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. CareFirst holds the NCQA accreditation. To learn more about this plan’s accreditation(s), please visit the following websites:
- National Committee for Quality Assurance (ncqa.org)
We require you to see specific physicians, 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 Blue Value Plus Option, a Standard Option, or a High Deductible Health Plan (HDHP).
HMOs emphasize preventive care such as routine office visits, physical exams, well-child 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 claim forms or pay bills. You pay only the copayments, coinsurance, and deductibles described in this brochure. When you receive emergency services from non-Plan providers, you may have to submit claim forms.
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.
General features of our Standard HealthyBlue & Blue Value Plus Options
CareFirst offers a Blue Value Plus in network only HMO with features including: No referrals, no member out-of-pocket for preventive care, and $10 copay for preferred generic drugs. The plan also provides benefits for routine vision exams. There is a $100 deductible for Self Only enrollment and $200 Self Plus One and Self and Family enrollment that applies to all prescription drugs except for Tier 1 preferred generics. In addition, Blue Value Plus option offers Blue Rewards where members can earn pecuniary rewards and redeem these rewards using their medical expense debit card.
Our Standard HealthyBlue offering includes no referrals, no member out-of-pocket for preventive care, and no copay for generic drugs. The plan also provides benefits for routine vision exams. The following additional provisions are also available under this plan: no member copay for any care received from a BlueChoice primary care physician (including pediatricians), members have out-of-network benefits, and a deductible applies to some services. In addition, Standard HealthyBlue offers Blue Rewards where members can earn pecuniary rewards and redeem these rewards using their medical expense debit card.
We have Open Access benefits
This means you can receive covered services from a participating provider without a required referral from your primary care physician or by another participating provider in our network.
We have Point-of-Service (POS) benefits
Our Standard HealthyBlue option, in addition to being Open Access, offers Point-of-Service benefits. This means you can receive covered services from an out-of-network provider; a provider outside of our BlueChoice network who participates in another BlueChoice network or a non-participating provider. However, if you receive services from an out-of-network provider outside of our BlueChoice network you may have higher out-of-pocket costs than you would have from our in-network providers.
How we pay providers
We contract with individual 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). Under Standard HealthyBlue, you will be responsible for charges in excess of our allowed benefit, in addition to any applicable deductible or copay, when you receive care from an out-of-network non-participating provider.
General Features of our HealthyBlue Advantage High Deductible Health Plan (HDHP)
Our HDHP is called the HealthyBlue Advantage HDHP. HDHPs have higher annual deductibles and annual out-of-pocket maximum limits than other types of FEHB plans. FEHB Program HDHPs also offer health savings accounts or health reimbursement arrangements. Please see below for more information about these savings features.
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 only from a in-network provider.
There is no medical or pharmacy deductible for the Standard HealthyBlue offering. There is no medical deductible for the Blue Value Plus Option. There is a $100 deductible for Self Only enrollment and $200 Self Plus One and Self and Family enrollment that applies to all prescription drugs except for Tier 1 preferred generics under the Blue Value Plus option. Under the HealthyBlue Advantage HDHP Option, there is a $1,400 Self Only enrollment deductible and $2,800 Self Plus One and Self and Family enrollment deductible in-network and there is a $3,000 Self Only enrollment deductible and $6,000 Self Plus One and Self and Family enrollment deductible out-of-network. The annual deductible must be met before Plan benefits are paid for care other than preventive care.
Health Savings Account (HSA)
You are eligible for an HSA if you are enrolled in an HDHP, not covered by any other health plan that is not an HDHP (including a spouse’s health plan, excluding specific injury insurance and accident, disability, dental care, vision care, or long-term coverage), not enrolled in Medicare, not received VA (except for veterans with a service-connected disability) or Indian Health Service (IHS) benefits within the last three (3) months, not covered by your own or your spouse’s flexible spending account (FSA), and are not claimed as a dependent on someone else’s tax return.
- You may use the money in your HSA to pay all or a portion of the annual deductible, copayments, coinsurance, or other out-of-pocket costs that meet the IRS definition of a qualified medical expense.
- Distributions from your HSA are tax-free for qualified medical expenses for you, your spouse, and your dependents, even if they are not covered by a HDHP.
- You may withdraw money from your HSA for items other than qualified medical expenses, but it will be subject to income tax and, if you are under 65 years old, an additional 20% penalty tax on the amount withdrawn.
- For each month that you are enrolled in an HDHP and eligible for an HSA, the HDHP will pass through (contribute) a portion of the health plan premium to your HSA. In addition, you (the account holder) may contribute your own money to your HSA up to an allowable amount determined by IRS rules. Your HSA dollars earn tax-free interest.
- You may allow the contributions in your HSA to grow over time, like a savings account. The HSA is portable – you may take the HSA with you if you leave the Federal government or switch to another plan.
Health Reimbursement Arrangement (HRA)
If you are not eligible for an HSA, or become ineligible to continue an HSA, you are eligible for a Health Reimbursement Arrangement (HRA). Although an HRA is similar to an HSA, there are major differences.
