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

HealthPartners

www.healthpartners.com/fehb
844-440-1900 TTY: 952-883-5127

2021



IMPORTANT:
  • Rates
  • Changes for 2021
  • Summary of Benefits
  • Accreditations
A Health Maintenance Organization (High and Standard Option)

This plan's health coverage qualifies as minimum essential coverage and meets the minimum value standard for the benefits it provides. See page (Applies to printed brochure only) for details.

This plan is accredited. See page (Applies to printed brochure only).

Serving: the entire state of Minnesota, entire state of Iowa, parts of Wisconsin, eastern North Dakota, and eastern South Dakota.

Enrollment in this Plan is limited. You must live or work in our geographic service area to enroll.              
See page 11 for requirements.

HealthPartners has been awarded "Excellent" Accreditation for most of its commercial HMO and Medicare Advantage plans from the National Committee for Quality Assurance (NCQA). NCQA is an independent, not-for-profit organization dedicated to measuring the quality of America's health care.

Enrollment codes for this Plan: 
V31 High Option - Self Only 
V33 High Option - Self Plus One 
V32 High Option - Self and Family 
V34 Standard Option - Self Only 
V36 Standard Option - Self Plus One 
V35 Standard Option - Self and Family 

Special notice - This plan is now serving the entire state of Iowa and 18 counties have been added to Wisconsin's service area.

FEHB LogoOPM Logo








Important notice from HealthPartners about our prescription drug coverage and Medicare


 

  

Important Notice from HealthPartners About
Our Prescription Drug Coverage and Medicare

The Office of Personnel Management (OPM) has determined that the HealthPartners High Option and Standard Option prescription drug benefit 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)

Table of Content



Introduction

This brochure describes the benefits of the HealthPartners High Option and the Standard Option Plan under HealthPartners' contract (CS 2875) with the United States Office of Personnel Management, as authorized by the Federal Employees Health Benefits law. Customer service may be reached at 844-440-1900 (TTY: 952-883-5127) or through our website: www.healthpartners.com/fehb. This Plan is underwritten by Group Health, Inc. The address for HealthPartners administrative office is: Group Health, Inc., dba HealthPartners, Inc., 8170 33rd Avenue South, Bloomington, MN 55425.

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, 2021, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each Plan annually. Benefit changes are effective January 1, 2021, and changes are summarized on page (Applies to printed brochure only). Rates are shown at the end 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 HealthPartners.
  • 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 health care 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 health care 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 (EOBs) 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 844-440-1900 and explain the situation.
    •  If we do not resolve the issue:

      CALL -- THE HEALTH CARE 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 he/she was disabled and incapable of self-support prior to age 26). 

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.

  • 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 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

HealthPartners complies with all applicable Federal civil rights laws, including Title VII of the Civil Rights Act of 1964.

You can also file a civil rights complaint with Office of Personnel Mangament 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. 20415-3160




Preventing Medical Mistakes

Medical mistakes continue to be a significant cause of preventable death within the United 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 health care and that of your 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 medications 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 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 your pharmacist about the medication 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 health care 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/topics/patient_safety.aspx. The Joint Commission helps health care organizations to improve the quality and safety of the care they deliver.
  • www.jointcommission.org/speakup.aspx. The Joint Commission's Speak Up™ patient safety program.
  • 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 health care 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 health care 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 doctors or the hospital had taken proper precautions. Errors in medical care that are clearly identifiable, preventable and serious in their consequences for patients, can indicate a significant problem in the safety and credibility of a health care 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.

You will not be billed for inpatient services related to treatment of specific hospital acquired conditions or for inpatient services needed to correct Never Events, if you use HealthPartners Open Access Network preferred providers. This policy helps to protect you from preventable medical errors and improve the quality of care you receive.




FEHB Facts

TermDefinition
Coverage information
  • 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 an 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 don’t 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, you must also contact your employing or retirement office.

  • Types of coverage available for you and your family

Self Only coverage is for you alone. Self Plus One coverage is for you and one eligible family member. Self and Family coverage is for you, and one eligible family member, or 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.

Your employing or retirement office will not notify you when a family member is no longer eligible to receive benefits, nor will we. 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 valid common-law marriage if you reside in 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 2021 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 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 2020 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).



TermDefinition
When you lose benefits
  • 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 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 Patient Protection and Affordable Care Act (ACA) did not eliminate TCC or change the TCC rules.  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 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 844-440-1900 or visit our website at www.healthpartners.com/fehb.

  • 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). OPM requires that FEHB plans be accredited to validate that plan operations and/or care management meet nationally recognized standards. HealthPartners holds the following accreditation: "Excellent" accreditation from the National Committee for Quality Assurance (NCQA). To learn more about this plan's accreditation, please visit www.ncqa.org. We generally 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. Contact us for a copy of our most recent provider directory. There is one provider directory for both Plan options. We give you a choice of enrollment in a High Option or a Standard Option.

The plans 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 the Plan's Open Access Network 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 and when you use the out-of-network benefit of Standard Option, 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.

Our network is subject to change. For the most current information on the network, visit our website at
www.healthpartners.com/fehb or call us at 844-440-1900 (TTY: 952-883-5127).

General features of our High and Standard Options

The Plan lets you receive care from a large network of providers. Referrals are not required and you do not need to choose a primary care clinic. Any time you or a member in your family needs care, you may choose to see any provider in this Network. With limited exceptions, if you seek care from a provider who does not participate in the Network, your care is considered out of network and may not be covered. Standard Option lets you obtain care in the Open Access Network or out of network.

We have Open Access benefits

The plans offers Open Access benefits. This means you can receive covered services from a HealthPartners Open Access Network participating provider without a required referral from your primary care physician or another participating provider in the network. 

How we pay providers

We contract with individual physicians, medical groups and hospitals to provide the Open Access Network 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). Out-of-network providers have not agreed to negotiated fees and you may be responsible for amounts above usual and customary levels.

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, our providers and facilities.  OPM’s FEHB website (www.opm.gov/insure) lists the specific types of information that we must make available to you.  Some of the required information is listed below.

  • HealthPartners is Minnesota’s only consumer-governed health Plan. Our Board of Directors is composed of consumer-elected members. HealthPartners is a licensed HMO in the State of Minnesota. Group Health, Inc., is a federally qualified HMO, and received that qualification in 1974.
  • Information on the following topics is available by calling HealthPartners Member Services: 
    • Details on your health plan benefits, claims and account balances
    • Assistance finding and choosing a provider in your network
    • Prescription drug information specific to your benefits
    • A warm transfer to HealthPartners Nurse Navigator program staffed by experience nurses who help research treatment options, coordinate care and guide you through difficult decisions
  • Member Services representatives are available from 7 a.m. until 6 p.m., Monday through Friday, Central Standard Time.

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.healthpartners.com/fehb. You can also contact us to request that we mail a copy to you.

If you want more information about us, call 844-440-1900 (TTY: 952-883-5127), or write to HealthPartners, P.O. Box 1309, Minneapolis, MN 55440-1309. You may also visit our website at www.healthpartners.com/fehb.

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.healthpartners.com/fehb 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.

Service area

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 following counties in Minnesota (includes all counties in Minnesota): Aitkin, Anoka, Becker, Beltrami, Benton, Big Stone, Blue Earth, Brown, Carlton, Carver, Cass, Chippewa, Chisago, Clay, Clearwater, Cook, Cottonwood, Crow Wing, Dakota, Dodge, Douglas, Faribault, Fillmore, Freeborn, Goodhue, Grant, Hennepin, Houston, Hubbard, Isanti, Itasca, Jackson, Kanabec, Kandiyohi, Kittson, Koochiching, Lac Qui Parle, Lake, LeSueur, Lincoln, Lyon, Mahnomen, Marshall, Martin, McLeod, Meeker, Mille Lacs, Morrison, Mower, Murray, Nicollet, Nobles, Norman, Olmsted, Otter Tail, Pennington, Pine, Pipestone, Polk, Pope, Ramsey, Red Lake, Redwood, Renville, Rice, Rock, Roseau, St. Louis, Scott, Sherburne, Sibley, Stearns, Steele, Stevens, Swift, Todd, Traverse, Wabasha, Wadena, Waseca, Washington, Watonwan, Wilkin, Winona, Wright and Yellow Medicine.

The following counties in Iowa (includes all counties in Iowa): Adair, Adams, Allamakee, Appanoose, Audobon, Benton, Black Hawk, Boone, Bremer, Buchanan, Buena Vista, Butler, Calhoun, Carroll, Cass, Cedar, Cerro Gordo, Cherokee, Chickasaw, Clarke, Clay, Clayton, Clinton, Crawford, Dallas, Davis, Decatur, Delaware, Des Moines, Dickinson, Dubuque, Emmet, Fayette, Floyd, Franklin, Fremont, Greene, Grundy, Guthrie, Hamilton, Hancock, Hardin, Harrison, Henry, Howard, Humboldt, Ida, Iowa, Jackson, Jasper, Jefferson, Johnson, Jones, Keokuk, Kossuth, Lee, Linn, Louisa, Lucas, Lyon, Madison, Mahaska, Marion, Marshall, Mills, Mitchell, Monona, Monroe, Montgomery, Muscatine,  O’Brien, Osceola, Page, Palo Alto, Plymouth, Pocahontas, Polk, Pottawattamie, Poweshiek, Ringgold, Sac, Scott, Shelby, Sioux, Story, Tama, Taylor, Union, Van Buren, Wapello, Warren, Washington, Wayne, Webster, Winnebago, Winneshiek, Woodbury, Worth and Wright.

The following counties in North Dakota: Adams, Barnes, Benson, Bottineau, Bowman, Burleigh, Cass, Cavalier, Dickey, Eddy, Emmons, Foster, Grand Forks, Grant, Griggs, Hettinger, Kidder, LaMoure, Logan, McHenry, McIntosh, McLean, Mercer, Morton, Mountaintrail, Nelson, Pembina, Pierce, Ramsey, Ransom, Renville, Richland, Rolette, Sargent, Sheridan, Sioux, Stark, Steele, Stutsman, Towner, Traill, Walsh, Ward and Wells.

The following counties in South Dakota: Aurora, Beadle, Bon Homme, Brookings, Brown, Brule, Campbell, Charles Mix, Clark, Clay, Codington, Corson, Davison, Day, Deuel, Douglas, Edmunds, Faulk, Grant, Gregory, Hamlin, Hand, Hanson, Harding, Hughes, Hutchinson, Hyde, Jerauld, Jones, Kingsbury, Lake, Lincoln, Lyman, Marshall, McCook, McPherson, Miner, Minnehaha, Moody, Perkins, Potter, Roberts, Sanborn, Spink, Tripp, Turner, Union, Walworth and Yankton.

The following counties in Wisconsin: Adams, Ashland, Barron, Bayfield, Brown, Buffalo, Burnett, Calumet, Chippewa, Clark, Crawford, Douglas, Dunn, Eau Claire, Florence, Forest, Grant, Green Lake, Iron, Jackson, Juneau, Kewaunee, La Crosse, Langlade, Lincoln, Manitowoc, Marathon, Marinette, Marquette, Menominee, Monroe, Oconto, Oneida, Outagamie, Pepin, Pierce, Polk, Portage, Price, Richland, Rusk, Shawano, St. Croix, Sauk, Sawyer, Taylor, Trempeleau, Vernon, Vilas, Washburn, Waupaca, Waushara, Winnebago and Wood.

If you or a covered family member move outside of our service area, you can enroll in another plan. 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 2021

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




Changes to High Option only

  • The plan will no longer cover Preventive Dental.
  • Hearing aid coverage for enrollees over age 18 is now through TruHearing. Enrollees are eligible for one hearing aid per ear each year at a copay of $699 per Advanced aid or $999 per Premium aid. See page (Applies to printed brochure only).
  • Eligible members enrolled in Medicare Parts A and B will be eligible to receive a Part B premium reimbursement of up to $1200 per calendar year.
  • Your share of the non-Postal premium will decrease. See page (Applies to printed brochure only).

Changes to Standard Option only

  • Your share of the non-Postal premium will increase. See page (Applies to printed brochure only).

Changes to both High Option and Standard Option plans

  • HealthPartners has expanded our Service Area for 2021. We are now available for members who live or work anywhere in the state of Iowa. We’ve also expanded into Northeastern Wisconsin by adding the following counties: Brown, Calumet, Florence, Forest, Green Lake, Kewaunee, Langlade, Lincoln, Manitowoc, Marinette, Marquette, Menominee, Oconto, Outagamie, Shawano, Waupaca, Waushara, Winnebago. Our service area in Minnesota, North Dakota and South Dakota remains unchanged.

  • Prostate Specific Antigen (PSA) will now be covered under Lab, X-ray and other diagnostic tests. 

  • The Plan will not apply more than $8,550 per calendar year to the out-of-pocket maximum of an individual covered under Self Plus One or Self and Family. See Page (Applies to printed brochure only).

  • The Plan will waive in-network cost-sharing for members enrolled in Medicare Parts A and B as their primary payor. Applicable deductibles, copays and coinsurance will be waived. Benefit limits and maximums still apply. We do not waive cost-sharing on prescription drugs or hearing aids. See page (Applies to printed brochure only).



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. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation letter (for annuitants) or your electronic enrollment system (such as Employee Express) confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your enrollment or if you need replacement cards, call us at 844-440-1900  (TTY: 952-883-5127) or write to us at Member Services, P.O. Box 1309, Minneapolis, MN 55440-1309. You may also request replacement cards through our website at www.healthpartners.com/fehb.

Where you get covered care

In Network: You get care from "Plan providers" and "Plan facilities." You will pay copayments, deductibles, and/or coinsurance. You can receive covered services from a participating provider without a referral from your primary care physician or another participating provider in the network.

Out of Network (Standard Option): You may choose to use your out-of-network benefits and receive care from any licensed provider. You may be billed for these services and may need to file a claim for reimbursement.

Plan providers

Plan providers are physicians and other health care professionals that we contract with to provide covered services to our members. We credential Plan providers according to national standards.

We list Plan providers in the HealthPartners Open Access Network provider directory, which we update periodically. For information that is updated weekly, visit www.healthpartners.com/fehb.

This Plan lets you receive care from more than 850,000 providers in the Open Access Network. Referrals are not required and you do not need to choose a primary care clinic. Any time you or a member in your family needs care, you may choose to see any provider in this network.

High Option: With limited exceptions, if you seek care from a provider who does not participate in the Open Access Network, your care is considered out of network and may not be covered.

Standard Option: With limited exceptions, if you seek care from a provider who does not participate in the Open Access Network, your care is considered out of network and the lower out-of-network benefits apply.

Plan facilities

Plan facilities are hospitals and other facilities that we contract with to provide covered services to our members. We list these in the Open Access Network provider directory, which we update periodically. The list is on our website: www.healthpartners.com/fehb.

High Option: With limited exceptions, if you seek care from a facility that does not participate in the Open Access Network, your care is considered out of network and may not be covered.

Standard Option: With limited exceptions, if you seek care from a facility that does not participate in the Open Access Network, your care is considered out of network and the lower out-of network benefits apply.

What you must do to get covered care

High Option: Any time you or a member in your family needs care, you should choose to see any provider in the Open Access Network. With limited exceptions, if you seek care from a provider who does not participate in the Network your care is considered out of network and may not be covered.

