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Compass Rose Health Planwww.compassrosebenefits.com888-438-91352022A Fee-for-Service Plan (High Option) with a Preferred ProviderOrganizationThis Plan's health coverage qualifies as minimum essential coverageand meets the minimum value standard for the benefits it provides. Seepage 8 for details. This Plan is accredited. See page 13 for details.Who may enroll in this Plan: Civilian Active and Retired employees ofthe following organizations:IMPORTANT Rates: Back Cover Changes for 2022: Page 15 Summary of Benefits: Page 114Central Intelligence Agency (CIA)Defense Intelligence Agency (DIA)Department of Defense/ Civilian and Civilian Retirees (DOD)Department of Energy, Office of Intelligence and CounterintelligenceDepartment of Homeland SecurityDepartment of StateDepartment of Treasury, Office of Intelligence and AnalysisDrug Enforcement Administration, Intelligence DivisionFederal Bureau of Investigation (FBI)National Geospatial-Intelligence Agency (NGA)National Reconnaissance Office (NRO)National Security Agency (NSA)Office of DNI (ODNI) and Affiliated CentersOffice of Naval IntelligenceUnited States Agency for International Development (USAID)Membership dues: There are no membership dues.Enrollment codes for this Plan:421 - Self Only423 - Self Plus One422 - Self and FamilyRI 72-007
Important Notice from the Compass Rose Health Plan AboutOur Prescription Drug Coverage and MedicareThe Office of Personnel Management (OPM) has determined that the Compass Rose Health Plan's prescription drugcoverage is, on average, expected to pay out as much as the standard Medicare prescription drug coverage will pay for allPlan participants and is considered Creditable Coverage. This means you do not need to enroll in Medicare Part D and payextra for prescription drug benefit coverage. If you decide to enroll in Medicare Part D later, you will not have to pay apenalty 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 willcoordinate 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 advisedIf you lose or drop your FEHB coverage and go 63 days or longer without prescription drug coverage that is at least as goodas Medicare’s prescription drug coverage, your monthly Medicare Part D premium will go up at least 1 percent per month forevery month that you did not have that coverage. For example, if you go 19 months without Medicare Part D prescriptiondrug coverage, your premium will always be at least 19 percent higher than what many other people pay. You will have topay this higher premium as long as you have Medicare prescription drug coverage. In addition, you may have to wait untilthe next Annual Coordinated Election Period (October 15 through December 7) to enroll in Medicare Part D.Medicare’s Low Income BenefitsFor 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 theseplaces: Visit www.medicare.gov for personalized help. Call 800-MEDICARE 800-633-4227, TTY 877-486-2048.RI 72-007
Table of ContentsCover Page .1Important Notice .1Table of Contents .1Introduction .4Plain Language .4Stop Healthcare Fraud! .4Discrimination is Against the Law .6Preventing Medical Mistakes .6FEHB Facts .8Coverage information .8No pre-existing condition limitation .8Minimum essential coverage (MEC) .8Minimum value standard .8Where you can get information about enrolling in the FEHB Program .8Types of coverage available for you and your family .8Family Member Coverage .9Children's Equity Act .10When benefits and premiums start .11When you retire .11When you lose benefits .11When FEHB coverage ends .11Upon divorce .11Temporary Continuation of Coverage (TCC) .12Finding Replacement Coverage .12Health Insurance Marketplace .12Section 1. How This Plan Works .13We have a Preferred Provider Organization (PPO).13How we pay providers .13Your rights and responsibilities .14Your medical and claims records are confidential .14Section 2. Changes for 2022 .15Changes to this Plan .15Section 3. How You Get Care .17Identification Cards .17Where you get covered care .17Covered Providers .17Covered Facilities .18Transitional Care .19If you are hospitalized when your enrollment begins .20You need prior Plan approval for certain services .20Inpatient hospital admission .20Other services.21How to request precertification for an admission or get prior authorization for Other services .22Non-urgent care claims .22Urgent care claims .22Concurrent care claims .232022 Compass Rose Health Plan1Table of Contents
The Federal Flexible Spending Account Program-FSAFEDS.23Emergency inpatient admission .23Maternity care .23If your hospital stay needs to be extended .24If your treatment needs to be extended .24If you disagree with our pre-service claim decision .24To reconsider a non-urgent care claim .24To reconsider an urgent care claim .24To file an appeal with OPM .24Section 4. Your Costs for Covered Services .25Cost-sharing .25Copayments .25Deductible .25Coinsurance .25If your provider routinely waives your cost .25Waivers .26Differences between our allowance and the bill .26Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments .27Carryover .28If we overpay you .28When Government facilities bill us .28Section 5. High Option Benefits .29High Option Overview .31Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals .32Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals .49Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services .61Section 5(d). Emergency Services/Accidents .66Section 5(e). Mental Health and Substance Use Disorder Benefits .69Section 5(f). Prescription Drug Benefits .73Section 5(g). Dental Benefits .83Section 5(h). Wellness and Other Special Features.84Non-FEHB Benefits Available to Plan Members.87Section 6. General Exclusions - Services, Drugs and Supplies We Do Not Cover .88Section 7. Filing a Claim for Covered Services .90Section 8. The Disputed Claims Process.92Section 9. Coordinating Benefits with Medicare and Other Coverage .95When you have other health coverage .95TRICARE and CHAMPVA .95Workers’ Compensation .95Medicaid .95When other Government agencies are responsible for your care .95When others are responsible for injuries.96When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) .96Clinical Trials .96When you have Medicare .96Medicare Part B Premium Reimbursement .-1The Original Medicare Plan (Part A or Part B) .97Tell Us About Your Medicare Coverage .99Private contract with your physician.992022 Compass Rose Health Plan2Table of Contents
