Coverage information - 9
• No pre-existing condition limitation - 9
• Minimum essential coverage (MEC) - 9
• Minimum value standard - 9
• Where you can get information about enrolling in the FEHB Program - 9
• Enrollment types available for you and your family - 9
• Family member coverage - 10
• Children’s Equity Act - 10
• When benefits and premiums start - 11
• When you retire - 11
When you lose benefits - 12
• When FEHB coverage ends - 12
• Upon divorce - 12
• Temporary Continuation of Coverage (TCC) - 12
• Finding replacement coverage - 12
• Health Insurance Marketplace - 13

General features of FEP Blue Focus - 14
We have a Preferred Provider Organization (PPO) - 14
How we pay professional and facility providers - 14
Your rights and responsibilities - 15
Your medical and claims records are confidential - 15

Identification cards - 17
Where you get covered care - 17
Balance Billing Protection - 17
• Covered professional providers - 17
• Covered facility providers - 17
What you must do to get covered care - 19
• Transitional care - 19
• If you are hospitalized when your enrollment begins - 19
You need prior Plan approval for certain services - 20
• Inpatient hospital admission, inpatient residential treatment center admission - 20
• Other services - 20
• Special prior authorization situations related to coordination of benefits (COB) - 24
• Prior notification – Maternity care - 25
How to request precertification for an admission or get prior approval for Other services - 25
• Non-urgent care claims - 25
• Urgent care claims - 26
• Concurrent care claims - 26
• Emergency inpatient admission - 26
• Maternity care - 26
• If your facility stay needs to be extended - 27
• If your treatment needs to be extended - 27
If you disagree with our pre-service claim decision - 27
• To reconsider a non-urgent care claim - 27
• To reconsider an urgent care claim - 27
• To file an appeal with OPM - 27

Cost-share/Cost-sharing - 28
Copayment - 28
Deductible - 28
Coinsurance - 28
If your provider routinely waives your cost - 28
Waivers - 29
Differences between our allowance and the bill - 29
Important Notice About Surprise Billing – Know Your Rights - 29
Your costs for other care - 30
Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments - 30
Carryover - 30
If we overpay you - 31
When Government facilities bill us - 31
The Federal Flexible Spending Account Program – FSAFEDS - 31

Section 5. FEP Blue Focus Overview - 34
Non-FEHB Benefits Available to Plan Members - 104

When you have other health coverage - 113
• TRICARE and CHAMPVA - 113
• Workers’ Compensation - 114
• Medicaid - 114
When other Government agencies are responsible for your care - 114
When others are responsible for injuries - 114
When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) - 115
Clinical trials - 116
When you have Medicare - 116
• The Original Medicare Plan (Part A or Part B) - 116
• Tell us about your Medicare coverage - 117
• Private contract with your physician - 117
• Medicare Advantage (Part C) - 117
• Medicare prescription drug coverage (Part D) - 118
• Medicare prescription drug coverage (Part B) - 118
When you are age 65 or over and do not have Medicare - 120
Physicians Who Opt-Out of Medicare - 121
When you have the Original Medicare Plan (Part A, Part B, or both) - 121