Standard Option: Any time you or a member in your family needs care, you should choose to see any provider in the Open Access Network. You may choose to use your out-of-network benefit and receive care from any licensed provider. You may be billed for these services and may need to file a claim for reimbursement.

Primary care

Members are not required to pick a primary clinic. However, we encourage members to work with personal physicians who will get to know them. Primary care providers are providers in the following categories: family and general practice, internal medicine, pediatrics, adolescent medicine, adult medicine and geriatrics. Your primary care physician will provide most of your health care or suggest that you see a specialist. You can see any specialist without a referral.

If you want to change your primary care physician or if your primary care physician leaves the Plan, simply choose another provider from the Open Access Network directory for in-network benefits. For the most up-to-date network provider information, visit www.healthpartners.com/fehb, where information is updated weekly.

Specialty care

Specialty care providers are providers who are not in the following categories: family and general practice, internal medicine, pediatrics, adolescent medicine, adult medicine and geriatrics.

You have direct access to any specialist in the Open Access Network without a referral.

If you are seeing a specialist when you enroll in our Plan and 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 Member Services at 844-440-1900 for assistance. You may receive services from your current specialist until we can make arrangements for you to see someone else.

If you have a chronic or disabling condition and lose access to your specialist because we:

  • terminate our contract with your specialist for 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 120 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 120 days.

  • Designated providers
You may be required to see a designated provider for transplants and bariatric surgery. A designated provider is a health care provider, group or association of health care providers designated by us to provide services, supplies or drugs for specified transplants or bariatric surgery.
Hospital care Your 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 HealthPartners Member Services immediately at 844-440-1900 (TTY: 952-883-5127). 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.

  • Determination of coverage
We cover eligible services only when medically necessary for the proper treatment of a member. Our medical or dental directors, or their designees, make coverage determinations of medical necessity, restrictions on access and appropriateness of treatment, and they make final authorization for covered services. Coverage determinations are based on established medical policies, which are subject to periodic review and modification by the medical or dental directors. Coverage determinations for prescription drugs are based on requirements established by the HealthPartners Pharmacy and Therapeutics Committee, and are subject to periodic review and modification.

You need prior Plan approval for certain services

Since your primary care physician arranges most referrals to specialists and inpatient hospitalization, the pre-service claim approval process only applies to care shown under Other services.

You must get prior approval for certain services.

Inpatient hospital admissionPrecertification/Prior-authorization 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.

Other services

Your primary care physician has authority to refer you for most services. For certain services, however, your physician must obtain prior approval from us. Before giving approval, we consider if the service is covered, medically necessary and follows generally accepted medical practice.

We call this review and approval process prior authorization. Your physician must obtain prior authorization for services such as:

  • Reconstructive surgery
  • Promising therapies/new technologies
  • Transplants
  • Medically necessary dental care, such as orthognathic surgery
  • Durable medical equipment and prosthetics
  • Home health care
  • Skilled nursing care
  • Hospice care
  • Habilitative therapy
  • Bariatric surgery
  • Growth hormone therapy (GHT)

The complete list, along with the criteria we use to review authorization requests, is available on
www.healthpartners.com/fehb or by calling HealthPartners Member Services at 844-440-1900 (TTY: 952-883-5127). Your physician is responsible for obtaining prior authorization. 

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 952-883-6333 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
  • 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 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 844-440-1900 (TTY: 952-883-5127). You may also call OPM's FEHB 2 at 202-606-3818 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 844-440-1900 (TTY: 952-883-5127). 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

  • Health Care FSA (HCFSA) – Reimburses you for eligible out-of-pocket health care 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 inpatient admission

If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your representative, the physician, or the hospital must phone us within two business days following the day of the emergency admission, even if you have been discharged from the hospital.

  • If 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 72 hours after we receive the claim.

Circumstances beyond our controlUnder certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will make all reasonable efforts to provide you with the necessary care.  
If you disagree with our pre-service claim decisions

If you have a pre-service claim and you do not agree with our decision regarding precertification of an inpatient admission or prior approval of other services, you may request a review in accord with the procedures detailed below.

If 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:

  1. Precertify your hospital stay or, if applicable, arrange for the health care provider to give you the care or grant your request for prior approval for a service, drug, or supply; or
  2. Ask you or your provider for more information.

You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days. 

If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due. We will base our decision on the information we already have. We will write to you with our decision.

    3.  Write to you and maintain our denial.

  • 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 requests for appeals and the exchange of information by phone, 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.

Example: With High Option, when you see your primary care physician, you pay a copayment of $25 per office visit.

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.

Any amounts paid or reimbursed by a third party, including but not limited to: point of service rebates, manufacturer coupons, debit cards or other forms of direct reimbursement to an enrollee for a product or service, will not apply toward your deductible.

High Option:  There is no calendar year deductible for medical care.  

Standard Option: 
For Network Expenses:
The calendar year deductible is $750 for persons enrolled for Self Only coverage, $1,500 for persons enrolled for Self Plus One coverage and $1,500 for families enrolled for Self and Family coverage. 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 a Self Plus One enrollment, the deductible is considered satisfied and benefits are payable to 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 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.

For Out-of-Network Expenses: The calendar year deductible is $2,000 for persons enrolled for Self Only coverage $4,000 for persons enrolled for Self Plus One coverage and $4,000 for families enrolled for Self and Family coverage. 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 $2,000. Under a Self Plus One enrollment, the deductible is considered satisfied and benefits are payable to you and one other eligible family member when the combined covered expenses applied to the calendar year deductible for your enrollment reach $4,000. 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 $4,000.

Note: If you change plans during Open Season, you do not have to start a new deductible under your prior plan between January 1 and the effective date of your new plan. If you change plans at another time during the year, you must begin a new deductible under your new plan.

If you change options in this Plan during the year, we will credit the amount of covered expenses already applied toward the deductible of your old option to the deductible of your new option.

Coinsurance

Coinsurance is the percentage of our negotiated fee (our plan allowance) that you must pay for your care. Coinsurance does not begin until you have met your calendar year deductible.

Example: In our Plan, you pay 20% of our allowance for durable medical equipment.

Your catastrophic protection out-of-pocket maximum

Any amounts paid or reimbursed by a third party, including but not limited to: point of service rebates, manufacturer coupons, debit cards or other forms of direct reimbursement to an enrollee for a product or service, will not apply to your catastrophic protection out-of-pocket maximum.

High Option:  If you are enrolled for Self Only coverage, when your copayments and/or coinsurance total $5,500 in a calendar year, you do not have to pay any more for covered services for the remainder of that calendar year.

If you are enrolled for Self Plus One coverage, when you and your dependent's copayments and/or coinsurance total $11,000 in  a calendar year, you and your dependent do not have to pay any more for covered services for the remainder of that calendar year. However, each enrollee will not pay more than $8,550 in a calendar year.

If you are enrolled for Self and Family coverage, when your family’s copayments and/or coinsurance total $11,000 in a calendar year, you and your dependents do not have to pay any more for covered services for the remainder of that calendar year. However, each enrollee will not pay more than $8,550 in a calendar year.

Standard Option:  In Network:  If you are enrolled for Self Only coverage, when your deductible, copayments and/or coinsurance total $6,500 in a calendar year, you do not have to pay any more for covered services for the remainder of that calendar year.

If you are enrolled for Self Plus One coverage, when you and your dependent's, deductible, copayments and/or coinsurance total $13,000 in a calendar year, you and your dependent do not have to pay any more for covered services for the remainder of that calendar year. However, each enrollee will not pay more than $8,550 in a calendar year.

If you are enrolled for Self and Family coverage, when your family’s deductible, copayments and/or coinsurance total $13,000 in a calendar year, you and your dependents do not have to pay any more for covered services for the remainder of that calendar year. However, each enrollee will not pay more than $8,550 in a calendar year.

 Out of Network:  There is no limit on your out-of-pocket expenses.

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 due to a qualifying life event (QLE) during the year, we will credit the amount of covered expenses already accumulated toward the catastrophic out-of-pocket limit of your prior option to the catastrophic protection limit of your new option.

When Government facilities bill usFacilities of the Department of Government Affairs, the Department of Defense and the Indian Health Services are entitled to seek reimbursement 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.



Section 5. High and Standard Option Benefits

See page (Applies to printed brochure only) for how our benefits changed this year. Pages (Applies to printed brochure only) and (Applies to printed brochure only) are a benefits summary 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)

Table of Content



Section 5. High and Standard Option Benefits Overview

This Plan offers both a High and a Standard Option. Both 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 High and Standard Option Section 5 is 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 claim forms, claims filing advice, or more information about High and Standard Option benefits, contact us at 844-440-1900 (TTY: 952-883-5127) on our website at www.healthpartners.com/fehb.  Each option offers unique features.

High Option:    

  • HealthPartners’ service area includes all counties in Minnesota and Iowa, parts of Wisconsin, eastern North Dakota and eastern South Dakota
  • You don't need to choose a primary clinic
  • You can see any network provider – primary care or specialist – without a referral
  • Preventive services, including routine eye exams and hearing exams, are covered at 100%
  • $250 incentive, in the form of a HealthPartners Wellness Account debit card to be used towards most qualified medical expenses, for each adult employee or spouse who completes an online health assessment and an eligible online health improvement program.

Standard Option:

  • HealthPartners’ service area includes all counties in Minnesota and Iowa, parts of Wisconsin, eastern North Dakota and eastern South Dakota
  • You don't need to choose a primary clinic
  • You can see any network provider – primary care or specialist – without a referral
  • In Network: Preventive services, including routine eye and hearing exams, are covered at 100%
  • In Network: Each year, each member's first five office visits are covered at 100%  
  • Deductibles apply to most services except as listed
  • Generic drug copayments have no deductible 
  • $250 incentive, in the form of a HealthPartners Wellness Account debit card to be used towards most qualified medical expenses, for each adult employee or spouse who completes an online health assessment and an eligible online health improvement program.

Both Options - As a member of either option, you have access to:

  • Worldwide emergency care
  • HealthPartners’ nationally recognized disease and case management programs
  • National network with over 950,000 providers.

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
  • To receive in-network benefits, you must use a physician in our provider network
  • 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.



Section 5(a). Medical Services and Supplies Provided by Physicians and Other Health Care Professionals

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.
  • For you to receive in-network benefits, Plan physicians must provide your care.
  • For Standard Option. For Network Expenses: The calendar year deductible is $750 for persons enrolled for Self Only coverage, $1,500 for persons enrolled for Self Plus One coverage and $1,500 for families enrolled for Self and Family coverage. For Out-of-Network Expenses: The calendar year deductible is $2,000 for persons enrolled for Self Only coverage, $4,000 for persons enrolled for Self Plus One coverage and $4,000 for families enrolled for Self and Family coverage. The calendar year deductible applies to almost all Standard Option benefits in this Section. We added "deductible does not apply" to show when the calendar year deductible does not apply.
  • 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.



Benefit Description : Diagnostic and treatment servicesHigh Option (You Pay)Standard Option (You Pay)

We cover professional services of physicians:

  • In an office
  • Office medical consultations
  • Second surgical opinion
  • Testing and treatment of sexually transmitted diseases and testing for HIV and HIV-related conditions provided by a Plan or non-Plan provider

Note: List of qualifying clinics is available at
www.healthpartners.com/fehb.

$25 per office visit

 

 

 

 

 

 

 

In Network:  $0 for the first 5 office, convenience clinic, telephone, urgent care visits and evisits combined in a calendar year (deductible does not apply), then 20% of charges, subject to the in-network deductible. Physician’s services, laboratory and radiology performed in conjunction with the same visit and on the same date of service are included; however, charges for day treatment services, group visits, office procedures and other ancillary services are not included and will be subject to your deductible and coinsurance.

Out of Network:  40% of charges after out-of-network deductible

 

  • At a convenience clinic

Note: For a list of convenience clinics, see your provider directory, call Member Services or visit our website at www.healthpartners.com/fehb.

$10 per office visit

In Network: $0 for the first 5 office, convenience clinic, telephone, urgent care visits and evisits combined in a calendar year (deductible does not apply), then 20% of charges, subject to the in-network deductible. Physician’s services, laboratory and radiology performed in conjunction with the same visit and on the same date of service are included; however, charges for day treatment services, group visits, office procedures and other ancillary services are not included and will be subject to your deductible and coinsurance.

Out of Network: 40% of charges after out-of-network deductible

  • Telehealth services

We cover telemedicine for services covered under this Plan, subject to our medical coverage criteria.

$25 per office visit

$500 annual copayment for inpatient and outpatient hospital services combined, then 10% of inpatient hospital charges

In Network: 20% of charges after in-network deductible

Out of Network: 40% of charges after out-of-network deductible

Nothing.

Nothing.

  • In an urgent care center

$25 per office visit

In or Out of Network:  $0 for the first 5 office, convenience clinic, telephone, urgent care visits and evisits combined in a calendar year (deductible does not apply), then 20% of charges, subject to the in-network deductible. Physician’s services, laboratory and radiology performed in conjunction with the same visit and on the same date of service are included; however, charges for day treatment services, group visits, office procedures and other ancillary services are not included and will be subject to your deductible and coinsurance.

  • Specialty drugs administered in an office
  • Specialty drugs administered in home

We cover specialty drugs that are used to treat chronic health conditions including but not limited to such conditions as transplant recipients, immunological conditions, growth hormone, bleeding disorder, HIV/AIDS.

20% of charges 

In Network: 40% of charges, after deductible

Out of Network: All charges

  • During a hospital stay
  • In a skilled nursing facility

 

$500 annual copayment for inpatient and outpatient hospital services combined, then 10% of inpatient hospital charges

In Network: 20% of charges after in-network deductible

Out of Network: 40% of charges after out-of-network deductible

  • At home physical therapy, occupational therapy, speech therapy, respiratory therapy and home health aide services

$25 per visit

In Network: 20% of charges after in-network deductible

Out of Network: 40% of charges after out-of-network deductible

Benefit Description : Injections administered in an office (other than specialty drugs)High Option (You Pay)Standard Option (You Pay)

Injections administered in an office (other than specialty drugs described above)

$2 per date of service

In Network: 20% of charges after in-network deductible 

Out of Network: 40% of charges after out-of-network deductible

Benefit Description : Lab, X-ray and other diagnostic testsHigh Option (You Pay)Standard Option (You Pay)

We cover tests, such as:

  • Blood tests
  • Urinalysis
  • Non-routine pap tests
  • Pathology
  • Routine prostate specific antigen (PSA) test - ) for men 40 years of age or over who are symptomatic or in a high-risk category and for all men 50 years of age or older

Nothing

In Network:  20% of charges after in-network deductible

Out of Network:  40% of charges after out-of-network deductible

  • X-rays
  • Non-routine mammograms
  • Ultrasound
  • Electrocardiogram and EEG
  • MRI/CT scans
20% of charges

In Network: 20% of charges after in-network deductible

Out of Network: 40% of charges after out-of-network deductible

Benefit Description : Preventive care, adultHigh Option (You Pay)Standard Option (You Pay)

Routine physicals

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
www.cdc.gov/vaccines/schedules/
• 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
www.uspreventiveservicestaskforce.org
• Individual counseling on prevention and reducing health risks
• 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
www.healthcare.gov/preventive-care-women/

Nothing

In Network:  Nothing

Out of Network:  40% of charges after out-of-network deductible

  • Routine hearing and eye exams

Nothing

In Network:  Nothing

Out of Network:  40% of charges after out-of-network deductible

  •  Routine mammogram - covered for women

Nothing

In Network:  Nothing

Out of Network:  40% of charges after out-of-network deductible

  • Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule

Nothing

In Network:  Nothing

Out of Network:  40% of charges after out-of-network deductible

  • Tobacco use screening and interventions

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

Nothing

In Network:  Nothing

Out of Network:  40% of charges after out-of-network deductible

We cover online account, online health assessment and online wellness courses

$250 incentive, in the form of a HealthPartners Wellness Account debit card to be used towards most qualified medical expenses, for each adult employee or covered spouse who registers for online services and completes an online health assessment and an eligible online health improvement program (Limit one incentive per adult employee or covered spouse per calendar year). 

