost STANDARD Option with Medicare parts A and B: $375
Member Cost BASIC Option without Medicare: 20% after deductible
Member Cost BASIC Option with Medicare parts A and B: 20% after deductible

Benefit: Rx
Member Cost STANDARD Option without Medicare: 
-All Generic $15
-Preferred brand $75
-Non-preferred brand $180
-Specialty 25% up to $500 through a contracted specialty pharmacy
Member Cost STANDARD Option with Medicare parts A and B:
-All Generic $15
-Preferred brand $75
-Non-preferred brand $180
-Specialty 25% up to $500 through a contracted specialty pharmacy
Member Cost BASIC Option without Medicare:
-All Generic $10
-Preferred brand 40% coinsurance up to $250
-Non-preferred brand 60% coinsurance up to $350
-Specialty 30% up to $500 through a contracted specialty pharmacy
Member Cost BASIC Option with Medicare parts A and B:
-All Generic $10
-Preferred brand 40% coinsurance up to $250
-Non-preferred brand 60% coinsurance up to $350
-Specialty 30% up to $500 through a contracted specialty pharmacy

Benefit: Rx mail order (90 day supply)
Member Cost STANDARD Option without Medicare: 2 x Retail Copay
Member Cost STANDARD Option with Medicare parts A and B: 2 x Retail Copay
Member Cost BASIC Option without Medicare: 2 x Retail Copay
Member Cost BASIC Option with Medicare parts A and B: 2 x Retail Copay

  • Tell us about your Medicare coverage
You must tell us if you or a covered family member has Medicare coverage, and let us obtain information about services denied or paid under Medicare if we ask. You must also tell us about other coverage you or your covered family members may have, as this coverage may affect the primary/secondary status of this Plan and Medicare.
  • Medicare Advantage (Part C)

If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage or a Medicare Managed Care plan. These are private healthcare choices (like HMOs and regional PPOs) in some areas of the country. To learn more about Medicare Advantage plans, contact Medicare at-800-MEDICARE (800-633-4227) (TTY: 877-486-2048) or at www.medicare.gov.

If you enroll in a Medicare Advantage plan, the following options are available to you:

This Plan and our Medicare Advantage plan:  We do not offer a Medicare Advantage plan.

This Plan and another plan’s Medicare Advantage plan: You may enroll in another plan’s Medicare Advantage plan and also remain enrolled in our FEHB plan. We will still provide benefits when your Medicare Advantage plan is primary, even out of the Medicare Advantage plan’s network and/or service area (if you use our Plan providers), however we will not waive any of our copayments, coinsurance, or deductibles. If you enroll in a Medicare Advantage plan, tell us. We will need to know whether you are in the Original Medicare plan or in a Medicare Advantage plan so we can correctly coordinate benefits with Medicare.

Suspended FEHB coverage to enroll in a Medicare Advantage plan: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a Medicare Advantage plan, eliminating your FEHB premium. (OPM does not contribute to your Medicare Advantage plan premium.) For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage or move out of the Medicare Advantage plan’s service area.

  • Medicare prescription drug coverage (Part D)

When we are the primary payor, we process the claim first. If you enroll in another plan's Medicare Part D plan and we are the secondary payor, when you fill your prescription at a Plan pharmacy that is not in the network 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. 

You will still need to follow the rules in this brochure for us to cover your care. We will only cover your prescription if it is written by a Plan provider and obtained at a Plan pharmacy or through our Plan mail service delivery program, except in an emergency or urgent care situation.

Medicare Part B Premium Reimbursement Standard Option only

With the Standard Option plan, members enrolled in Medicare Parts A and B are eligible to be reimbursed up to $850 per calendar year for Medicare Part B premium payments.  




