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

General features of our Standard and Basic Options - 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

Changes to our Standard Option only - 15
Changes to our Basic Option only - 15
Changes to both our Standard and Basic Options - 17

Identification cards - 18
Where you get covered care - 18
Balance Billing Protection - 18
• Covered professional providers - 18
• Covered facility providers - 18
What you must do to get covered care - 20
• Transitional care - 21
• If you are hospitalized when your enrollment begins - 21
You need prior Plan approval for certain services - 22
• Inpatient hospital admission, inpatient residential treatment center admission, or skilled nursing facility admission - 22
• Other services - 22
• Surgery by Non-participating providers under Standard Option - 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 - 29
If your provider routinely waives your cost - 29
Waivers - 29
Differences between our allowance and the bill - 29
Important Notice About Surprise Billing — Know Your Rights - 32
Your costs for other care - 32
Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments - 33
Carryover - 33
If we overpay you - 34
When Government facilities bill us - 34
The Federal Flexible Spending Account Program – FSAFEDS - 34

Section 5. Standard and Basic Option Overview - 37
Non-FEHB Benefits Available to Plan Members - 132

When you have other health coverage - 141
• TRICARE and CHAMPVA - 141
• Workers’ Compensation - 142
• Medicaid - 142
When other Government agencies are responsible for your care - 142
When others are responsible for injuries - 142
When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) - 144
Clinical trials - 144
When you have Medicare - 144
• The Original Medicare Plan (Part A or Part B) - 144
• Tell us about your Medicare coverage - 145
• Private contract with your physician - 145
• Medicare Advantage (Part C) - 146
• Medicare prescription drug coverage (Part D) - 146
• Medicare Prescription Drug Plan Employer Group Waiver Plan (PDP EGWP) - 146
• Medicare prescription drug coverage (Part B) - 146
When you are age 65 or over and do not have Medicare - 148
Physicians Who Opt-Out of Medicare - 149
When you have the Original Medicare Plan (Part A, Part B, or both) - 149