Total maximum incentive amount is $250 Self and $500 Family. 

Additional information is available at
www.healthpartners.com/fehb

$250 incentive, in the form of a HealthPartners Wellness Account debit card to be used towards most qualified medical expenses, for each adult employee or covered spouse who registers for online services and completes an online health assessment and an eligible online health improvement program (Limit one incentive per adult employee or covered spouse per calendar year). 

Total maximum incentive amount is $250 Self and $500 Family. 

Additional information is available at
www.healthpartners.com/fehb

Not covered: Physical exams and immunizations required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel.

All charges

All charges
Benefit Description : Preventive care, childrenHigh Option (You Pay)Standard 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
    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
    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
    www.uspreventiveservicestaskforce.org

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

Nothing

In Network:  Nothing

Out of Network:  40% of charges after out-of-network deductible

Benefit Description : Maternity careHigh Option (You Pay)Standard Option (You Pay)

We cover complete maternity (obstetrical) care, such as:

  • Prenatal care
  • Screening for gestational diabetes for pregnant women 
  • Postnatal care

Nothing for routine prenatal care, the first postpartum care visit or routine gestational diabetes screening. $25 per office visit for postpartum care visits thereafter.

In Network:  Nothing.

Out of Network:  40% of charges after out-of-network deductible

 

  • Delivery

 Note: Here are some things to keep in mind:

  • You do not need to prior authorize your vaginal delivery. 
  • 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 and other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment. Surgical benefits, not maternity benefits, apply to circumcision.
  • We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury.
  • We pay non-routine prenatal and postnatal care the same as for illness and injury.

Note: When a newborn requires non-routine treatment during or after the mother's confinement, the newborn is considered a patient in his or her own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.

$500 annual copayment for inpatient and outpatient hospital services combined, then Nothing for inpatient hospital maternity charges

In Network: $1,500 copayment for inpatient hospital maternity services, then Nothing for inpatient hospital charges

Out of Network: 40% of charges after out-of-network deductible

  • Breastfeeding support, supplies and counseling for each birth
Nothing

In Network: Nothing

Out of Network: 40% of charges after out-of-network deductible

Benefit Description : Family planning High Option (You Pay)Standard Option (You Pay)
Contraceptive counseling on an annual basisNothing

In Network: Nothing

Out of Network: 40% of the charges after out-of-network deductible

We cover a range of voluntary family planning services, such as:

  • Family planning services provided by a Plan provider or non-Plan provider
Nothing

In Network:  Nothing

Out of Network:  40% of charges after out-of-network deductible

  • Voluntary sterilization procedures for women (See surgical procedures in Section 5(b) for vasectomy coverage)
Nothing

In Network: Nothing

Out of Network: 40% of charges after out-of-network deductible

  • Surgically implanted contraceptives
  • Injectable contraceptive drugs (such as Depo Provera)
  • Intrauterine devices (IUDs)
  • Diaphragms

Note: We cover oral contraceptives under the prescription drug benefit. 

Nothing

In Network: Nothing

Out of Network: 40% of charges after out-of-network deductible

Not covered:

  • Reversal of voluntary surgical sterilization
  • Genetic counseling and genetics studies except when the results would influence a treatment or management of a condition or family planning decision.
All chargesAll charges
Benefit Description : Advance care planningHigh Option (You Pay)Standard Option (You Pay)

We cover advance care planning in an office

Nothing

In Network: 20% of charges after in-network deductible.

Out of Network: 40% of charges after out-of-network deductible

Benefit Description : Medication therapy disease management programHigh Option (You Pay)Standard Option (You Pay)

If you meet our criteria for coverage, you may qualify for our Medication Therapy Disease Management Program. The program covers consultations with a designated pharmacist.

Nothing

In Network: Nothing

Out of Network: All charges

Benefit Description : Infertility servicesHigh Option (You Pay)Standard Option (You Pay)
We cover diagnosis of infertility20% of charges

In Network:  20% of charges after in-network deductible

Out of Network:  40% of charges after out-of-network deductible

 

We cover treatment of infertility:

  • Artificial insemination (AI)
    • Intravaginal insemination (IVI)
    • Intracervical insemination (ICI)
    • Intrauterine insemination (IUI)

Treatment of infertility is limited to a $5,000 maximum benefit per calendar year. Drugs for treatment of infertility are not subject to this maximum. (See "Prescription drug benefits - limited benefits" under Section 5(f) Prescription drug benefits)

20% of charges and all charges beyond $5,000 calendar year limit

In Network: 20% of charges after in-network deductible and all charges beyond the $5,000 calendar year limit (combined for In Network and Out of Network)

Out of Network: 40% of charges after out-of-network deductible and all charges beyond the $5,000 calendar year limit (combined for In Network and Out of Network)

We cover drugs for treatment of infertility (limited to products listed on the Infertility Products List)20% of charges and all charges beyond $3,000 calendar year limit

In Network: 20% of charges after in-network deductible, and all charges beyond $3,000 calendar year limit

Out of Network: All charges

Not covered: 

  • Assisted reproductive technology (ART) procedures,
    such as:
    • In vitro fertilization (IVF)
    • Embryo transfer, gamete intra-fallopian transfer (GIFT) and zygote
      intra-fallopian transfer (ZIFT)
  • Services and supplies related to ART procedures
  • Cost of donor sperm or egg 
  • Cost of storage of donor sperm, ova or embryo 
  • Treatment of infertility after reversal of sterilization
  • Artificial insemination for surrogate pregnancy
All chargesAll charges
Benefit Description : Allergy careHigh Option (You Pay)Standard Option (You Pay)

We cover:

  • Testing and treatment
  •  Allergy injections and serum

$25 per office visit

In Network:  20% of charges after in-network deductible

Out of Network:  40% of charges after out-of-network deductible

 

Not covered:

  • Provocative food testing
  • Sublingual allergy desensitization
All chargesAll charges
Benefit Description : Treatment therapiesHigh Option (You Pay)Standard Option (You Pay)

We cover:

  • Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue Transplants beginning on page (Applies to printed brochure only).

  • Respiratory and inhalation therapy

Note: Cardiac rehabilitation following a qualifying event/condition is covered under Physical and occupational therapies on page (Applies to printed brochure only).

  • Dialysis – hemodialysis and peritoneal dialysis
  • Intravenous (IV)/Infusion therapy (other than specialty drugs described below)

For services received in an office or outpatient hospital: $25 per visit

Inpatient hospital services: $500 annual copayment for inpatient and outpatient hospital services combined, then 10% of charges

In Network:  20% of charges after in-network deductible

Out of Network:  40% of charges after out-of-network deductible

  • Blood and blood plasma (unless replaced) and blood derivatives for the treatment of blood disorders
20% of charges

In Network: 20% of charges after in-network deductible

Out of Network: 40% of charges after out-of-network deductible

We cover Applied Behavior Therapy (ABA), Intensive Early Intervention Behavioral Therapy (IEIBT), and Lovaas for the treatment of Autism Spectrum Disorder for children under age 18. For other autism services covered under this contract, see the habilitative benefit under Physical and Occupational Therapy and under Speech Therapy.$25 per visit

In Network: 20% of charges after in-network deductible

Out of Network: All charges

  • Specialty drugs

We cover specialty drugs that are used to treat chronic health conditions including but not limited to such conditions as transplant recipients, immunological conditions, growth hormone, bleeding disorder, HIV/AIDS.

20% of charges

In Network: 40% of charges, after deductible

Out of Network: All charges

Growth hormone therapy (GHT)

Note: Growth hormone is covered under the prescription drug benefit. See Services requiring our prior approval in Section 3.

Note: We only cover GHT when we preauthorize the treatment. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment. We will only cover GHT services and related services and supplies that we determine are medically necessary. See Other services under You need prior Plan approval for certain services on page (Applies to printed brochure only).

 

20% of charges

In Network: 20% of charges after in-network deductible

Out of Network: 40% of charges after out-of-network deductible

Not covered: Growth hormones which are not for growth hormone deficiency or chronic renal insufficiency

 

All chargesAll charges

We cover gene therapy treatment that meets our current medical coverage criteria. Gene therapy must be provided by a designated provider. Specific types of gene therapy are limited to therapies and conditions specified in our medical coverage criteria.

For services received in an office: $25 per visit 

For services received in a hospital: $500 annual copayment for inpatient and outpatient hospital services combined, then 10% of charges 

For services received in the home: 20% of the charges incurred

In Network: 20% of charges after in-network deductible 

Out of Network: All charges

Benefit Description : Physical and occupational therapiesHigh Option (You Pay)Standard Option (You Pay)

We cover:

  • Rehabilitative therapy to restore bodily function when there has been a total or partial loss of bodily function due to illness or injury. You must achieve significant functional improvement, within a predictable period of time (generally within a period of two months), toward your maximum potential ability to perform functional daily living activities.
  • Habilitative care rendered for congenital, developmental or medical conditions which have significantly limited the successful initiation of normal speech and motor development.

Note: To be considered habilitative, significant functional improvement and measurable progress must be made toward achieving functional goals and your maximum potential ability, within a predictable period of time. Our Plan Medical Director will determine whether measurable progress has been made based on objective documentation.

For services received in an office or outpatient hospital: $25 per visit

Inpatient hospital services: $500 annual copayment for inpatient and outpatient hospital services combined, then 10% of charges

In Network:  20% of charges after in-network deductible

Out of Network:  40% of charges after out-of-network deductible

  • Cardiac rehabilitation following a qualifying event/condition is provided for Phase I and Phase II if it is medically necessary. Phase III and IV are not covered.

$25 per office visit

Nothing for inpatient or outpatient hospital

In Network: 20% of charges after in-network deductible

Out of Network: 40% of charges after out-of-network deductible

Not covered:

  • Long-term rehabilitative therapy (maintenance care)
  • Exercise programs
All chargesAll charges
Benefit Description : Speech therapy High Option (You Pay)Standard Option (You Pay)

We cover:

  • Speech therapy for congenital, developmental or medical conditions which have significantly limited the successful initiation of normal speech development.
  • Usually 60 visits or two months per condition per year

For services received in an office or outpatient hospital: $25 per visit

Inpatient hospital services: $500 annual copayment for inpatient and outpatient hospital services combined, then 10% of charges

In Network:  20% of charges after in-network deductible

Out of Network:  40% of charges after out-of-network deductible

Not covered: Long term rehabilitative therapy (maintenance care)

All charges All charges
Benefit Description : Hearing services (testing, treatment, and supplies)High Option (You Pay)Standard Option (You Pay)

We cover:

  • Treatment related to illness or injury, including evaluation and diagnostic hearing tests performed by an M.D., D.O., or audiologist


    Note: For routine hearing screening performed during a child’s preventive care visit, see Section 5(a) Preventive care, children.
Nothing

In Network: 20% of charges after in-network deductible

Out of Network: 40% of charges after out-of-network deductible

  • External hearing aids for members age 18 or younger who have hearing loss that is not correctable by other covered procedures. Coverage is limited to one basic, standard hearing aid for each ear every three years. A basic hearing aid is defined as a hearing device that consists of a microphone, amplifier, volume control, battery and receiver. It does not include upgrades above and beyond the functionality of a basic hearing aid, including but not limited to hearing improvements for group settings, background noise, Bluetooth/remote control functionality, or extended warranties.
  • Implanted hearing related devices, such as bone- anchored hearing aids (BAHA) and cochlear implants based on our criteria.

Not covered:

  • Charges for upgrades above the cost of a basic, standard hearing aid
  • Hearing aids, testing and examinations for them, unless noted above
20% of the charges

In Network: 20% of charges after in-network deductible

Out of Network: 40% of charges after out-of-network deductible

  • Hearing Aids

The plan covers up to two TruHearing-branded hearing aids every year (one per ear per year). This benefit is limited to TruHearing Advanced and Premium hearing aids, which come in various styles and colors. Premium hearing aids are available in rechargeable style options for an additional $75 per aid. You must see a TruHearing provider to use this benefit. TruHearing offers a national network of providers. Call 833-718-5803 to schedule an appointment (for TTY, dial 711).

Hearing aid purchase includes:

  • 3 provider visits within the first year of hearing aid purchase
  • 45-day trial period
  • 3-year extended warranty
  • 48 batteries per aid for non-rechargeable models

This benefit does not include or cover any of the following:

  • Additional cost for optional hearing aid rechargeability
  • Ear molds
  • Hearing aid accessories
  • Additional provider visits
  • Additional batteries or batteries when a rechargeable hearing aid is purchased
  • Hearing aids that are not TruHearing-branded hearing aids
  • Costs associated with loss and damage warranty claims

Costs associated with excluded items are the responsibility of the enrollee and not covered by the plan.

$699 copayment per aid for Advanced Aids*

$999 copayment per aid for Premium Aids*

A rechargeable battery option is available on some Premium hearing aids for an additional $75 per aid.

*Please note that this service does not apply to your maximum out-of-pocket amount for medical services.

All charges

Benefit Description : Vision services (testing, treatment, and supplies)High Option (You Pay)Standard Option (You Pay)

We cover:

  • Eye exams to determine the need for vision correction
  • Annual eye refractions

Note: See Preventive care, adult; Preventive care, children

 

Nothing

In Network: Nothing

Out of Network: 40% of charges after out-of-network deductible

  • Diagnosis and treatment of illness and injury to the eye

$25 per office visit

In Network: 20% of charges after in-network deductible

Out of Network: 40% of charges after out-of-network deductible

Initial evaluation, lenses and fitting for contact or eyeglass lenses if medically necessary for the post surgical treatment of cataracts or for the treatment of aphakia or keratoconus

$25 per office visit

All charges for lens replacement beyond the initial pair

In Network: 20% of charges after in-network deductible

Out of Network: 40% of charges after out-of-network deductible

All charges for lens replacement beyond the initial pair

Not covered:

  • Eyeglasses or contact lenses, except as shown above
  • Eye exercises and orthoptics
  • Radial keratotomy and other refractive surgery
All chargesAll charges
Benefit Description : Foot careHigh Option (You Pay)Standard Option (You Pay)

We cover routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes

 

$25 per office visit

In Network:  20% of charges after in-network deductible

Out of Network:  40% of charges after out-of-network deductible

 

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 chargesAll charges
Benefit Description : Orthopedic and prosthetic devices High Option (You Pay)Standard Option (You Pay)

We cover:

  • Artificial limbs and eyes
  • Prosthetic sleeve or sock
  • Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy
  • Internal prosthetic devices, such as artificial joints, pacemakers, and surgically implanted breast implant following mastectomy
  • Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome
  • Orthopedic and corrective shoes when approved by this Plan based on our criteria
  • Hearing aids and implantable hearing-related devices as described under Hearing Services on page (Applies to printed brochure only).
20% of charges

In Network:  20% of charges after in-network deductible

Out of Network:  40% of charges after out-of-network deductible

Note: For information on the professional charges for the surgery to insert an implant, see Section 5(b) Surgical procedures. For information on the hospital and/or ambulatory surgery center benefits, see Section 5(c) Services provided by a hospital or other facility and ambulance services.