Primary Payor Chart

A. When you – or your covered spouse are age 65 or over and have Medicare and you...The primary payor for the individual with Medicare is MedicareThe primary payor for the individual with Medicare is this Plan
1) Have FEHB coverage on your own as an active employee
2) Have FEHB coverage on your own as an annuitant or through your spouse who is an annuitant
3) Have FEHB through your spouse who is an active employee
4) Are a reemployed annuitant with the Federal government and your position is excluded from the FEHB (your employing office will know if this is the case) and you are not covered under FEHB through your spouse under #3 above
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...
  • You have FEHB coverage on your own or through your spouse who is also an active employee
  • You have FEHB coverage through your spouse who is an annuitant
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. (or if your covered spouse is this type of judge) and you are not covered under FEHB through your spouse under #3 above
7) Are enrolled in Part B only, regardless of your employment status ✓ for Part B services ✓ for other services
8) Are a Federal employee receiving Workers' Compensation ✓ *
9) Are a Federal employee receiving disability benefits for six months or more


B. When you or a covered family member...The primary payor for the individual with Medicare is MedicareThe primary payor for the individual with Medicare is this Plan
1) Have Medicare solely based on end stage renal disease (ESRD) and..
  • It is within the first 30 months of eligibility for or entitlement to Medicare due to ESRD (30-month coordination period)
  • It is beyond the 30-month coordination period and you or a family member are still entitled to Medicare due to ESRD
2) Become eligible for Medicare due to ESRD while already a Medicare beneficiary and...
  • This Plan was the primary payor before eligibility due to ESRD (for 30-month coordination period)
  • Medicare was the primary payor before eligibility due to ESRD
3) Have Temporary Continuation of Coverage(TCC) and...
  • Medicare based on age and disability
  • Medicare based on ESRD (for the 30-month coordination period)
  • Medicare based on ESRD (after the 30-month coordination period)


C. When either you or a covered family member are eligible for Medicare solely due to disability and you...The primary payor for the individual with Medicare is MedicareThe primary payor for the individual with Medicare is this Plan
1) Have FEHB coverage on your own as an active employee or through a family member who is an active employee
2) Have FEHB coverage on your own as an annuitant or through a family member who is an annuitant
D. When you are covered under the FEHB Spouse Equity provision as a former spouse

*Workers' Compensation is primary for claims related to your condition under Workers’ Compensation.




Section 10. Definitions of Terms We Use in This Brochure

TermDefinition
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of the same year.
Clinical trials cost categories

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is either Federally funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration; or is a drug trial that is exempt from the requirement of an investigational new drug application.

  • Routine care costs – costs for routine services, such as doctor visits, lab tests, x-rays and scans, and hospitalizations related to treating the patient’s condition whether the patient is in a clinical trial or is receiving standard therapy.
  • Extra care costs – costs related to taking part in a clinical trial, such as additional tests that a patient may need as part of the trial, but not as part of the patient’s routine care.
  • Research costs – costs related to conducting the clinical trial, such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes. These costs are generally covered by the clinical trials.  This plan does not cover these costs.
Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See Section 4.
Copayment A copayment is a fixed amount of money you pay when you receive covered services. See Section 4.
Cost-sharingCost-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.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care(1) Assistance with activities of daily living, for example, walking, getting in and out of bed, dressing, feeding, toileting, and taking medicine. (2) Care that can be performed safely and effectively by people who, in order to provide the care, do not require medical licenses or certificates, or the presence of a supervising licensed nurse. Custodial care that last 90 days or more is sometimes known as long term care.
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 those services. See Section 4.
Experimental or investigational services

We do not cover a service, supply, item, or drug that we consider experimental. We consider a service, supply, item, or drug to be experimental when the service, supply, item or drug:

(1) has not been approved by the FDA; or

(2) is the subject of a new drug or new device application on file with the FDA; or

(3) is part of a Phase I or Phase II clinical trial, as the experimental or research arm of a Phase III clinical trial; or is intended to evaluate the safety, toxicity, or efficacy of the service; or

(4) is available as the result of a written protocol that evaluates the service’s safety, toxicity, or efficacy; or

(5) is subject to the approval or review of an Institutional Review Board; or

(6) requires an informed consent that describes the service as experimental or investigational.

