If you or your eligible dependent(s) take any of the actions that would make you eligible for health account dollars, you are entitled to receive those health account dollars on a debit card that will automatically be sent to you from our wellness program partner. 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, Reduction of fractures of the jaws or facial bones, Surgical correction of cleft lip, cleft palate or severe functional malocclusion, 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, Removal of impacted teeth that are not completely erupted (bony, partial bony and soft tissue impaction), Autologous pancreas islet cell transplant (as an adjunct to total or near total pancreatectomy) only for patients with chronic pancreatitis, Small intestine with multiple organs, such as the liver, stomach, and pancreas, Advanced Hodgkins lymphoma with recurrence (relapsed), Advanced Myeloproliferative Disorders (MPDs), Advanced non-Hodgkins lymphoma with recurrence (relapsed), Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome), Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell tumors, Aggressive non-Hodgkins lymphomas (Mantle Cell lymphoma, adult T-cell leukemia/lymphoma, peripheral T-cell lymphomas and aggressive Dendritic Cell neoplasms). If you join Value Option during Open Season, you receive the full PCA of $100 per Self Only, $200 for Self Plus One, or $200 per Self and Family as of your effective date of coverage. We will pay medical emergencies specifically listed in Section 5(d). Preadmission testing (within 7 days of admission), limited to: Blood or blood plasma, if not donated or replaced, Dressings, splints, casts, and sterile tray services, Medical supplies and equipment, including oxygen, Anesthetics, including nurse anesthetist services, Occupational, physical, cognitive, and speech therapy, Medical supplies, appliances, and equipment; and any covered items billed by a hospital for use at home, Operating, recovery, and other treatment rooms, Administration of blood, blood plasma, and other biologicals, Blood and blood plasma, if not donated or replaced, Physical,occupational, cognitive, and speechtherapy (when surgery performed on the same day), Outpatientobservation room and all related services, Outpatient services and supplies for the delivery of a newborn, Outpatient services and supplies for a voluntary female sterilization, Specialty drugs, including biotech, biological, biopharmaceutical, and oral chemotherapy drugs, Medicare has made payment, we cover the applicable copayments; or. January 1 for continuing enrollments and for all annuitant enrollments; The first day of the first full pay period of the new year for enrollees who change plans or options or elect FEHB coverage during the Open Season; or. The Specialty Connect feature allows you to submit your specialty medication prescription to your local CVS Pharmacy. See page 13, Section 1. Nonprofit. Medical Services and Supplies Provided by Physicians and Other HealthcareProfessionals, CDHP/Value Option Section 5(b). We cover prescribed medications and supplies as described in the chart beginning on page (Applies to printed brochure only). Evidence in the medical record that attempts at weight loss in the one year period prior to surgery have been ineffective. Spinal surgeries performed in an inpatient or outpatient setting. Note: Prior approval is required for all specialty drugs used to treat chronic medical conditions. Organ/tissue transplants. If you do not telephone the Plan within two business days, penalties may apply - seeWarningunderInpatient hospital admissionsearlier in this Section andIf your hospital stay needs to be extendedbelow. Please refer to prior authorization information in Section 3. Dental and vision coverage provided by First Health Life & Health Insurance Company, Cambridge Life Insurance Company or Vision Service Plan, Inc. The Plan, its medical staff and/or an independent medical review determines whether services, supplies and charges meet the coverage requirements of the Plan (subject to the disputed claims procedure described in Section 8. irming an adverse benefit determination will include information sufficient to identify the claim involved (including the date of service, thehealthcare provi. Finally, if you qualify for coverage under another group health plan (such as your spouses plan), you may be able to enroll in that plan, as long as you apply within 30 days of losing FEHB Program coverage. Each person seeking assistance with behavior change responds to treatment options in their own, access their account. Note: If you are using an In-Network provider for mental health or substance use disorder treatment, you will not have to submit a claim. Note: Prior approval is required for all specialty drugs used to treat chronic medical conditions. A Medicare non-participating provider is a provider who has not enrolled in Medicare and does not accept Medicare payments. Expenses in excess of the Plan allowance or maximum benefit limitations, Amounts you pay for non-compliance with this Plans cost containment requirements, Any amount in excess of our Plan allowance or maximum benefit limitations or expenses not covered under the Traditional Health Coverage. See Section 5(f). See page 158, Non-FEHB Benefits Available to Plan Members for more details. For services rendered by a covered provider that participates in the Plans mental health and substance use disorder network, our allowance is based on a negotiated rate agreed to under the provider's network agreement. Medical emergency at the In-Network benefit level. Physical therapy to prevent falls for community- dwelling adults age 65 and older as recommended by the U.S. Preventive Services Task Force (USPSTF), Identifies the specific professional skills the patient requires; and, Indicates the length of time the services are needed., For treatment (excluding hearing aids) related to illness or injury, including evaluation and diagnostic hearing tests performed by an M.D., D.O., or audiologist, Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear im, First hearing aid and examination, limited to services necessitated by accidental injury, One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery (such as for cataracts) when purchased within one year. You and your provider will receive written confirmation of the precertificationfrom Cigna Behavioral Health for the initial and any ongoing authorizations. You will be going to a new website, operated on behalf of the Blue Cross and Blue Shield Service Benefit Plan by a third party. How can Checkbook's Guide to Health Plans for Federal Employees help me? When you enroll in the Value Option during Open Season, we will give you a PCA in the amount of $100 for Self Only, or $200 for Self Plus One, or $200 for Self and Family. The Guide provides: As a result, the Guide gives you a solid basis for selecting the best health or dental plan for you and your family. The non-PPO benefits are the standard benefits of this option. $350 copayment per admission for all other admissions. The good news is all our MHBP plans offer in and out of network benefits. A compound drug is a medication made by combining, mixing or altering ingredients in response to a prescription, to create a customized drug that is not otherwise commercially available. Individuals may register online at www.mycigna.comor by calling the toll-free number at 855-511-1893. Members will have access to a Transformation Coach and a suite of online tools to help track food and activity. 