 

  • Wigs required due to hair loss caused by alopecia areata

20% of charges, and all charges beyond one wig per calendar year limit

In Network:  20% of charges after in-network deductible, and all charges beyond one wig per calendar year limit

Out of Network:  40% of charges after out-of-network deductible, and all charges beyond one wig per calendar year limit

Not covered:

  • Over-the-counter foot orthotics
  • Non-custom orthopedic and corrective shoes, arch supports, foot orthotics, heel pads and heel cups
  • Replacement or repair of any covered items if they are damaged or destroyed by member misuse, abuse or carelessness; lost; or stolen
  • Duplicate or similar items
  • Items which are primarily educational in nature or for hygiene, vocation, comfort, convenience or recreation
  • Other equipment and supplies, including but not limited to assistive devices, that we determine are not eligible for coverage
All chargesAll charges
Benefit Description : Durable medical equipment (DME)High Option (You Pay)Standard Option (You Pay)

We cover rental or purchase of durable medical equipment, at our option, including repair and adjustment, when prescribed by your Plan physician. Covered items include:

  • Oxygen
  • Dialysis equipment
  • Hospital beds
  • Wheelchairs
  • Crutches
  • Walkers
  • Blood glucose monitors
  • Insulin pumps
  • Diabetic supplies
  • Disposable needles and syringes needed for the administration of covered medications
  • Compression garments

Note: Covered items may be subject to limitations or require prior authorization. We reserve the right to determine if an item will be approved for rental vs. purchase. 

 

20% of charges

In Network:  20% of charges after in-network deductible

Out of Network:  40% of charges after out-of-network deductible

Specialty dietary treatment for phenylketonuria (PKU)20% of charges

In Network: 20% of charges

Out of Network: 40% of charges after out-of-network deductible

Not covered:

  • Replacement or repair of any covered items if they are damaged or destroyed by member misuse, abuse or carelessness; lost; or stolen
  • Duplicate or similar items
  • Items which are primarily educational in nature or for hygiene, vocation, comfort, convenience or recreation
  • Household equipment, such as exercise cycles, air purifiers, water purifiers, air conditioners, non-allergenic pillows, mattresses or water beds
  • Household fixtures, such as escalators or elevators, ramps, swimming pools or saunas
  • Modifications to the home, such as wiring, plumbing or charges to install equipment
  • Vehicle, car or van modifications, such as hand brakes, hydraulic lifts and car carriers
  • Rental of medically necessary durable medical equipment while your own equipment is being repaired, that is beyond one month rental
  • Other equipment and supplies, including but not limited to assistive devices, that we determine are not eligible for coverage 
  • We require that certain diabetic supplies and equipment be purchased at a pharmacy
All chargesAll charges
Benefit Description : Home health servicesHigh Option (You Pay)Standard Option (You Pay)

We cover home health care ordered by a Plan physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), or home health aide, as shown below. You need to be homebound (i.e., unable to leave home without considerable effort due to a medical condition) to receive home health services. You do not need to be homebound to receive total parenteral nutrition/intravenous ("TPN/IV") therapy. 

Note: We waive the requirement that you be homebound if you have a life-threatening, non-curable condition which has a prognosis of survival of two years or less.

  • At home physical therapy, occupational therapy, speech therapy, respiratory therapy and home health aide services

$25 per visit

In Network: 20% of charges after in-network deductible

Out of Network: 40% of charges after out-of-network deductible
  • TPN/intravenous therapy (other than specialty drugs described below), skilled nursing services, nonroutine prenatal and postnatal services, and phototherapy
20% of chargesIn Network: 20% of charges after in-network deductible

Out of Network: 40% of charges after out-of-network deductible
  • Specialty drugs administered in home

    We cover specialty drugs that are used to treat chronic health conditions including but not limited to such conditions as transplant recipients, immunological conditions, growth hormone, bleeding disorder, HIV/AIDS.
20% of charges

In Network: 40% of charges, after deductible

Out of Network: All charges


• Palliative care

Palliative care includes symptom management, education and establishing goals of care.

If you are eligible to receive palliative care in the home and you are not homebound, there is a maximum of 12 visits per calendar year. Additional palliative care visits are eligible under the home health services benefit if you are homebound and meet all other requirements defined in this section.


$25 per visit


In Network: 20% of charges after in-network deductible

Out of Network: 40% of charges after out-of-network deductible

  • Routine prenatal and postnatal services and child health services
Nothing

In Network: Nothing

Out of Network: 40% of charges after out-of-network 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
All chargesAll charges
Benefit Description : Chiropractic High Option (You Pay)Standard Option (You Pay)

We cover chiropractic services for rehabilitative care, provided to diagnose and treat acute neuromusculo-skeletal conditions, limited to:

  • Manipulation of the spine
  • Adjunctive procedures such as massage therapy, ultrasound, electrical muscle stimulation, and vibratory therapy,  when they are performed in conjunction with other treatment by a chiropractor, are part of a prescribed treatment plan and are not billed separately

$25 per office visit

In Network:  20% of charges after in-network deductible

Out of Network:  40% of charges after out-of-network deductible

Not covered:

  • Naturopathic services
  • Hypnotherapy

All charges

All charges

Benefit Description : Alternative treatmentsHigh Option (You Pay)Standard Option (You Pay)

We cover:

  • Acupuncture – by a certified Plan acupuncturist for:
    • anesthesia
    • pain relief
    • headaches
    • nausea
  • Biofeedback for:
    • incontinence
    • headaches
    • musculo-skeletal spasms which do not respond to other treatments
    • mental/nervous disorders

$25 per office visit

In Network:  20% of charges after in-network deductible

Out of Network:  40% of charges after out-of-network deductible

Not covered:

  • Naturopathic services
  • Hypnotherapy
All charges All charges
Benefit Description : Educational classes and programsHigh Option (You Pay)Standard Option (You Pay)

We cover:

  • Education for preventive services
  • Tobacco cessation programs, including individual, group, phone counseling, and physician prescribed over-the-counter (OTC) and prescription drugs approved by the FDA to treat nicotine dependence. Includes up to two quit attempts and up to four counseling sessions
  • Physician prescribed over-the-counter (OTC) and prescription drugs approved by the FDA to treat tobacco dependence whether or not one is enrolled in a smoking cessation program
  • Education for the management of chronic health problems (such as diabetes)
 Nothing

In Network: Nothing

Out of Network: 40% of charges after out-of-network deductible




Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Health Care Professionals

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.
  • For you to receive in-network benefits, Plan physicians must provide your care. 
  • 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 health care professional for your surgical care. The amount that you pay for these services depends on where the services are provided and follows the benefits described in Section 5(a) and 5(c) unless otherwise specified below.
  • YOUR PHYSICIAN MUST GET PRIOR AUTHORIZATION FOR SOME SURGICAL PROCEDURES. Please refer to the prior authorization information shown in Section 3 to be sure which services require prior authorization.
  • For you to receive in-network benefits, Plan physicians must provide your care. 

  • For Standard Option. For Network Expenses: The calendar year deductible is $750 for persons enrolled for Self Only coverage, $1,500 for persons enrolled for Self Plus One coverage and $1,500 for families enrolled for Self and Family coverage. For Out-of-Network Expenses: The calendar year deductible is $2,000 for persons enrolled for Self Only coverage, $4,000 for persons enrolled for Self Plus One coverage and $4,000 for families enrolled for Self and Family coverage. The calendar year deductible applies to almost all Standard Option benefits in this Section. We added "deductible does not apply" to show when the calendar year deductible does not apply.




Benefit Description : Surgical proceduresHigh Option (You Pay)Standard Option (You Pay)

We cover a comprehensive range of services, such as:

  • Operative procedures, including normal pre- and post-operative care by the surgeon
  • Treatment of fractures, including casting
  • Correction of amblyopia and strabismus
  • Endoscopy procedures
  • Biopsy procedures
  • Removal of tumors and cysts
  • Correction of congenital anomalies (see Reconstructive surgery)
  • Vasectomy
  • Treatment of burns
  • Gender reassignment surgery that meets medical coverage criteria
  • Insertion of internal prosthetic devices.
    See 5(a) -- Orthopedic and prosthetic devices for device coverage information

Note: Generally, we pay for internal prostheses (devices) according to where the procedure is done. For example, we pay Hospital benefits for a pacemaker and Surgery benefits for insertion of the pacemaker.

$25 per office visit

$500 annual copayment for inpatient and outpatient hospital services combined, then 10% of charges

In Network:  20% of charges after in-network deductible

Out of Network:  40% of charges after out-of-network deductible

Surgical treatment of morbid obesity (bariatric surgery)

See Services requiring our prior approval on page (Applies to printed brochure only). See bariatric surgery criteria on www.healthpartners.com/fehb

$25 per office visit

$500 annual copayment for inpatient and outpatient hospital services combined, then 10% of charges.

In Network: 20% of charges after in-network deductible

Out of Network: All charges

Not covered:

  • Reversal of voluntary sterilization
  • Routine treatment of conditions of the foot; see Foot care
All charges All charges
Benefit Description : Reconstructive surgery High Option (You Pay)Standard Option (You Pay)

We cover:

  • 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 to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital anomalies are: protruding ear deformities, cleft lip, cleft palate, birth marks, port wine stains, webbed fingers and webbed toes.

Note: Port wine stains do not have to result in a functional defect to be covered.

  • All stages of breast reconstruction surgery following a mastectomy, such as:
    • surgery to produce a symmetrical appearance of breasts
    • treatment of any physical complications, such as lymphedemas
    • breast prostheses and surgical bras and replacements (see Prosthetic devices)  

$25 per office visit

$500 annual copayment for inpatient and outpatient hospital services combined, then 10% of charges

In Network:  20% of charges after in-network deductible

Out of Network:  40% of charges after out-of-network deductible

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.

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 repair of accidental injury

 

All chargesAll charges
Benefit Description : Oral and maxillofacial surgery High Option (You Pay)Standard Option (You Pay)

We cover oral surgical procedures, limited to:

  • Reduction of fractures of the jaws or facial bones
  • Surgical correction of cleft lip, cleft palate
  • Removal of stones from salivary ducts
  • Excision of leukoplakia or malignancies
  • Excision of cysts and incision of abscesses when done as independent procedures
  • Other surgical procedures that do not involve the teeth or their supporting structures, including non-dental treatment of temporomandibular joint dysfunction (TMJ)

$25 per office visit

$500 annual copayment for inpatient and outpatient hospital services combined, then 10% of charges

In Network:  20% of charges after in-network deductible

Out of Network:  40% of charges after out-of-network deductible

We cover orthognathic surgery for the treatment of a skeletal malocclusion when a functional occlusion cannot be achieved through non-surgical treatment alone and a demonstrable functional impairment exists.

 

25% of charges

In Network:  25% of charges after in-network deductible

Out of Network:  50% of charges after out-of-network deductible

Not covered:

  • Oral implants and transplants
  • Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva and alveolar bone)
  • Orthodontic services (pre or post operative) associated with orthognathic surgery
All charges All charges
Benefit Description : Organ/tissue transplantsHigh Option (You Pay)Standard Option (You Pay)

These solid organ transplants are subject to medical necessity and experimental investigational review by the Plan. See Other services in Section 3 for prior authorization procedures. Solid organ 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
$500 annual copayment for inpatient and outpatient hospital services combined, then 10% of charges

In Network:  20% of charges after in-network deductible

Out of Network:  40% of charges after out-of-network deductible

These tandem blood or marrow stem cell transplants for covered transplants are not subject to medical necessity review by the Plan.  Refer to Other Services in Section 3 for prior authorization procedures.

  • Autologous tandem transplants for
    • AL Amyloidosis
    • Multiple myeloma (de novo and treated)
    • Recurrent germ cell tumors (including testicular cancer)
$500 annual copayment for inpatient and outpatient hospital services combined, then 10% of charges

In Network: 20% of charges after in-network deductible

Out of Network: 40% of charges after out-of-network deductible

These blood or marrow stem cell transplants are not subject to medical necessity and experimental investigational review by the Plan. Refer to Other services in Section 3 for prior authorization procedures.

Physicians consider many features to determine how diseases will respond to different types of treatment. Some of the features measured are the presence or absence of normal and abnormal chromosomes, the extension of the disease throughout the body, and how fast the tumor cells grow.  By analyzing these and other characteristics, physicians can determine which diseases will respond to treatment without transplant and which diseases may respond to transplant. 

The Plan extends coverage for the diagnosis 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
  • Hurler’s syndrome, Maroteaux-Lamy syndrome
  • Infantile malignant osteopetrosis
  • Kostmann’s syndrome
  • Leukocyte adhesion deficiencies
  • Marrow failure and related disorders (i.e., Fanconi's, Paroxysmal Nocturnal Hemoglobinuria, pure red cell aplasia)
  • Mucolipidosis (e.g., Gaucher’s disease, metachromatic leukodystrophy, adrenoleukodystrophy)
  • Myelodysplasia/myelodysplastic syndromes 
  • Paroxysmal nocturnal hemoglobinuria
  • Phagocytic/hemophagocytic deficiency diseases (e.g., Wiskott-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)
  • AL Amyloidosis
  • Breast Cancer
  • Epithelial ovarian cancer 
  • Multiple myeloma 
  • Neuroblastoma
  • Recurrent germ cell tumors (including testicular, mediastinal, retroperitoneal)
$500 annual copayment for inpatient and outpatient hospital services combined, then 10% of charges

In Network:  20% of charges after in-network deductible

Out of Network:  40% of charges after out-of-network deductible

Mini-transplants performed in a clinical trial setting (non-myeloablative, reduced intensity conditioning or RIC) for members with a diagnosis listed below are subject to medical necessity review by the Plan.  Refer to Other services in Section 3 for prior authorization procedures:

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, Paroxysmal Nocturnal Hemoglobinuria, 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
$500 annual copayment for inpatient and outpatient hospital services combined, then 10% of charges

In Network: 20% of charges after  in-network deductible

Out of Network: 40% of charges after out-of-network 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 and 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.

$500 annual copayment for inpatient and outpatient hospital services combined, then 10% of charges.

In Network: 20% of charges after in-network deductible

Out of Network: 40% of charges after out-of-network deductible

Allogeneic transplants for

  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Sickle cell anemia

Autologous transplants for

  • Advanced childhood kidney cancers
  • Advanced Ewing sarcoma
  • Childhood rhabdomyosarcoma
  • Mantle cell (Non-Hodgkin lymphoma)
$500 annual copayment for inpatient and outpatient hospital services combined, then 10% of charges    

In Network: 20% of charges after in-network deductible

Out of network: 40% of charges after out-of-network deductible

HealthPartners Designated Transplant Providers and HealthPartners Centers of Excellence - These are local and national Designated Transplant Centers based upon their experience, clinical outcomes, service, access, cost, coordination of care, research and education. For a list of participating programs visit
www.healthpartners.com/fehb.