We carefully evaluate whether a particular therapy is safe and effective or offers a reasonable degree of promise with respect to improving health outcomes. The primary source of evidence about health outcomes of any intervention is peer-reviewed medical or dental literature.

Group health coverage Health care benefits that are available as a result of your employment, or the employment of your spouse, and that are offered by an employer or through membership in an employee organization. Health care coverage may be insured or indemnity coverage, self-insured or self-funded coverage, or coverage through health maintenance organizations or other managed care plans. Health care coverage purchased through membership in an organization is also “group health coverage.”

Healthcare professional

A physician or other healthcare professional licensed, accredited, or certified to perform specified health services consistent with state law.

Medically necessaryAll benefits need to be medically necessary in order for them to be covered benefits. Generally, if your Plan physician provides the service in accord with the terms of this brochure, it will be considered medically necessary. However, some services are reviewed in advance of you receiving them to determine if they are medically necessary. When we review a service to determine if it is medically necessary, a Plan physician will evaluate what would happen to you if you do not receive the service. If not receiving the service would adversely affect your health, it will be considered medically necessary. The services must be a medically appropriate course of treatment for your condition. If they are not medically necessary, we will not cover the services. In case of emergency services, the services that you received will be evaluated to determine if they were medically necessary.
Never eventCertain Hospital Acquired Conditions, as defined by Medicare, including things like wrong-site surgeries, transfusion with the wrong blood type, pressure ulcers (bedsores), falls or trauma, and nosocomial infections (hospital-acquired infections) associated with surgeries or catheters, that are directly related to the provision of an inpatient covered service at a Plan provider.

Our allowance

Our allowance is the amount we use to determine our payment and your coinsurance for covered services. We determine our allowance as follows:

  • The amount a Contracting Institutional Provider or a Participating Professional Provider has agreed with the Carrier to accept as payment in full for Covered Services.

You should also see Important Notice About Surprise Billing - Know Your Rights in Section 4 that describes your protections against surprise billing under the No Surprises Act.

Plan facilities

Plan facilities are hospitals and other facilities in the service area that the Carrier contracts with to provide covered services to members.

Plan providers

Plan providers are physicians and other health care professionals in the services area that the Carrier contract with to provide covered services to members.

Post-service claimsAny claims that are not pre-service claims.  In other words, post-service claims are those claims where treatment has been performed and the claims have been sent to us in order to apply for benefits.
Pre-service claimsThose claims (1) that require precertification, prior approval, or a referral and (2) where failure to obtain precertification, prior approval, or a referral results in a reduction of benefits.
ReimbursementA carrier's pursuit of a recovery if a covered individual has suffered an illness or injury and has received, in connection with that illness or injury, a payment from any party that may be liable, any applicable insurance policy, or a worker's compensation program or insurance policy, and the terms of the carrier's health benefits plan requires the covered individual, as a result of such payment, to reimburse the carrier out of the payment to the extent of the benefits initially paid or provided.  The right of reimbursement is cumulative with and not exclusive of the right of subrogation.
SubrogationA carrier's pursuit of a recovery from any party that may be liable, any applicable insurance policy, or a worker's compensation program or insurance policy, as successor to the rights of a covered individual who suffered an illness or injury and has obtained benefits from the carrier's health benefit plan.

Urgent care claims

A claim for medical care or treatment is an urgent care claim if waiting for the regular time limit for non-urgent care claims could have one of the following impacts:

  • Waiting could seriously jeopardize your life or health;
  • Waiting could seriously jeopardize your ability to regain maximum function; or
  • In the opinion of a physician with knowledge of your medical condition, waiting would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.

Urgent care claims involve Pre-service claims and not Post-service claims. We will determine whether or not a claim is an urgent care claim by applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine.