Medicare Advantage (Part C).99Medicare prescription drug coverage (Part D).101When you are 65 and you do NOT have Medicare .103When you have the Original Medicare Plan (Part A, Part B, or both) .105Section 10. Definitions of Terms We Use in This Brochure .106Index .112Summary of Benefits for the Compass Rose Health Plan - 2022 .1142022 Rate Information for Compass Rose Health Plan .1182022 Compass Rose Health Plan3Table of Contents
IntroductionThis brochure describes the benefits of the Compass Rose Health Plan under contract (CS 1065) between Compass RoseHealth Plan and the United States Office of Personnel Management, as authorized by the Federal Employees Health Benefitslaw. Customer service may be reached at 888-438-9135 or through our website: www.compassrosebenefits.com. The addressfor the Compass Rose Health Plan claims office is:UMRP.O. Box 8095Wausau, WI 54402-8095This 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 Oneor Self and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right tobenefits that were available before January 1, 2022, unless those benefits are also shown in this brochure.OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2022, and changes aresummarized on page 15. Rates are shown at the end of this brochure.Plain LanguageAll 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 eachcovered family member; “we” means the Compass Rose Health Plan. We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the United StatesOffice 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 Healthcare Fraud!Fraud increases the cost of healthcare 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 Programregardless of the agency that employs you or from which you retired.Protect Yourself From Fraud – Here are some things 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 healthcareprovider, authorized health benefits plan, or OPM representative. Let only the appropriate medical professionals review your medical record or recommend services. Avoid using healthcare providers who say that an item or service is not usually covered, but they know how to bill us to getit paid. Carefully review explanation of benefits (EOBs) statements that you receive from us. Periodically review your claims 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, ormisrepresented any information, do the following:2022 Compass Rose Health Plan4Introduction/Plain Language/Advisory
- Call the provider and ask for an explanation. There may be an error.- If the provider does not resolve the matter, call us at 888-438-9135 and explain the situation.- If we do not resolve the issue:CALL – THE HEALTHCARE FRAUD HOTLINE877-499-7295OR go to 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 ManagementOffice of the Inspector General Fraud Hotline1900 E Street NW Room 6400Washington, 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); or- Your child age 26 or over (unless they are disabled and incapable of self-support prior to age 26). A carrier may request thatan 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, withyour retirement office (such as OPM) if you are retired, or with the National Finance Center if you are enrolled underTemporary Continuation of Coverage (TCC). Fraud or intentional misrepresentation of material fact is prohibited under the Plan. You can be prosecuted for fraud andyour agency may take action against you. Examples of fraud include falsifying a claim to obtain FEHB benefits, trying to orobtaining services or coverage for yourself or for someone who is not eligible for coverage, or enrolling in the Plan when youare 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 healthinsurance benefits for which you have not paid premiums. It is your responsibility to know when you or a family member isno longer eligible to use your health insurance coverage.2022 Compass Rose Health Plan5Introduction/Plain Language/Advisory
Discrimination is Against the LawThe Compass Rose Health Plan complies with all applicable Federal civil rights laws, including Title VII of the Civil RightsAct of 1964.You can also file a civil rights complaint with the Office of Personnel Management by mail at: Office of PersonnelManagement Healthcare and Insurance Federal Employee Insurance Operations, Attention: Assistant Director FEIO,1900 EStreet NW, Suite 3400-S, Washington, D.C. 20415-3610.Preventing Medical MistakesMedical mistakes continue to be a significant cause of preventable deaths within the United States. While death is the mosttragic outcome, medical mistakes cause other problems such as permanent disabilities, extended hospital stays, longerrecoveries, and even additional treatments. Medical mistakes and their consequences also add significantly to the overall costof healthcare. Hospitals and healthcare providers are being held accountable for the quality of care and reduction in medicalmistakes by their accrediting bodies. You can also improve the quality and safety of your own healthcare and that of yourfamily 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 medication and dosages 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 to latex. Ask about any risks or side effects of the medication and what to avoid while taking it. Be sure to write down what yourdoctor or pharmacist says. Make sure your medication is what the doctor ordered. Ask the pharmacist about your medicine if it looks different thanyou 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 notbe 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 dosingfrom 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 orprovider's portal? Do not assume the results are fine if you do not get them when expected. Contact your healthcare provider and ask foryour 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 onehospital or clinic to choose from to get the healthcare you need.2022 Compass Rose Health Plan6Introduction/Plain Language/Advisory
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
Compass Rose Health Plan www.compassrosebenefits.com 888-438-9135 2022 A Fee-for-Service Plan (High Option) with a Preferred Provider Organization IMPORTANT Rates: Back Cover Changes for 2022: Page 15 Summary of Benefits: Page 114 This Plan's health coverage qualifies as minimum essential coverage