Transplant procedures must be performed at HealthPartners Designated Transplant CentersIn Network: transplant procedures must be performed at HealthPartners Designated Transplant Centers to receive in-network benefits
Note: We cover related medical and hospital expenses of the donor when we cover the recipient.  We cover donor screening tests and donor search expense for the actual solid organ donor or up to four bone marrow/stem cell transplant donors in addition to the testing of family members.$500 annual copayment for inpatient and outpatient hospital services combined, then 10% of charges

In Network: 20% of charges after in-network deductible

Out of Network: 40% of charges after out-of-network deductible

Not covered:

  • Donor screening tests and donor search expenses, except as shown above
  • Implants of artificial organs
  • Transplants not listed as covered
All ChargesAll Charges

Transplant Travel Benefit for transplants provided at HealthPartners Centers of Excellence. 

We may provide travel and lodging when an enrollee needs a transplant and a designated transplant center is greater than 100 miles from the enrollee’s primary address.

This benefit is subject to our medical policies (medical coverage criteria).

When submitting receipts for travel and lodging, the enrollee will need to attach a letter explaining that the receipts are in conjunction with an authorized organ or bone marrow transplant and include the recipient’s name and member ID number or complete a Lodging and Travel Claim form with the receipts.

Transplant travel benefits are covered under the organ/tissue transplant services benefit above.

Expenses for travel, and lodging for the enrollee (the transplant recipient) and one adult companion, or up to two companions for a transplant recipient that is a minor dependent, may be covered, up to a maximum of $10,000 per transplant. Lodging coverage is limited to $100 per day.

In Network:Transplant travel benefits are covered under the organ/tissue transplant services benefit above.

Expenses for travel, and lodging for the enrollee (the transplant recipient) and one adult companion, or up to two companions for a transplant recipient that is a minor dependent, may be covered, up to a maximum of $10,000 per transplant. Lodging coverage is limited to $100 per day.

Out of Network: All Charges

Benefit Description : AnesthesiaHigh Option (You Pay)Standard Option (You Pay)

We cover professional services provided in –

  • Hospital (inpatient)
  • Skilled nursing facility
  • Hospital outpatient department
  • Ambulatory surgical center
$500 annual copayment for inpatient and outpatient hospital services combined, then 10% of charges

In Network:  20% of charges after in-network deductible

Out of Network:  40% of charges after out-of-network deductible


We cover professional services provided in an office

$25 per office visit


In Network: 20% of charges after in-network deductible

Out of Network: 40% of charges after out-of-network deductible




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

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.
  • For you to receive in-network benefits, Plan physicians must provide your care and you must be hospitalized in a Plan facility.  
  • 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 PRIOR AUTHORIZATION FOR SOME HOSPITAL STAYS. Please refer to Section 3 to be sure which services require prior authorization.
  • For Standard Option. For Network Expenses: The calendar year deductible is $750 for persons enrolled for Self Only coverage, $1,500 for persons enrolled for Self Plus One coverage and $1,500 for families enrolled for Self and Family coverage. For Out-of-Network Expenses: The calendar year deductible is $2,000 for persons enrolled for Self Only coverage, $4,000 for persons enrolled for Self Plus One coverage and $4,000 for families enrolled for Self and Family coverage. The calendar year deductible applies to almost all Standard Option benefits in this Section. We added "deductible does not apply" to show when the calendar year deductible does not apply.



Benefit Description : Inpatient hospitalHigh Option (You Pay)Standard Option (You Pay)

We cover room and board, such as

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

For Maternity Care see page (Applies to printed brochure only).

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

$500 annual copayment for inpatient and outpatient hospital services combined, then 10% of charges

In Network:  20% of charges after in-network deductible

Out of Network:  40% of charges after out-of-network deductible 

We cover other hospital services and supplies, such as:

  • Operating, recovery, maternity, and other treatment rooms
  • Prescribed drugs and medications
  • Diagnostic laboratory tests and X-rays
  • Administration of blood and blood products
  • Blood or blood plasma (unless replaced) and blood derivatives
  • Dressings, splints, casts, and sterile tray services
  • Medical supplies and equipment, including oxygen
  • Anesthetics, including nurse anesthetist services
  • Take-home items
  • Medical supplies, appliances, medical equipment and any covered items billed by a hospital for use at home
  • MRI / CT scans
$500 annual copayment for inpatient and outpatient hospital services combined, then 10% of charges

In Network:  20% of charges after in-network deductible

Out of Network:  40% of charges after out-of-network deductible

Not covered:

  • Custodial care
  • Non-covered facilities, such as nursing homes, extended care facilities, schools
  • Personal comfort items, such as phone, television, barber services, guest meals and beds
  • Private nursing care
All charges All charges
Benefit Description : Outpatient hospital or ambulatory surgical centerHigh Option (You Pay)Standard Option (You Pay)

We cover:

  • Operating, recovery and other treatment rooms
  • Prescribed drugs and medications
  • Diagnostic laboratory tests, X-rays and pathology services
  • Administration of blood, blood plasma and other biologicals
  • Pre-surgical testing
  • Dressings, casts and sterile tray services
  • Medical supplies, including oxygen
  • Anesthetics and anesthesia service

Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We do not cover the dental procedures.

$500 annual copayment for inpatient and outpatient hospital services combined, then 10% of charges

In Network:  20% of charges after in-network deductible

Out of Network:  40% of charges after out-of-network deductible

  • MRI / CT scans
  • Blood and blood plasma (unless replaced) and blood derivatives
20% of charges

In Network:  20% of charges after in-network deductible

Out of Network:  40% of charges after out-of-network deductible

 


  • Specialty drugs

We cover specialty drugs that are used to treat chronic health conditions including but not limited to such conditions as transplant recipients, immunological conditions, growth hormone, bleeding disorder, HIV/AIDS.


20% of charges

In Network: 40% of charges, after in-network deductible

 Out of Network: All charges

Benefit Description : Extended care benefits/Skilled nursing care facility benefitsHigh Option (You Pay)Standard Option (You Pay)

We cover a comprehensive range of benefits for up to 120 days per calendar year when full-time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as determined by your Plan doctor and prior authorized by this Plan. All necessary services are covered, including:

  • Bed, board and general nursing care
  • Drugs, biologicals, services and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by your Plan doctor.
$500 annual copayment for inpatient and outpatient hospital services combined, then 10% of charges

In Network:  20% of charges after in-network deductible

Out of Network:  40% of charges after out-of-network deductible

   Not covered: Custodial care

 

All charges All charges
Benefit Description : Home hospice careHigh Option (You Pay)Standard Option (You Pay)

We cover supportive and palliative care in your home or a hospice if you are terminally ill. We cover the following services:

  • Outpatient care, family counseling and continuous care
  • Inpatient care, when medically necessary 
  • Respite care
  • End of life care

Note: Respite care is limited to 5 days per episode, and respite care and continuous care combined are limited to 30 days. 

Note: Inpatient hospital care:  designed for those patients who require an acute hospital admission for pain or symptom control related to the terminal illness. Free-standing hospice: a hospice inpatient unit set up as a geographically distinct building.  Residential hospices/hospice houses:  goal is to provide longer-term care, in homelike settings, for patients who cannot be cared for in their own homes. Staffing and intensity of services are comparable to a board-and-care home or other types of licensed residential facility. A residential hospice program may be operated by a home care hospice or by an independent agency that contracts with a community hospice for professional services. Payment for residential room and board is made privately.

Nothing

In Network:  20% of charges after in-network deductible

Out of Network:  40% of charges after out-of-network deductible

Not covered:

  • Independent nursing, homemaker services
  • Room and board expenses in a residential hospice facility, free standing hospice or skilled nursing facility 
All charges All charges
Benefit Description : AmbulanceHigh Option (You Pay)Standard Option (You Pay)

We cover:

Ambulance and medical transportation for medical emergencies described in Section 5(d) (other than Non-Emergency Fixed Air Ambulance Transportation)   

20% of charges

In or Out of Network:  20% of charges after in-network deductible 

Non-Emergency Fixed Wing Air Ambulance Transportation in Network20% of charges20% of charges after in-network deductible

Non-Emergency Fixed Wing Air Ambulance Transportation Out of Network

Note: Fixed Wing Air Ambulance is an aircraft such as an airplane, jet, or turbo prop plan that is able to travel longer distances than its counterpart, the Rotary Wing Air Ambulance (i.e. the helicopter). Fixed Wing Air Ambulance transport requires prior authorization from HealthPartners.


All charges40% of charges after out-of-network deductible



Section 5(d). Emergency Services/Accidents

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.
  • 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.
  • For Standard Option. For Network Expenses: The calendar year deductible is $750 for persons enrolled for Self Only coverage, $1,500 for persons enrolled for Self Plus One coverage and $1,500 for families enrolled for Self and Family coverage. For Out-of-Network Expenses: The calendar year deductible is $2,000 for persons enrolled for Self Only coverage, $4,000 for persons enrolled for Self Plus One coverage and $4,000 for families enrolled for Self and Family coverage. The calendar year deductible applies to almost all Standard Option benefits in this Section. We added "deductible does not apply" to show when the calendar year deductible does not apply.



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 life-threatening emergencies, contact the local emergency system (e.g., 911 phone system) or go to the nearest hospital emergency room. In other situations, if you need emergency care, call your clinic, or, after clinic hours, call the CareLine® service at 612-339-3663 or 800-551-0859 (TTY: 952-883-5474). A CareLine nurse or Plan doctor will recommend how, when and where to obtain the appropriate treatment.

Emergencies Out-of-Network: You must notify us within two days of admittance to an out-of-network hospital, or as soon as reasonably possible under the circumstances. If a Plan doctor believes care can be better provided in a Plan hospital, you will be transferred when medically feasible. Follow-up care recommended by non-Plan providers must be approved by this Plan or provided by our providers.




Benefit Description : Emergency careHigh Option (You Pay)Standard Option (You Pay)

We cover:

  • Emergency and urgently needed care at a doctor’s office
  • Emergency and urgently needed care at an urgent care clinic

$25 per office visit 

$0 for the first 5 office, convenience clinic, telephone, urgent care visits and evisits combined in a calendar year (deductible does not apply), then 20% of charges, subject to the in-network deductible. Physician’s services, laboratory and radiology performed in conjunction with the same visit and on the same date of service are included; however, charges for day treatment services, group visits, office procedures and other ancillary services are not included and will be subject to your deductible and coinsurance.

  • Emergency and urgently needed care as an outpatient in a hospital, including doctors' services

$100 per visit

The ER copayment is waived if you are admitted to the hospital

20% of charges after in-network deductible
  •  Emergency and urgently needed inpatient hospital services
$500 annual copayment for inpatient and outpatient hospital services combined, then 10% of charges20% of charges after in-network deductible

Not covered:

  • Elective care or non-emergency care
  • Medical and hospital costs resulting from a normal full-term delivery of a baby at an Out of Network provider
All chargesAll charges
Benefit Description : AmbulanceHigh Option (You Pay)Standard Option (You Pay)

We cover professional ambulance service when medically appropriate.

Note: See 5(c) for non-emergency service

20% of charges

In or Out of Network: 20% of charges after in-network deductible

Ambulance and medical transportation for medical emergencies described in Section 5(d) (other than Non-Emergency Fixed Wing Air Ambulance Transportation)20% of chargesIn or Out of Network: 20% of charges after in-network deductible
Non-Emergency Fixed Wing Air Ambulance Transportation in Network20% of charges20% of charges after in-network deductible

Non-Emergency Fixed Wing Air Ambulance Transportation Out of Network

Note: Fixed Wing Air Ambulance is an aircraft such as an airplane, jet, or turbo prop plan that is able to travel longer distances than its counterpart, the Rotary Wing Air Ambulance (i.e. the helicopter). Fixed Wing Air Ambulance transport requires prior authorization from HealthPartners.


All charges

40% of charges after out-of-network deductible




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

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.
  • You do not need a referral from your primary care physician to obtain mental health or substance abuse services.
  • Our Behavioral Health Personalized Assistance Line (PAL) staff can match you with a network provider who can meet your behavioral health needs. We can identify providers by specialty and by specific diagnostic, language and cultural competence. If you have an urgent need, we can link you to same day/next day psychiatric appointments. Call 952-883-5811 or 888-638-8787.
  • The calendar year deductible, or for facility care, the inpatient deductible, applies to almost all benefits in this section. We added "Deductible does not apply." to show when a deductible does not apply.
  • For Standard Option. For Network Expenses: The calendar year deductible is $750 for persons enrolled for Self Only coverage, $1,500 for persons enrolled for Self Plus One coverage and $1,500 for families enrolled for Self and Family coverage. For Out-of-Network Expenses: The calendar year deductible is $2,000 for persons enrolled for Self Only coverage, $4,000 for persons enrolled for Self Plus One coverage and $4,000 for families enrolled for Self and Family coverage. The calendar year deductible applies to almost all Standard Option benefits in this Section. We added "deductible does not apply" to show when the calendar year deductible does not apply. 
  • 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.



Benefit Description : Professional servicesHigh Option (You Pay)Standard Option (You Pay)

We cover professional services by licensed professional mental health and substance use disorder treatment practitioners when acting within the scope of their license, such as psychiatrists, psychologists, clinical social workers, licensed professional counselors, or marriage and family therapists.

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

We cover diagnosis and treatment of psychiatric conditions, mental illness, or mental disorders.  Services include:

  • Diagnostic evaluation
  • Crisis intervention and stabilization for acute episodes
  • Medication evaluation and management (pharmacotherapy)
  • Psychological and neuropsychological testing necessary to determine the appropriate psychiatric treatment
  • Treatment and counseling (including individual therapy visits)
  • Diagnosis and treatment of alcoholism and drug use, including detoxification, treatment and counseling
  • Professional charges for intensive outpatient treatment in a provider’s office or other professional setting
  • Electroconvulsive therapy
  • Treatment for gender dysphoria that meets medical coverage criteria
$25 per visit

In Network: $0 for the first 5 office, convenience clinic, telephone, urgent care visits and evisits combined in a calendar year (deductible does not apply), then 20% of charges, subject to the in-network deductible. Physician’s services, laboratory and radiology performed in conjunction with the same visit and on the same date of service are included; however, charges for day treatment services, group visits, office procedures and other ancillary services are not included and will be subject to your deductible and coinsurance.