If you believe your claim qualifies as an urgent care claim, please contact Customer Care at 800-315-3144. You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care.

Us/We

Us and We refer to Medical Mutual of Ohio.

You You refers to the enrollee and each covered family member.



Index

Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.




Index Entry
(Page numbers solely appear in the printed brochure)



Summary of Benefits for the Standard Option of Medical Mutual of Ohio - 2022

  • Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the definitions, limitations, and exclusions in this brochure. You can obtain a copy of our Summary of Benefits and Coverage at www.MedMutual.com/feds.  On this page we summarize specific expenses we cover; for more detail, look inside.
  • If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.
  • We only cover services provided or arranged by Plan physicians, except in emergencies.



Standard Option BenefitsYou PayPage

Medical services provided by physicians and other health care professionals:
Diagnostic and treatment services provided in the office

$25 per primary care office visit
$45 per specialty care office visit

27

Services provided by a hospital: Inpatient
Services provided by a hospital: Outpatient

$650 per admission
$375 per outpatient surgery

47
48

Emergency benefits: In-area
Emergency benefits: Out-of-area

$250 per visit
$250 per visit

51
51

Mental health and substance use disorder treatment:

Regular cost-sharing

52-54

Prescription drugs:

Retail pharmacy
Tier 1 - $15 per prescription or refill for all generic drugs
Tier 2 - $75 per prescription or refill for Preferred brand-name drugs
Tier 3 - $180 per prescription or refill for Non-Preferred brand-name drugs
Tier 4 - Specialty 25% up to $500 through a contracted specialty pharmacy

Mail order
Tier 1 - $30 per prescription or refill for mail-order generic drugs for up to 90-day supply
Tier 2 - $150 per prescription or refill for mail-order preferred brand-name drugs for up to 90-day supply
Tier 3 - $360 per prescription or refill for mail-order non-preferred brand-name drugs for up to 90-day supply
Tier 4 - Mail order not available for Specialty medications

56-57

Dental care:

No benefit. Except for Accidental Injury to teeth

60

Vision care:

Refractions;
$25 per primary care office visit
$45 per specialty care office visit

35

Special features:

24/7 Nurse Line; Centers of Excellence; Services for the deaf, hard or hearing or speech impaired, Wellness, Disease and Maternity Management 

61-62

Protection against catastrophic costs (your catastrophic protection out-of-pocket maximum):

Nothing after $6,000/Self Only or $12,000/per Self Plus One or Self and Family enrollment per year. Some costs do not count toward this protection.

22




Summary of Benefits for the Basic Option of Medical Mutual of Ohio – 2022

  • Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the definitions, limitations, and exclusions in this brochure. You can obtain a copy of our Summary of Benefits and Coverage at www.MedMutual.com/feds.  On this page we summarize specific expenses we cover; for more detail, look inside.
  • If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.
  • We only cover services provided or arranged by Plan physicians, except in emergencies.
  • The calendar year deductible for the Basic Option is $750 per person ($1,500 per Self Plus One, or $1,500 per Self and Family enrollment).  We added "after deductible" when the deductible applies.



Basic Option BenefitsYou payPage

Medical services provided by physicians and other health care professionals:
Diagnostic and treatment services provided in the office

$30 per primary care office visit
$60 per specialty care office visit

27

Services provided by a hospital: Inpatient
Services provided by a hospital: Outpatient

20% after deductible
20% after deductible

47
48

Emergency benefits: In-area
Emergency benefits: Out-of-area

$250 per visit
$250 per visit

51
51

Mental health and substance use disorder treatment:

Regular cost-sharing

52-54

Prescription drugs:

Retail pharmacy
Tier 1 - $10 per prescription or refill for all generic drugs
Tier 2 - 40% coinsurance up to $250 per prescription or refill for Preferred brand-name drugs
Tier 3 - 60% coinsurance up to $350 per prescription or refill for Non- Preferred brand-name drugs
Tier 4 - Specialty 30% up to $500 through a contracted specialty pharmacy