3. Note: When surgery is not performed on the same day, see Section 5(a). These providers accept the Plan allowance as their charge. CDHP/Value Option Out-of-Network benefits: Our allowance is based on two times the Medicare reimbursement rate. 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 $600. Emergency room physician care not related to Accidental injury or Medical emergency. NALC Health Benefit Plan holds the following accreditation: Accreditation Association for Ambulatory Health Care (AAAHC) and vendors that support the NALC Health Benefit Plan hold accreditations from the National Committee for Quality Assurance and URAC. If your physician does not participate with Medicare and is not a member of our PPO network, then you are responsible for your out-of-network deductibles, coinsurance, and any balance up to 115% of the Medicare approved amount. BENEFEDS | Federal Benefits Enrollment (FEDVIP, FSAFEDS, FLTCIP) If your enrollment continues after you are no longer eligible for coverage (e.g., 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. The calendar year deductible applies to almost all benefits in this Section. A full list of participating pharmacies is available at. Surgical procedures. Gaps in care occur when individuals do not receive or adhere to care that is consistent with medically proven guidelines for prevention or treatment. We pay benefits according to the appropriate benefit section, such as Section 5(c). Precertification is required. To make your request, please contact our Customer Service Department by writing NALC Health Benefit Plan, 20547 Waverly Court, Ashburn, VA 20149or calling 703-729-4677 or 888-636-NALC (6252). MHBP offers dental benefits with year round enrollment. As a Federal employee, you serve the needs of the country. As a federal employee, you have the ability to choose from the widest selection of health plans in the country. You may obtain up to a 30-day fill and unlimited refills for each prescription purchased at a non-network retail pharmacy; however, if you purchase more than two fills, you will need to file a paper claim to receive reimbursement. The Plan extends coverage for the diagnoses as indicated below. You may elect to receive a $100 a day, $75 a day, $50 a day, or $30 a day plan. There are many other acute conditions that are medical emergencies--what they all have in common is the need for quick action in order to avoid bodily injury, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. Note: Under the High Option, Consumer Driven Health Plan and Value Option, when Medicare benefits are exhausted, or services are not covered by Medicare, our benefits are subject to the definitions, limitations, and exclusions in this brochure. 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. Thisis a discount program andnot insurance, and the member must pay theentire discounted charge fordental services. If you exhaust your PCA, the Traditional Medical Coverage begins after you satisfy the calendar year deductible. 4. These may include some over-the-countervitamins, nicotine replacement medications, and low dose aspirin for certain patients. You can also find the PPO directory on our website at www.nalchbp.org. 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. Your Costs for Covered Services for more information. Participants in the program must obtain prior approval from the Cigna LifeSOURCE Transplant Network to receive limited travel and lodging benefits. All Standard Option members, as well as Basic Option members with Medicare Part B primary, can get prescription drugs they regularly take conveniently delivered to their home. See Section 5(b). See Wellness Incentive Programs in this section for more details. When a covered service or supply is subject to a deductible, only the Plan allowance for the service or supply counts toward the deductible. Other hospital services and supplies, such as: Note: We base payment on who bills for the services or supplies. 24 hours a day, 7 days a week, except major holidays. High Option:You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM. Claims processed by Medicaid as the primary payor will require Medicaid to submit a reimbursement request to the Plan. FSAs include Health Care FSA (HCFSA), Limited Expense FSA for those with an HSA (LEX), and Depen- dent Care FSA (DCFSA). Each plan's FEHB brochure is the official statement of benefits. The Disputed Claims Process). Differences between our allowance and the bill. Outpatient hospital or ambulatory surgical center. All compound drugs. Real Appeal encourages members to make small changes toward larger long-term health results with sustained support throughout the duration of the program. FAILURE TO DO SO WILL RESULT IN A DENIAL OF BENEFITS. The Dental Network transitioned effective January 1, 2022. Residential Treatment Center. Enrollees in the Plan must be members, or associate members, of the NALC. You are not eligible for coverage under TCC or the Spouse Equity Law. These plans are optional, with all premiums paid by the employee without any subsidy from the Postal Service. Medical treatment with a likely side effect of infertility as established by the American Society of Reproductive Medicine and the American Society of Clinical Oncology. For a complete list of immunizations go to the Centers for Disease Control (CDC) website at, Anesthesia related to delivery or amniocentesis, Other tests medically indicated for the unborn child or as part of the maternity care. Eligibility for the Plans PCA is determined on the first day of the month of your effective day of enrollment in the CDHP or Value Option Plan and will be prorated for the length of the enrollment.
Palmer Coolum Slope Rating,
Tijuana Crime Rate 2023,
Room For Rent Vergennes, Vt,
Kirkland Park And Ride,
Terrell High School Football,
Articles L