Out of Network: 40% of charges after out-of-network deductible

Group therapy visits for mental health$12.50 per visit

In Network: 20% of charges after in-network deductible

Out of Network: 40% of charges after out-of-network deductible

Benefit Description : DiagnosticsHigh Option (You Pay)Standard Option (You Pay)

We cover:

  • Outpatient diagnostic tests provided and billed by a licensed mental health and substance use disorder treatment practitioner
  • Outpatient diagnostic tests provided and billed by a laboratory, hospital or other covered facility
  • Inpatient diagnostic tests provided and billed by a hospital or other covered facility

$25 per visit

In Network: 20% of charges after in-network deductible

Out of Network: 40% of charges after out-of-network deductible

Benefit Description : Inpatient hospital or other covered facilityHigh Option (You Pay)Standard Option (You Pay)

We cover inpatient services provided and billed by a hospital or other covered facility

  • Room and board, such as semiprivate or intensive accommodations, general nursing care, meals and special diets, and other hospital services
$500 annual copayment for inpatient and outpatient hospital services combined, then 10% of inpatient hospital charges

In Network: 20% of charges after in-network deductible

Out of Network: 40% of charges after out-of-network deductible

Benefit Description : Outpatient hospital or other covered facilityHigh Option (You Pay)Standard Option (You Pay)

We cover outpatient services provided and billed by a hospital or other covered facility

  • Services in approved treatment programs, such as partial hospitalization, half-way house, residential treatment, full-day hospitalization, or facility-based intensive outpatient treatment
$25 per visit

In Network: 20% of charges after in-network deductible

Out of Network: 40% of charges after out-of-network deductible

Benefit Description : Not coveredHigh Option (You Pay)Standard Option (You Pay)
  • Marriage counseling services
All chargesAll charges



Section 5(f). Prescription Drug Benefits

Important things you should keep in mind about these benefits:

  • We cover prescribed drugs and medications, as described in the chart beginning on the next page.
  • 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.
  • Members must make sure their prescribers obtain prior approval/authorizations for certain prescription drugs and supplies before coverage applies.  Prior approval/authorization must be renewed periodically.
  • Federal law prevents the pharmacy from accepting unused medications.
  • 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.
  • For Standard Option. For Network Expenses: The calendar year deductible is $750 for persons enrolled for Self Only coverage, $1,500 for persons enrolled for Self Plus One coverage and $1,500 for families enrolled for Self and Family coverage. For Out-of-Network Expenses: The calendar year deductible is $2,000 for persons enrolled for Self Only coverage, $4,000 for persons enrolled for Self Plus One coverage and $4,000 for families enrolled for Self and Family coverage. The deductible does not apply to generic preferred drugs. The deductible does apply to brand and specialty drugs. We added "deductible does not apply" to show when the calendar year deductible does not apply.
  • The Plan uses the GenericsAdvantageRx Formulary. It covers fewer brand-name drugs at the preferred brand level. It excludes drugs for sexual dysfunction. Other drugs may be excluded for certain indications.



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.
  • Where you can obtain them.
    • High Option: You must fill the prescription at a Plan pharmacy or by mail.
    • Standard Options: For in-network benefits, you must fill the prescription at a Plan pharmacy or by mail. Out-of-network benefits apply when you do not use a Plan pharmacy.
    • For both Options, specialty drugs must be obtained at a designated vendor. The specialty drug list is available by calling Member Services or by visiting our website at www.healthpartners.com/fehb.
  • The plan uses the GenericsAdvantageRx formulary. Check to see which drugs are covered and the level of coverage. The formulary excludes drugs for sexual dysfunction. 
  • We cover preferred and non-preferred drugs. Preferred drugs are a list of drugs that we selected to meet patient needs at a lower cost.
  • These are the dispensing limitations. Unless otherwise specified in this section, you may receive up to a 30-day supply per prescription. Certain drugs may require prior authorization as indicated on the formulary. HealthPartners may require prior authorization for the drug and also the site where the drug will be provided. All drugs are subject to our utilization review process and quantity limits. New prescriptions to treat certain chronic conditions are limited to a 30-day supply. Certain non-preferred drugs require prior authorization. In addition, certain drugs may be subject to any quantity limits applied as part of our trial program. A 90-day supply will be covered and dispensed only at pharmacies that participate in our extended day supply program. No more than a 30-day supply of Specialty Drugs will be covered and dispensed at a time, unless it’s a manufacturer supplied drug that cannot be split that supplies the enrollee with more than a 30-day supply, or unless specified on the specialty drug list. If a copayment is required, you must pay one copayment for each 30-day supply, or portion thereof, except for mail order drugs, see benefit described below.
  • A generic equivalent will be dispensed if it is available, unless your physician specifically requires a name brand through a prior authorization submission, and that request is approved. Other formulary limitations, such as quantity limits, may still apply. If your physician does not require a brand name drug or we do not approve the request, you have to pay your applicable copayment or coinsurance plus the difference in cost between the name brand drug and the generic.
  • Why use generic drugs? Generic drugs offer a safe and economic way to meet your prescription drug needs. The generic name of a drug is its chemical name; the name brand is the name under which the manufacturer advertises and sells a drug. Under Federal law, generic and name brand drugs must meet the same standards for safety, purity, strength, and effectiveness. A generic prescription costs you – and us - less than a name brand prescription.
  • If you request a refill too soon after the last one was filled, it may not be filled at that time. It may require up to 14 days to get mail order prescriptions filled, so this service is best for maintenance drugs, not for drugs you need immediately or for drugs you are taking on a short-term basis. Federal or state regulations may prevent us from filling certain prescriptions through mail order service, such as laws that prohibit us from sending narcotic drugs across state lines.
  • Cost Sharing Limits for Insulin: We will limit your cost-sharing on prescription insulin to no more than the net price of the prescription insulin drug. This requirement applies at the point of sale, including deductible payments and the cost-sharing amounts charged once the deductible is met.

    Cost-sharing.
    This means a deductible payment, copayment, or coinsurance amount that you must pay for covered prescription insulin in accordance with the terms and conditions of this health plan.

    Net price.
    This means our cost for prescription insulin, including any rebates or discounts received by or accrued directly or indirectly to us from a drug manufacturer or pharmacy benefit manager.
  • When you have to file a claim. You do not need to file a claim for drugs obtained at a network pharmacy or through our designated mail order service. You would need to file a claim for prescription drugs covered as part of an out-of-area emergency, if you did not get them at a network pharmacy. See Section 7 for instructions on filing a claim.

A member who is called to active military duty can call HealthPartners Member Services Department at 844-440-1900 to get information on how to get a medium-term supply of drugs.

In the event of a national or other emergency, you can call HealthPartners Member Services Department at 844-440-1900 to get information on how to get a supply of drugs to meet your needs.




Benefit Description : Covered medications and suppliesHigh Option (You Pay)Standard Option (You Pay)

We cover the following medications and supplies prescribed by a licensed provider and obtained from a Plan pharmacy or through our designated mail order program:

  • Drugs and medications that by Federal law of the United States require a physician's prescription for their purchase, except those listed as Not covered.

$5 for preferred low cost generic drugs

$25 for preferred high cost generic drugs

$45 for brand-name preferred drugs

$90 for non-preferred drugs

The copayment applies per 30-day supply, or portion thereof

In Network: 

$5 for preferred low cost generic drugs (deductible does not apply)

$25 for preferred high cost generic drugs (deductible does not apply)

$60 for brand-name preferred drugs after deductible

$150 for non-preferred drugs after deductible

The copayment applies per 30-day supply, or portion thereof  

Out of Network:  40% of charges after out-of-network deductible

We cover women's contraceptive drugs, devices, and the morning after pill.

We cover injectable, implantable contraceptive drugs or devices (such as Depo Provera, Norplant, IUDs) (This benefit applies whether the birth control drug or device is used for birth control or for a medically necessary purpose other than birth control).

Note: Over-the-counter contraceptive drugs and devices approved by the FDA require a written prescription by an approved provider.

Nothing for generic preferred drugs

All charges for non-preferred drugs

In Network: Nothing for generic preferred drugs; All charges for non-preferred drugs

Out of Network: 40% of charges after out-of-network deductible

We cover physician prescribed over-the-counter and prescription drugs for tobacco cessation, no limit

Note: Over-the-counter and appropriate prescription drugs approved by the FDA to treat tobacco and nicotine dependence are covered under the tobacco cessation benefit. (See page (Applies to printed brochure only).)

Nothing

In Network: Nothing

Out of Network: 40% of charges after out-of-network deductible

Preventive medications

Preventive Medications with a USPSTF recommendation of A or B are covered without cost-share when prescribed by a health care 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

In Network: Nothing

Out of Network: 40% of charges after out-of-network deductible

Diabetic supplies limited to

  • disposable needles and syringes for the administration of covered medications
  • blood glucose testing meters and strips
  • other diabetes supplies such as lancets and pen needles or insulin syringes

20% of charges

In Network: 20% of charges after in-network deductible

Out of Network: 40% of charges after out-of-network deductible

Drugs for breast cancer prevention for women at high risk for breast cancer who have not yet been diagnosed with the disease.

Nothing for preferred drugs

$90 for non-preferred drugs

In Network: Nothing for preferred drugs; $150 for non-preferred drugs after deductible

Out of Network: 40% of charges after out-of-network deductible

We cover specialty drugs.

Note: Specialty drugs are injectable and oral medications that are used to treat chronic health conditions including but not limited to such conditions as transplant recipients, immunological conditions, growth hormone, bleeding disorder, HIV/AIDS. Please refer to the drug plan formulary to determine if the drug you have been prescribed by your physician needs to be filled by one of the plan's Specialty Pharmacy providers.

  • For safety, all mailing will be shipped based on temperature requirements and considerations.
  • Specialty drugs cannot be obtained through the traditional 90-day mail order program.

20% coinsurance for specialty drugs

In Network: 40% coinsurance for specialty drugs, after in-network deductible

Out of Network: All charges

Not covered:

  • Drugs and supplies for cosmetic purposes
  • Vitamins, nutrients and food supplements not listed as a covered benefit even if a physician prescribes or administers them, except as specified.
  • Nonprescription medications
  • Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies
  • Medical supplies such as dressings and antiseptics
  • Drugs to enhance athletic performance
  • Sexual dysfunction drugs
  • Replacement of prescription drugs, medications, equipment and supplies due to loss, damage or theft
  • Medical cannabis
  • Drugs that are newly approved by the FDA until they are reviewed and approved by HealthPartners Pharmacy and Therapeutics Committee.
  • Drugs on the Excluded Drug List. The Excluded Drug List includes select drugs within a therapy class that are not eligible for coverage. This includes drugs that may be excluded for certain indications. The Excluded Drug List is available at healthpartners.com/fehb
All chargesAll charges
Benefit Description : Mail order benefitsHigh Option (You Pay)Standard Option (You Pay)

You may also get outpatient prescription drugs which can be self-administered through the designated mail order service. For information on how to obtain drugs through HealthPartners mail order service, please visit www.healthpartners.com/fehb.

This benefit does not apply to drugs listed under Limited Benefits below.

$10 for preferred low cost generic drugs

$50 for preferred high cost generic drugs

$90 for brand-name preferred drugs

$180 for non-preferred drugs

The copayment applies per 90-day supply, or portion thereof

In Network: 

$10 for preferred low cost generic drugs (deductible does not apply)

$50 for preferred high cost generic drugs (deductible does not apply)

$120 for brand-name preferred drugs after deductible

$300 for non-preferred drugs after deductible

The copayment applies per 90-day supply, or portion thereof

Out of Network:  40% of charges after out-of-network deductible

Benefit Description : Prescription drug benefits - limited benefitsHigh Option (You Pay)Standard Option (You Pay)
  • Growth hormones
  • 20% of charges

    In Network: 20% of charges after in-network deductible

    Out of Network: 40% of charges after out-of-network deductible

    Drugs for treatment of infertility (limited to products listed on the Infertility Products List)20% of charges and all charges beyond $3,000 calendar year limit

    In Network: 20% of charges after in-network deductible, and all charges beyond $3,000 calendar year limit 

    Out of Network: All charges




    Section 5(g). Dental Benefits

    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.
    • 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.
    • For Standard Option. For Network Expenses: The calendar year deductible is $750 for persons enrolled for Self Only coverage, $1,500 for persons enrolled for Self Plus One coverage and $1,500 for families enrolled for Self and Family coverage. For Out-of-Network Expenses: The calendar year deductible is $2,000 for persons enrolled for Self Only coverage, $4,000 for persons enrolled for Self Plus One coverage and $4,000 for families enrolled for Self and Family coverage. The calendar year deductible applies to almost all Standard Option benefits in this Section. We added "deductible does not apply" to show when the calendar year deductible does not apply.
    • We cover hospitalization for dental procedures only when a non-dental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient or as required for children who receive anesthesia per our medical policy. See Section 5(c) for inpatient hospital benefits. We do not cover the dental procedure unless it is 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.  



    Benefit Description : Accidental injury benefitHigh Option (You Pay)Standard Option (You Pay)

    We cover:

    • Accidental dental services In Network: Restorative services and supplies provided by Plan dentists necessary to promptly repair or replace sound, natural, unrestored teeth, including the cost and installation of necessary prescription dental prosthetic items or devices. The need for these services must directly result from an accidental injury, not including injury from biting or chewing. Coverage is limited to the initial treatment (or course of treatment) and/or restoration. Only services provided within 24 months from the date of injury are covered.
    20% of charges20% of charges after in-network deductible
    • Emergency accidental dental services Out of Network: Emergency dental services for accidental injury, as described above, when they are provided by Out of Network dentists if the injuries require immediate treatment.
    30% of charges30% of charges after in-network deductible



    Section 5(h). Wellness and Other Special Features

    TermDefinition
    CareLine® ServiceWhen you call the CareLine service, you reach a skilled nurse who is specially trained to assess medical conditions of all kinds. Call 612-339-3663 or 800-551-0859 and talk with a registered nurse who will discuss treatment options and answer your health questions.
    BabyLine ServiceIf you’re an expecting or new parent and have questions after regular clinic hours, our BabyLine service is just for you. The BabyLine service is staffed by obstetric nurses who can help with questions relating to pregnancy, new baby care, nursing, and postpartum concerns. Call 612-333-BABY (333-2229) or 800-845-9297.
    Behavioral Health Personalized Assistance Line (PAL)

    Our Behavioral Health Personalized Assistance Line (PAL) staff can match you with the network provider that best meets your behavioral health needs. We can identify providers based on:

    • Specialty or subspecialty
    • Specific diagnostic, language and cultural competence

    And if you have an urgent need, we can link you to same day/next day psychiatric appointments. Call 952-883-5811 or 888-638-8787.

    Nurse Navigators

    Nurse Navigators are experienced nurses who can help research treatment options, coordinate care and guide you through difficult decisions. Call 844-440-1900.

    Services for the deaf and hearing impaired

    If you are deaf or hearing impaired, we have special phone lines which you may call for the following services:

    Member Services: 952-883-5127

    CareLine Service: 952-883-5474

    BabyLine Service: 952-883-5474
    Online tools

    As a Plan member, you have instant access to detailed, secured information and helpful services tailored to you. Depending on your coverage, you may be able to:

    • View your personal health record
    • See your claims information
    • View your benefits
    • View your medical and dental provider networks
    • Find health and wellness information 
    • Order new ID cards
    • Make appointments at HealthPartners Clinics 
    • Refill a mail order prescription or a prescription at a HealthPartners Clinic
    • Determine the retail and mail order costs of specific drugs
    • See all the medications on the HealthPartners preferred list of covered drugs
    • Estimate your annual cost of medical care
    To access your personalized member page, visit www.healthpartners.com/fehb.

    virtuwell™

    virtuwell™ is an online clinic that treats everyday illnesses so you- or your kids-can get better.