Mail Order
Tier 1 - $20 per prescription or refill for mail order generic drugs for up to a 90-day supply
Tier 2 - 40% coinsurance up to $500 maximum for mail order preferred brand for up to a 90-day supply
Tier 3 - 60% up to $700 maximum for mail order for non-preferred brand-name drugs for up to a 90-day supply
Tier 4 - Mail order not available for Specialty medications

56-57

Dental care:

No benefit. Except for Accidental Injury to teeth

60

Vision care:

Refractions;
$30 per primary care office visit
$60 per specialty care office visit

35

Special features:

24/7 Nurse Line; Centers of Excellence; Services for the deaf, hard or hearing or speech impaired, Wellness, Disease and Maternity Management

61-62

Protection against catastrophic costs (your catastrophic protection out-of-pocket maximum):

The deductible accumulates towards the out-of-pocket maximum.

Nothing after $6,500/Self Only or $13,000/per Self Plus One or Self and Family enrollment per year. Some costs do not count toward this protection.

22




2022 Rate Information for Medical Mutual of Ohio

To review premium rates for all FEHB health plan options please go to www.opm.gov/FEHBpremiums or www.opm.gov/Tribalpremium. 

Premiums for Tribal employees are shown under the Monthly Premium Rate column. The amount shown under employee contribution is the maximum you will pay. Your Tribal employer may choose to contribute a higher portion of your premium. Please contact your Tribal Benefits Officer for exact rates.




The Northeast Ohio counties of Ashland, Ashtabula, Columbiana, Cuyahoga, Erie, Lake, Geauga, Huron, Lorain, Mahoning, Medina, Portage, Richland, Stark, Summit, Trumbull, Wayne
Type of EnrollmentEnrollment CodePremium Rate
BiWeekly
Gov't Share
Premium Rate
BiWeekly
Your Share
Premium Rate
Monthly
Gov't Share
Premium Rate
Monthly
Your Share
Standard Option Self Only644$244.86$238.76$530.53$517.31
Standard Option Self Plus One646$524.63$539.32$1,136.70$1,168.53
Standard Option Self and Family645$574.13$586.54$1,243.95$1,270.84
The Northwest Ohio counties of Allen, Auglaize, Defiance, Fulton, Henry, Lucas, Mercer, Ottawa, Putnam, Sandusky, Seneca, Williams, Wood
Type of EnrollmentEnrollment CodePremium Rate
BiWeekly
Gov't Share
Premium Rate
BiWeekly
Your Share
Premium Rate
Monthly
Gov't Share
Premium Rate
Monthly
Your Share
Standard Option Self OnlyX64$244.86$267.44$530.53$579.45
Standard Option Self Plus OneX66$524.63$602.44$1,136.70$1,305.29
Standard Option Self and FamilyX65$574.13$655.40$1,243.95$1,420.03
Basic Option Self OnlyX61$140.87$46.95$305.21$101.73
Basic Option Self Plus OneX63$309.91$103.30$671.47$223.82
Basic Option Self and FamilyX62$338.09$112.69$732.52$244.17
The Northeast Ohio counties of Ashland, Ashtabula, Columbiana, Cuyahoga, Erie, Lake, Geauga, Huron, Lorain, Mahoning, Medina, Portage, Richland, Stark, Summit, Trumbull, Wayne
Type of EnrollmentEnrollment CodePremium Rate
BiWeekly
Gov't Share
Premium Rate
BiWeekly
Your Share
Premium Rate
Monthly
Gov't Share
Premium Rate
Monthly
Your Share
Basic Option Self OnlyUX1$142.93$47.64$309.68$103.22
Basic Option Self Plus OneUX3$314.45$104.81$681.30$227.10
Basic Option Self and FamilyUX2$343.03$114.34$743.23$247.74