- An HRA does not earn interest.
- An HRA is not portable if you leave the Federal government or switch to another plan.
We protect you against catastrophic out-of-pocket expenses for covered services. The IRS limits annual out-of-pocket expenses for covered services, including deductibles, coinsurance and copayments, to no more than $7,000 for Self Only enrollment, and $14,000 for a Self Plus One or Self and Family. Our plan specific out-of-pocket limits are as follows:
For the Standard HealthyBlue Option, the catastrophic limit is $5,000 per Self Only enrollment and $10,000 per Self Plus One and Self and Family enrollment for in-network services. For out-of-network services, the catastrophic limit is $8,500 per Self Only enrollment and $18,000 per Self Plus One and Self and Family enrollment.
For the Blue Value Plus Option, the catastrophic limit is $6,000 per Self Only enrollment and $12,000 per Self Plus One and Self and Family enrollment for in-network services.
- For the HealthyBlue Advantage HDHP, the catastrophic limit is $5,000 per Self Only enrollment and $10,000 per Self Plus One and Self and Family enrollment for in-network services. For out-of-network services, the catastrophic limit is $7,000 per Self Only enrollment and $14,000 per Self Plus One and Self and Family enrollment.
- Individual Coverage:
- The member must meet the individual out-of-pocket maximum.
- Each Member can satisfy his/her own individual out-of-pocket maximum by meeting the individual out-of-pocket maximum. In addition, eligible expenses of all covered family members can be combined to satisfy the family out-of-pocket maximum.
- An individual family member cannot contribute more than the individual out-of-pocket maximum toward meeting the family out-of-pocket Maximum
Once the family out-of-pocket maximum has been met, this will satisfy the out-of-pocket maximum for all family members.
These amounts apply to the out-of-pocket maximum:
- Co-payments and coinsurance for all covered services.
- Prescription drug benefit Rider co-payments and coinsurance for all covered services.
- Note: When the member has reached the out-of-pocket maximum, no further co-payments, coinsurance or deductible will be required in that benefit period for covered services. The in-network and out-of-network out-of-pocket maximum contributes towards one another.
Health education resources and account management tools
We make available a wide variety of self-service tools and resources to help you take personal control of your health. Below is a list of some of these tools and resources, many of which are available through our website at www.carefirst.com/fedhmo.
- Health education resources — preventive guidelines, patient safety tips, wellness and disease information, prescription drug interaction and pricing tools, and newsletters
- Account management tools — online claims payment history and HSA or HRA balance information
- Consumer choice information — online provider directory and health services pricing tool
- Care support information — case management programs
For more information about these and other available tools and resources, please see the HDHP Section.
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, providers, and facilities from OPM’s FEHB website (www.opm.gov/healthcare-insurance), which lists the specific types of information that we must make available to you.
Some of the required information is listed below:
- We are in compliance with Federal and State licensing and certification requirements
- We have been in existence since 1984
- We are a non-profit corporation
- CareFirst BlueChoice, Inc. is an independent licensee of the BlueCross and BlueShield Association, a registered trademark of the BlueCross and BlueShield Association and a registered trademark of CareFirst of Maryland, Inc.
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 www.carefirst.com/fedhmo. You can also contact us to request that we mail a copy to you.
By law, you have the right to access your protected health information (PHI). For more information regarding access to PHI, visit our website www.carefirst.com/fedhmo to obtain our Notice of Privacy Practices. You can also contact us to request that we mail you a copy of that Notice.
If you want more information about us, call (toll free) (888) 789-9065 or write to Mail Administrator, P.O. Box 14114, Lexington, KY 40512-4114. You may also contact us by visiting our website at www.carefirst.com/fedhmo.
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. In addition, we may use or disclose your information for health benefits administration purposes (such as claims and enrollment processing, care management and wellness offerings, claims payment and fraud detection and prevention efforts), and our business operations (including for quality measurement and enhancement and benefit improvement and development. You may view our Notice of Privacy Practice for more information about how we use and disclose member information by visiting our website at www.carefirst.com/fedhmo/
To enroll in this Plan, you must live in or work in our service area. This is where our providers practice. Our service area is: The District of Columbia; the state of Maryland; in Virginia, the cities of Alexandria and Fairfax, Arlington County, the town of Vienna and the area of Fairfax and Prince William Counties in Virginia lying east of route 123.
Under the Standard HealthyBlue and Blue Value Plus, if you elect to receive care outside of our service area, the care will be treated as out-of-network with the exception of emergency care.
If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live outside of the service area (for example, if your child goes to college in another state), you may be able to take advantage of our Guest Membership Program. This program will allow you or your dependents, which reside outside of the service area for an extended period of time, to utilize the benefits of an affiliated Blue Cross and Blue Shield HMO. Please contact us toll free at (888)789-9065 for more information on the Guest Membership Program. 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.