    • Quickly and conveniently get care for over 40 common conditions
    • get a diagnosis, treatment plan and prescription if needed- all in less than an hour
    • you pay nothing. See section 5(a)
    • 24/7, with nurse practitioners available

    Mobile tools

    Download the HealthPartners app or visit the mobile site to find and manage your health plan on-the-go.

    Use your smartphone to:

    • Access your Member ID card
    • Check your plan balances including your deductible
    • Search for the closest care locations to you
    • Get cost estimates
    • View claims and Explanation of Benefits (EOBs)
    • …and more

    Download the app today in your app store or visit m.healthpartners.com to learn more about HealthPartners mobile offerings, visit www.healthpartners.com/gomobile.

    If you have a mobile phone that can get text messages, you can receive a variety of texts from HealthPartners. Either opt in to receive weekly texts or add a phone number in your myHealthPartners account to get text specific to you.

    Text one of these commands to 77199:

    • DED: For how much is remaining until you meet your deductible
    • YUM: For better-for-you eating tips from yumPower
    • FAMILY: For ideas to support your family's health
    • QUITNOW: For tips to help you quit smoking

    Health assessment and wellness courses

    There’s no greater reward than living a healthy life. In case you need extra incentive, we've got one for you. When you complete your health assessment and register and complete an eligible online health improvement program, you are entitled to receive a contribution of $250 into your HealthPartners Wellness Account debit card to be used for most qualified medical expenses, prescriptions and IRS 213(d) vision expenses. For those with Self Plus One or Self and Family coverage, each adult employee or covered spouse, is eligible for the $250 contribution to the HealthPartners Wellness Account. We will send the policyholder two debit cards to access the account. Please keep your card for future use even if you use all of your health account dollars; you may be eligible for wellness incentives in subsequent benefit years. We do not send new cards to continuing participants until the card expires. The account funds must be used by December 31, 2022 or the account will be forfeited.

    After completing the online health assessment, you may access online wellness courses to set personalized goals designed to improve your health through increased exercise, healthier nutrition habits, managing your weight, reduced stress, better emotional health, or goals that focus on managing a specific condition. You must complete the health assessment and complete an eligible online health improvement program no later than December 31, 2021 in order to receive these incentives.

    Getting rewarded is simple.

    • Log into your myHealthPartners account at www.healthpartners.com/fehb. If you don't have a username and password, click on “sign up for myHealthPartners”.

    • Take your health assessment.

    • Register for an eligible online health improvement program

    • Complete the eligible online health improvement program.

    • Don’t forget, this includes your covered spouse!

    • One set of two debit cards will be sent to access the funds in your HealthPartners Wellness Account.

    Medicare Premium Reimbursement for High Option members enrolled in both Medicare Parts A and B

    High option members enrolled in both Medicare Part A and Part B are eligible to be reimbursed up to $1,200 per calendar year for their Medicare Part B premium payments. Eligible members must notify HealthPartners of their Medicare enrollment status. For more information on how to get reimbursement for your paid Medicare Part B premiums, please call 844-440-1900 or visit healthpartners.com/fehb/medicare.

    Flexible benefits option

    Under the flexible benefits option, we determine the most effective way to provide services.

    • We may identify medically appropriate alternatives to regular contract benefits as a less costly alternative. If we identify a less costly alternative, we will ask you to sign an alternative benefits agreement that will include all of the following terms in addition to other terms as necessary. Until you sign and return the agreement, regular contract benefits will continue.
    • Alternative benefits will be made available for a limited time period and are subject to our ongoing review. You must cooperate with the review process.
    • By approving an alternative benefit, we do not guarantee you will get it in the future.
    • The decision to offer an alternative benefit is solely ours, and except as expressly provided in the agreement, we may withdraw it at any time and resume regular contract benefits.
    • If you sign the agreement, we will provide the agreed-upon alternative benefits for the stated time period (unless circumstances change). You may request an extension of the time period, but regular contract benefits will resume if we do not approve your request.

    Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process. However, if at the time we make a decision regarding alternative benefits, we also decide that regular contract benefits are not payable, then you may dispute our regular contract benefits decision under the OPM disputed claim process (see Section 8).




    Section 5(i). Non-FEHB Benefits Available to Plan Members

    The benefits listed in this section are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim about them. Fees you pay for these services do not count toward FEHB deductibles or catastrophic protection out-of-pocket maximums. These programs and materials are the responsibility of the Plan, and all appeals must follow the Plan's guidelines. For additional information contact the Plan at 844-440-1900 (TTY: 952-883-5127) or visit www.healthpartners.com/fehb.

    For both High Option and Standard Option, HealthPartners is proud to offer value-added services that help members lead healthier lifestyles.




    TermDefinition

    Eyewear discount

    You may be eligible for an eyewear discount at Plan optical centers, including HealthPartners Eye Care Centers and EyeMed retailers such as Target, LensCrafters, etc.  For more information on the program visit www.healthpartners.com/fehb or call member services at 844-440-1900.

    Healthy discounts program

    HealthPartners retail savings program gives you discounts on tools and services from reputable organizations to help you be as healthy as you can be. Complete information and list of partner organizations can be found online at www.healthpartners.com/fehb or call member services at 844-440-1900




    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 When you need prior Plan approval for certain services.

    We do not cover the following:

    • 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, drugs, or supplies you receive without charge while in active military service
    • Services or supplies furnished by yourself, immediate relatives or household members, such as spouse, parents, children, brothers or sisters by blood, marriage or adoption.
    • Services or supplies we are prohibited from covering under the Federal Law.
    • Charges for phone, data, software or mobile applications/apps unless specifically described as covered in our medical coverage criteria for the device or service.



    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 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 obtain your prescription drugs at Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment, coinsurance or deductible.

    You will only need to file a claim when you receive services from non-plan providers. Sometimes these providers bill us directly. Check with the provider. If you need to file a claim, here is the process:




    TermDefinition

    Medical and hospital 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, contact us at 844-440-1900 (TTY: 952-883-5127), or at our website at www.healthpartners.com/fehb

    When you must file a claim – such as for services you received outside the Plan's Network– submit it on the CMS -1500 or a claim form 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
    • 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:
    HealthPartners Claims
    P.O. Box 1289
    Minneapolis, MN 55440-1289

    Prescription drugsSubmit your claims to
    HealthPartners Claims
    P.O. Box 1289
    Minneapolis, MN 55440-1289
    Other supplies or servicesSubmit your claims to
    HealthPartners Claims
    P.O. Box 1289
    Minneapolis, MN 55440-1289
    Deadline for filing your claimSend 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 procedures

    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 representativeYou 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 health care 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 phone 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 health care 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 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 us at 844-440-1900 or visit our website at www.healthpartners.com/fehb.

    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 Service Department by writing HealthPartners Claims, P.O. Box 1289, Minneapolis, MN 55440-1289 or calling 844-440-1900 (TTY: 952-883-5127).

    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 health care 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 his/her 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 Services, P.O. Box 1309, Minneapolis, MN 55440-1309; 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.

    e) Include your email address (optional for member), if you would like to receive our decision via email. Please note that by giving us your email, we may be able to provide our decision more quickly.

    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 the 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 2, 1900 E Street NW, Washington, DC 20415-3620.

    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
    • 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 health care 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 844-440-1900.  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 2 at 202-606-3818 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 health care 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 the NAIC website at www.NAIC.org.

    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. For example, we will generally only make up the difference between the primary payor’s benefits payment and 100% of the Plan allowance, subject to our applicable coinsurance or copayment amounts, except when Medicare is the primary payor (see page 82). Thus, it is possible that the combined payments from both plans may not equal the entire amount billed by the provider.

    Note: When we pay secondary to primary coverage you have from a prepaid plan (HMO), we base our benefits on your out-of-pocket liability under the prepaid plan (generally, the prepaid plan’s copayments), subject to our coinsurance or copayment amounts.
    In certain circumstances when we are secondary and there is no adverse effect
    on you (that is, you do not pay any more), we may also take advantage of any provider discount arrangements your primary plan may have and only make up the difference between the primary plan’s payment and the amount the provider has agreed to accept as payment in full from the primary plan.

    Note: Any visit limitations that apply to your care under this Plan are still in effect when we are the secondary payor. Remember: Even if you do not file a claim with your other plan, you must still tell us that you have double coverage, and you must also send us documents about your other coverage if we ask for them.

    • TRICARE and CHAMPVA

    TRICARE is the health care 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

    Our right to pursue and receive subrogation and reimbursement recoveries is a condition of, and a limitation on, the nature of benefits or benefit payments and on the provision of benefits under our coverage.

    If you have received benefits or benefit payments as a result of an injury or illness and you or your representatives, heirs, administrators, successors, or assignees receive payment from any party that may be liable, a third party's insurance policies, your own insurance policies, or a workers' compensation program or policy, you must reimburse us out of that payment. Our right of reimbursement extends to any payment received by settlement, judgment, or otherwise.

    We are entitled to reimbursement to the extent of the benefits we have paid or provided in connection with your injury or illness. However, we will cover the cost of treatment that exceeds the amount of the payment you received.

    Reimbursement to us out of the payment shall take first priority (before any of the rights of any other parties are honored) and is not impacted by how the judgment, settlement, or other recovery is characterized, designated, or apportioned. Our right of reimbursement is not subject to reduction based on attorney fees or costs under the "common fund" doctrine and is fully enforceable regardless of whether you are "made whole" or fully compensated for the full amount of damages claimed.

    We may, at our option, choose to exercise our right of subrogation and pursue a recovery from  any liable party as successor to your rights.

    If you do pursue a claim  or case related to your injury or illness, you must promptly notify us and cooperate with our reimbursement or subrogation efforts.

    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. 

    If you are a participant in a clinical trial, this health plan will provide related care as follows, if it is not provided by the clinical trial:

    • 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.

    When you have Medicare

    For more detailed information on “What is Medicare?” and “Should I Enroll in Medicare?” please contact Medicare at 800-MEDICARE (800-633-4227), (TTY 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 844-440-1900.

    To be eligible for full cost-share waiving, members must be enrolled in both Parts A and B of Original Medicare. For members enrolled in High and Standard Option and also enrolled in the Original Medicare Plan (Part A and B) as your primary payor – we will waive your out-of-pocket costs (applicable deductibles, copays and coinsurance) at in-network providers as follows:

    • Inpatient hospital benefits: We waive applicable deductibles, copays and coinsurance.
    • Medical and surgery benefits and mental health/substance use disorder care: We waive applicable deductibles, copays and coinsurance.
    • Office visits: We waive the applicable deductibles, copays and coinsurance at In-Network Providers.
    • Physical, speech and occupational therapy benefits: Applicable deductibles, copays and coinsurance is waived.
    • Benefit limits and maximums still apply.
    • There is no change to your prescription drug coverage. We do not waive deductibles, copays, or coinsurance.
    • We do not waive cost-sharing on hearing aids through TruHearing.

    You can find more information about how our Plan coordinates benefits with Medicare by calling our FEHB Member Services team at 844-440-1900 or visit healthpartners.com/fehb/medicare.

    Cost sharing may not apply if the Original Medicare Plan is your primary payor

    – For Medicare covered services we will coordinate benefits to potentially reduce your out-of-pocket costs as follows: 

    When Medicare Part A is primary –

    • You may experience a reduction in cost sharing for our in-network:

    − Annual hospital copayments for Medicare covered services;

    − Hospital coinsurance for Medicare covered services. 

    Note: Once you have exhausted your Medicare Part A benefits, you must then pay the applicable copayment or coinsurance.

    When Medicare Part B is primary –

    • You may experience a reduction in cost sharing for our in-network:

    − Coinsurance and copayments for inpatient and outpatient services and supplies provided by physicians and other covered health care professionals for Medicare covered services; and

    − Coinsurance and/or copayment for outpatient facility services for Medicare covered services. 

    Note: We do not waive benefit limitations, such as the 25-visit limit for home nursing visits. In addition, we do not waive any coinsurance or copayments for prescription drugs.

    A physician may ask you to sign a private contract agreeing that you can be billed directly for services ordinarily covered by Original Medicare. Should you sign an agreement, Medicare will not pay any portion of the charges, and we will not increase our payment. We will still limit our payment to the amount we would have paid after Original Medicare’s payment. You may be responsible for paying the difference between the billed amount and the amount we paid.

    Please review the following table.  It illustrates your cost share if you are enrolled in Medicare Part B.  If you purchase Medicare Part B, your provider is in our network and participates in Medicare, then we waive some costs because Medicare will be the primary payor.  

    Benefit Description: Deductible
    High Option You Pay Without Medicare: $0
    High Option You Pay With Medicare Part B: $0
    Standard Option You Pay Without Medicare: In Network: $750/Self Only; $1,500/Self Plus One; $1,500/Family; Out of Network: $2,000/Self Only; $4,000/Self Plus One; $4,000/Family
    Standard Option You Pay With Medicare: In Network: $750/Self Only; $1,500/Self Plus One; $1,500/Family; Out of Network: $2,000/Self Only; $4,000/Self Plus One; $4,000/Family

    Benefit Description: Out-of-Pocket Maximum
    High Option You Pay Without Medicare: Self Only: Nothing after $5,500; Self Plus One: Nothing after $11,000, subject to a maximum of $8,550 per enrollee; Self and Family: Nothing after $11,000, subject to a maximum of $8,550 per enrollee
    High Option You Pay With Medicare Part B: Self Only: Nothing after $5,500; Self Plus One: Nothing after $11,000, subject to a maximum of $8,550 per enrollee; Self and Family: Nothing after $11,000, subject to a maximum of $8,550 per enrollee
    Standard Option You Pay Without Medicare: In Network: Self Only: Nothing after $6,500; Self Plus One: Nothing after $13,000, subject to a maximum of $8,550 per enrollee; Self and Family: Nothing after $13,000, subject to a maximum of $8,550 per enrollee; Out of Network: No maximum
    Standard Option You Pay With Medicare: In Network: Self Only: Nothing after $6,500; Self Plus One: Nothing after $13,000, subject to a maximum of $8,550 per enrollee; Self and Family: Nothing after $13,000, subject to a maximum of $8,550 per enrollee; Out of Network: No maximum

    Benefit Description: Part B Premium Reimbursement Offered
    High Option You Pay Without Medicare: NA
    High Option You Pay With Medicare Part B: Up to $1,200
    Standard Option You Pay Without Medicare: NA
    Standard Option You Pay With Medicare: None

    Benefit Description: Primary Care Physician
    High Option You Pay Without Medicare: $25
    High Option You Pay With Medicare Part B: Nothing for most Medicare covered services and never more than $25
    Standard Option You Pay Without Medicare: In Network: You pay $0 for 5 visits, then 20% after deductible; Out of Network: 40% after deductible
    Standard Option You Pay With Medicare: In Network: Nothing for most Medicare covered services and never more than 20% after deductible; Out of Network: Nothing for most Medicare covered services and never more than 40% after deductible

    Benefit Description: Specialist
    High Option You Pay Without Medicare: $25
    High Option You Pay With Medicare Part B: Nothing for most Medicare covered services and never more than $25
    Standard Option You Pay Without Medicare: In Network: 20% after deductible; Out of Network: 40% after deductible
    Standard Option You Pay With Medicare: In Network: Nothing for most Medicare covered services and never more than 20% after deductible; Out of Network: Nothing for most Medicare covered services and never more than 40% after deductible

    Benefit Description: Inpatient Hospital
    High Option You Pay Without Medicare: $500 annual copayment for inpatient & outpatient combined, then 10% of charges
    High Option You Pay With Medicare Part B: Nothing for most Medicare covered services and never more than a $500 annual copayment for inpatient & outpatient combined, then 10% of charges
    Standard Option You Pay Without Medicare: In Network: 20% after deductible; Out of Network: 40% after deductible
    Standard Option You Pay With Medicare: In Network: Nothing for most Medicare covered services and never more than 20% after deductible; Out of Network: Nothing for most Medicare covered services and never more than 40% after deductible

    Benefit Description: Outpatient Surgery - Hospital
    High Option You Pay Without Medicare: $500 annual copayment for inpatient & outpatient combined, then 10% of charges
    High Option You Pay With Medicare Part B: Nothing for most Medicare covered services and never more than a $500 annual copayment for inpatient & outpatient combined, then 10% of charges
    Standard Option You Pay Without Medicare: In Network: 20% after deductible; Out of Network: 40% after deductible
    Standard Option You Pay With Medicare: In Network: Nothing for most Medicare covered services and never more than 20% after deductible; Out of Network: Nothing for most Medicare covered services and never more than 40% after deductible

    Benefit Description: Incentives Offered
    High Option You Pay Without Medicare: N/A
    High Option You Pay With Medicare Part B: Health assessment and wellness courses. For more information see page (Applies to printed brochure only)
    Standard Option You Pay Without Medicare:
    Standard Option You Pay With Medicare: Health assessment and wellness courses. For more information see page (Applies to printed brochure only)

    You can find more information about how our plan coordinates benefits with Medicare by visiting www.healthpartners.com/fehb.

