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
Types of coverage 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 - 11

When FEHB coverage ends - 11
Upon divorce - 12
Temporary Continuation of Coverage (TCC) - 12
Finding replacement coverage - 12
Health Insurance Marketplace - 12

Section 1. How This Plan Works - 13
General features of FEP Blue Focus - 13
We have a Preferred Provider Organization (PPO) - 13
How we pay professional and facility providers - 13
Your rights and responsibilities - 14
Your medical and claims records are confidential - 14

Section 2. Changes for 2020 - 15

Section 3. How You Get Care - 16
Identification cards - 16
Where you get covered care - 16

Covered professional providers - 16
Covered facility providers - 16

What you must do to get covered care - 18

Transitional care - 18
If you are hospitalized when your enrollment begins - 18

You need prior Plan approval for certain services - 19

Inpatient hospital admission, inpatient residential treatment center admission - 19
Other services - 19
Special prior authorization situations related to coordination of benefits (COB) - 23
Prior notification – Maternity care - 24
How to request precertification for an admission or get prior approval for Other services - 24
Non-urgent care claims - 25
Urgent care claims - 25
Concurrent care claims - 26
Emergency inpatient admission - 26
Maternity care - 26
If your facility stay needs to be extended - 26
If your treatment needs to be extended - 26

If you disagree with our pre-service claim decision - 26

To reconsider a non-urgent care claim - 27
To reconsider an urgent care claim - 27
To file an appeal with OPM - 27
The Federal Flexible Spending Account Program – FSAFEDS - 27

Section 4. Your Costs for Covered Services - 28
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 Non-participating providers! - 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

Section 5. FEP Blue Focus Benefits - 32
FEP Blue Focus Overview - 34
Non-FEHB Benefits Available to Plan Members - 112

Section 6. General Exclusions – Services, Drugs, and Supplies We Do Not Cover - 113

Section 7. Filing a Claim for Covered Services - 115

Section 8. The Disputed Claims Process - 118

Section 9. Coordinating Benefits With Medicare and Other Coverage - 121
When you have other health coverage - 121

TRICARE and CHAMPVA - 121
Workers’ Compensation - 122
Medicaid - 122

When other Government agencies are responsible for your care - 122
When others are responsible for injuries - 122
When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) - 123
Clinical trials - 123
When you have Medicare - 124

What is Medicare? - 124
Should I enroll in Medicare? - 124
The Original Medicare Plan (Part A or Part B) - 125
Tell us about your Medicare coverage - 126
Private contract with your physician - 126
Medicare Advantage (Part C) - 126
Medicare prescription drug coverage (Part D) - 126
Medicare prescription drug coverage (Part B) - 126

When you are age 65 or over and do not have Medicare - 128
Physicians Who Opt-Out of Medicare - 129
When you have the Original Medicare Plan (Part A, Part B, or both) - 129

Section 10. Definitions of Terms We Use in This Brochure - 131

Index - 140

Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan FEP Blue Focus – 2020 - 141

2020 Rate Information for the Blue Cross and Blue Shield Service Benefit Plan - 146