    • 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 prescription drug coverage (Part B)

    This health plan does not coordinate its prescription drug benefits with Medicare Part B.

    • 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 plan. These are private health care 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 or call us at 844-440-1900 (TTY: 952-883-5127) or see our website at www.healthpartners.com/fehb.

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

    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 Medicare Part D and we are the secondary payor, we will review claims for your prescription drug costs that are not covered by Medicare Part D and consider them for payment under the FEHB plan.




    Primary Payer Chart

    A. When you – or your covered spouse are age 65 or over and have Medicare and you the primary payer for the individual with Medicare is ...The Primary Payer for individual with Medicare is…The Primary Payer for individual 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
    8) Are a Federal employee receiving Workers' Compensation disability benefits for six months or more


    B. When you or a covered family member...The Primary Payer for individual with Medicare is…The Primary Payer for individual 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 payer before eligibility due to ESRD (for 30 month coordination period)
    • Medicare was the primary payer 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 Payer for individual with Medicare is…The Primary Payer for individual 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

    Biosimilar Drug

    A prescription drug, approved by the Food and Drug Administration (FDA), that the FDA has determined is biosimilar to and interchangeable with a biological brand name drug. Biosimilar drugs are not considered generic drugs and are not covered under the generic drug benefit.

    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 review 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

    See Section 4 page (Applies to printed brochure only).

    Copayment

    See Section 4 page (Applies to printed brochure only).

    Cost-sharing

    See Section 4 page (Applies to printed brochure only).

    Covered services Care we provide benefits for, as described in this brochure.

    Deductible

    See Section 4 page (Applies to printed brochure only).

    Experimental or investigational service

    As determined by us, a drug, device, medical, behavioral health or dental treatment is investigative if reliable evidence does not permit conclusions concerning its safety, effectiveness, or positive effect on health outcomes and will be considered investigative unless all of the following categories of reliable evidence are met:

    • There is final approval from the appropriate government regulatory agency, if required. This includes whether a drug or device can be lawfully marketed for its proposed use by the United States Food and Drug Administration (FDA); and
    • The drug or device or medical, behavioral health or dental treatment or procedure is not the subject of ongoing Phase I, II or III clinical trials; and
    • The drug, device or medical, behavioral health or dental treatment or procedure is not under study and further studies are not needed (such as post-marketing clinical trial requirements) to determine maximum tolerated dose, toxicity, safety, effect on health outcomes or efficacy as compared to existing standard means of treatment or diagnosis; and
    • There is conclusive evidence in major peer-reviewed medical journals demonstrating the safety, effectiveness and positive effect on health outcomes (the beneficial effects outweigh any harmful effects) of the service or treatment when compared to standard established service or treatment.  Each article must be of well-designed investigations, using generally acceptable scientific standards that have been produced by nonaffiliated, authoritative sources with measurable results.  Case reports do not satisfy this criterion.  This also includes consideration of whether a drug is included in one of the standard reference compendia or “Major Peer Reviewed Medical Literature” (defined below) for use in the determination of a medically necessary accepted indication of drugs and biologicals used off-label as appropriate for its proposed use.

    Major Peer Reviewed Medical Literature. This means articles from major peer reviewed medical journals that have recognized the drug or combination of drugs' safety and effectiveness for treatment of the indication for which it has been prescribed. Each article shall meet the uniform requirements for manuscripts submitted to biomedical journals established by the International Committee of Medical Journal Editors or be published in a journal specified by the United States Secretary of Health and Human Services pursuant to United States Code, title 42, section 1395x, paragraph (t), clause (2), item (B), as amended, as acceptable peer review medical literature. Each article must use generally acceptable scientific standards and must not use case reports to satisfy this criterion.

    Health care professionalA physician or other health care professional licensed, accredited, or certified to perform specified health services consistent with state law.
    Medical necessity

    This plan defines medically necessary care as care that is appropriate for the condition, including those related to mental health. It includes the kind and level of service. It includes the number of treatments. It also includes where you get the service and how long it continues. Medically necessary care must:

    • Be the service that other providers would usually order
    • Help you get better, or stay as well as you are
    • Help stop the condition from getting worse
    • Help prevent and find health problems

    Plan allowance

    Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Plans determine their allowances in different ways. We determine our allowance as follows:

    • For covered services delivered by Plan providers, or Plan referral providers, our allowance is the provider’s discounted charge for a given medical/surgical service, procedure or item, which Plan providers have agreed to accept as payment in full.
    • For covered services delivered by non-Plan providers, our allowance is the provider’s charge for a given medical/surgical service, procedure or item, according to the usual and customary charge amount. A contracted rate may apply if such arrangement is available to HealthPartners.
    • For the usual and customary charge for covered services delivered by non-network providers, our payment is calculated using one of the following options to be determined at HealthPartners’ discretion: 1) a percentage of the Medicare fee schedule; 2) a comparable schedule if the service is not on the Medicare fee schedule; or 3) a commercially reasonable rate for such service.
    • The usual and customary charge is the maximum amount allowed we consider in the calculation and payment of charges incurred for certain covered services. You must pay for any charges above the usual and customary charge, and they do not apply to the catastrophic protection out-of-pocket maximum.
    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 workers' compensation program or insurance policy, and the terms of the carrier's health benefits plan require 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 that carrier's health benefits plan.

    Urgent care claims

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

    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 usually involve pre-service claims and 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 our customer service department. 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 have the same meaning as HealthPartners and its related organizations.
    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)
    Accidental injury, dental
    Acupuncture
    Allergy
    Alternative treatment
    Ambulance
    Anesthesia
    BabyLine
    Biofeedback
    Blood and blood plasma
    CareLine
    Carryover
    Catastrophic protection
    Changes for 2021
    Chemical dependency
    Chemotherapy
    Child health services
    Chiropractic
    Cholesterol test
    Claims
    Coinsurance
    Colorectal cancer screening
    Contraceptive drugs and devices
    Copayment
    Cost sharing
    Covered care
    Deductible
    Dental care
    Diagnostic services
    Dialysis
    Drug abuse
    Durable medical equipment
    Educational programs
    Eye, eyeglasses
    Family planning
    Foot care
    General exclusions
    Growth hormone therapy
    Healthy Discount program
    Hearing services
    Home health services
    Hospice care
    Hospital, inpatient
    Hospital, outpatient
    Immunization
    Infertility services
    IV therapy
    Lab test
    Mail order pharmacy
    Mammogram
    Maternity care
    Medical necessity
    Mental Health
    MRI/CT scan
    New technologies
    Nurse navigator
    Nursery care
    Occupational therapy
    Office visit
    Open access
    Oral and maxillofacial surgery
    Orthopedic device
    Out-of-pocket maximum
    Pap test
    Physical therapy
    Plan allowance
    Plan facility
    Plan provider
    Postnatal care
    Prenatal care
    Prescription drug
    Preventive care, adult
    Preventive care, child
    Primary care
    Prior approval (authorization)
    Promising therapies
    Prosthetic device
    Reconstructive surgery
    Second surgical opinion
    Service area
    Sexually transmitted disease (STD)
    Skilled nursing facility
    Specialty care
    Speech therapy
    Subrogation
    Surgery
    Tobacco cessation
    Transplants
    Treatment therapies
    Ultrasound
    Urgent care
    virtuwell
    Vision, eye
    X-ray



    Summary of Benefits for 2021 High Option

    • Do not rely on this chart alone. All benefits are subject to the definitions, limitations and exclusions in this brochure. You can obtain a copy of our Summary of Benefits and Coverage as required by the Affordable Care Act at www.healthpartners.com/fehb.
    • 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.

     




    TermDefinition 1Definition 2

    Medical services provided by physicians:

    • Diagnostic and treatment services provided in the office, urgent care and convenience clinic and by evisit and telephone

    $10 per convenience clinic visit; $25 per office visit; $45 per urgent care visit; nothing for virtuwell evisits 

    26

    virtuwell

    Nothing

    26

    Services provided by a hospital:

    • Inpatient and Outpatient

    $500 annual copayment for inpatient & outpatient combined, then 10% of charges

    51

    Emergency benefits:

    • In-area and out-of-area

    $100 per emergency room visit; $45 per office or urgent care center visit

    55

    Mental health and substance use disorder treatment

    Regular cost sharing

    57

    Prescription drugs:

    • Retail pharmacy (generally a 30-day supply)

    $5 for low cost generic preferred drugs; $25 for high cost generic preferred drugs; $45 for brand-name preferred drugs; $90 for non-preferred drugs; 20% for specialty drugs

    60

    • Mail order service (generally a 90-day supply)

    $10 for low cost generic preferred drugs; $50 for high cost generic preferred drugs; $90 for brand-name preferred drugs; $180 for non-preferred drugs

    64

    Dental care:

    • Accidental injury

     

    20% of charges, if Plan dentist provides care

    30% of charges when provided by Out of Network dentist if the injuries require immediate treatment.

    65

    Vision care

    Nothing for preventive care

    37

    Protection against catastrophic costs

    (out-of-pocket maximum)

    Self Only: Nothing after $5,500; Self Plus One: Nothing after $11,000, subject to a maximum of $8,550 per enrollee; Self and Family: Nothing after $11,000, subject to a maximum of $8,550 per enrollee

    20

    Special features:

    CareLine® service, Nurse Navigator, Behavioral Health Personalized Assistance Line, special phone lines for deaf and hearing impaired, personalized member page on website, health improvement programs

    66




    Summary of Benefits for 2021 Standard Option

    • Do not rely on this chart alone. All benefits are subject to the definitions, limitations and exclusions in this brochure. You can obtain a copy of our Summary of Benefits and Coverage as required by the Affordable Care Act at www.healthpartners.com/fehb.
    • 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. 



    TermDefinition 1Definition 2

    Medical services provided by physicians:

    • Diagnostic and treatment services provided in the office, urgent care and convenience clinic and by evisit and telephone

    In Network: $0 for 5 visits, then 20% after deductible
    Out of Network: 40% after deductible

    26

    virtuwell

    Nothing

    26

    Services provided by a hospital

    • Inpatient and Outpatient

    In Network: 20% after deductible
    Out of Network: 40% after deductible

    51

    Emergency outpatient hospital benefits

    • In-area and out-of-area

    20% after in-network deductible

    55

    Mental health and substance use disorder treatment

    Regular cost sharing

    57

    Prescription drugs:

    • Retail pharmacy (generally a 30-day supply)

    In Network copayments: $5 for low cost generic preferred drugs; $25 for high cost generic preferred drugs; $60 for brand name preferred drugs after deductible; $150 for non-preferred drugs after deductible; 20% for specialty drugs after deductible.

    Out of Network: 40% after deductible.

     

    60

    • Mail order service (generally a 90-day supply)

    In Network copayments: $10 for low cost generic preferred drugs; $50 for high cost generic preferred drugs; $120 for brand name preferred drugs after deductible; $300 for non-preferred drugs after deductible. Out of Network: 40% after deductible.

    64

    Dental care:

    • Accidental injury

     

    In Network: 20% after deductible. Out of Network: 30% after deductible.

    65

    Vision care

    Nothing for preventive care

    37

    Protection against catastrophic costs (out-of-pocket maximum)

    In Network: Self Only: Nothing after $6,500; Self Plus One: Nothing after $13,000, subject to a maximum of $8,550 per enrollee; Self and Family: Nothing after $13,000, subject to a maximum of $8,550 per enrollee; Out of Network: no maximum

    20

    Special features:

    CareLine® service, Nurse Navigator, Behavioral Health Personalized Assistance Line, special phone lines for deaf and hearing impaired, personalized member page on website, health improvement programs

    66




    2021 Rate Information for HealthPartners

    To compare your FEHB health plan options please go to www.opm.gov/fehbcompare.

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

    Non-Postal rates apply to most non-Postal employees. If you are in a special enrollment category, contact the agency that maintains your health benefits enrollment.

    Postal rates apply to certain United States Postal Service employees as follows.

    • Postal Category 1 rates apply to career bargaining unit employees who are represented by the following agreement: NALC.
    • Postal Category 2 rates apply to career bargaining unit employees who are represented by the following agreement: PPOA.

    Non-postal rates apply to all career non-bargaining unit Postal Service employees and career bargaining unit employees who are represented by the following agreements: APWU, IT/AS, NPMHU, NPPN and NRLCA. Postal rates do not apply to non-career Postal employees, Postal retirees, and associate members of any Postal employee organization who are not career Postal employees.

    If you are a Postal Service employee and have questions or require assistance, please contact:

    USPS Human Resources Shared Service Center: 1-877-477-3273, option 5. Federal Relay Service 1-800-877-8339

    Premiums for Tribal employees are shown under the monthly non-Postal 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.

     




    Type of EnrollmentEnrollment CodeNon-Postal Premium
    BiWeekly
    Gov't Share
    Non-Postal Premium
    BiWeekly
    Your Share
    Non-Postal Premium
    Monthly
    Gov't Share
    Non-Postal Premium
    Monthly
    Your Share
    Postal Premium
    BiWeekly
    Category 1 Your Share
    Postal Premium
    BiWeekly
    Category 2 Your Share
    High Option Self OnlyV31$231.26$77.08$501.05$167.02$74.00$63.98
    High Option Self Plus OneV33$511.07$170.35$1,107.31$369.10$163.54$141.39
    High Option Self and FamilyV32$562.25$188.85$1,218.21$409.17$181.04$157.62
    Standard Option Self OnlyV34$176.33$58.78$382.06$127.35$56.43$48.79
    Standard Option Self Plus OneV36$389.70$129.90$844.35$281.45$124.70$107.82
    Standard Option Self and FamilyV35$429.56$143.18$930.71$310.23$137.46$118.84