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GEHA Benefit Planwww.geha.com800-821-61362020A Fee-for-Service (High and Standard Options) health plan with aPreferred Provider OrganizationThis plan's health coverage qualifies as minimum essential coverageand meets the minimum value standard for the benefits it provides.See page 7 for details. This plan is accredited. See page 12.Sponsored and administered by:Government Employees Health Association, Inc.IMPORTANT Rates: Back Cover Changes for 2020: Page 14 Summary of Benefits: Page 125Who may enroll in this Plan: All Federal employees and annuitantswho are eligible to enroll in the Federal Employees Health BenefitsProgram may become members of GEHA. You must be, or mustbecome a member of Government Employees Health Association, Inc.To become a member: You join simply by signing a completedStandard Form 2809, Health Benefits Registration Form, evidencingyour enrollment in the Plan.Membership dues: There are no membership dues for the Year 2020.Enrollment codes for this Plan:311 High Option - Self Only313 High Option - Self Plus One312 High Option - Self and Family314 Standard Option - Self Only316 Standard Option - Self Plus One315 Standard Option - Self and FamilyRI 71-006
Important Notice from Government Employees Health Association, Inc. AboutOur Prescription Drug Coverage and MedicareOPM has determined that the Government Employees Health Association, Inc. prescription drug coverage is, on average,expected to pay out as much as the standard Medicare prescription drug coverage will pay for all plan participants and isconsidered Creditable Coverage. This means you do not need to enroll in Medicare Part D and pay extra for prescription drugcoverage. If you decide to enroll in Medicare Part D later, you will not have to pay a penalty for late enrollment as long asyou 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’s at least as goodas Medicare’s prescription drug coverage, your monthly Medicare Part D premium will go up at least 1% per month for everymonth that you did not have that coverage. For example, if you go 19 months without Medicare Part D prescription drugcoverage, your premium will always be at least 19 percent higher than what many other people pay. You will have to pay thishigher premium as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the nextAnnual 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.
Table of ContentsIntroduction .3Plain Language .3Stop Health Care Fraud! .3Discrimination is Against the Law .4Preventing Medical Mistakes .5FEHB Facts .7Coverage information .7 No pre-existing condition limitation.7 Minimum essential coverage (MEC) .7 Minimum value standard (MVS) .7 Where you can get information about enrolling in the FEHB Program .7 Types of coverage available for you and your family .7 Family member coverage .8 Children’s Equity Act .9 When benefits and premiums start .9 When you retire .10When you lose benefits .10 When FEHB coverage ends .10 Upon divorce .10 Temporary Continuation of Coverage (TCC) .10 Finding Replacement Coverage .10 Health Insurance Marketplace .11Section 1. How This Plan Works .12General features of our High and Standard Options .12How we pay providers .13Your rights and responsibilities .13Your medical and claims records are confidential .13Section 2. Changes for 2020 .14Changes to High and Standard Options .14Section 3. How You Get Care .16Identification cards .16Where you get covered care .16 Covered providers.16 Covered facilities .16 Transitional care .18 If you are hospitalized when your enrollment begins.18You need prior Plan approval for certain services .19 Inpatient hospital admission (including Residential Treatment Centers, Skilled Nursing Facility, Long TermAcute Care or Rehab Facility) .19 Non-urgent care claims .20 Urgent care claims .20 Concurrent care claims .20 Emergency inpatient admission .21 Maternity care .21 NICU cases .21 If your hospital stay needs to be extended .21 Other services that require preauthorization .222020 GEHA Benefit Plan1Table of Contents
Radiology/Imaging procedures preauthorization .23 If your treatment needs to be extended .24If you disagree with our pre-service claims decision .24 To reconsider a non-urgent care claim .24 To reconsider an urgent care claim .24 To file an appeal with OPM .25Overseas claims.25Section 4. Your Costs for Covered Services .26 Coinsurance .26 Copayments .26 Cost-sharing .26 Deductible .26 If your provider routinely waives your cost .26 Waivers .27 Differences between our allowance and the bill .27 Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments .28 Carryover .28 If we overpay you .29 When Government facilities bill us .29Section 5. Benefits .30High and Standard Option Overview .32Non-FEHB Benefits Available to Plan Members.96Section 6. General Exclusions - Services, Drugs and Supplies We Do Not Cover .97Section 7. Filing a Claim for Covered Services .99Section 8. The Disputed Claims Process.102Section 9. Coordinating Benefits with Medicare and Other Coverage .105When you have other health coverage or auto insurance.105 TRICARE and CHAMPVA .105 Workers’ Compensation .105 Medicaid .106When other Government agencies are responsible for your care .106When others are responsible for injuries.106When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) .107Clinical trials .107When you have Medicare .108 What is Medicare? .108 Should I enroll in Medicare? .108 The Original Medicare Plan (Part A or Part B).109 Tell us about your Medicare coverage .111 Private contract with your physician.111 Medicare Advantage (Part C) .112 Medicare prescription drug coverage (Part D) .112When you are age 65 or over and do not have Medicare .114When you have the Original Medicare Plan (Part A, Part B, or both) .115Section 10. Definitions of Terms We Use in This Brochure .116Index.123Summary of Benefits for the High Option of the Government Employees Health Association, Inc. 2020 .125Summary of Benefits for the Standard Option of the Government Employees Health Association, Inc. 2020 .1272020 Rate Information for Government Employees Health Association, Inc. (GEHA) Benefit Plan .1302020 GEHA Benefit Plan2Table of Contents
IntroductionThis brochure describes the benefits of Government Employees Health Association, Inc. under our contract (CS 1063) withthe United States Office of Personnel Management, as authorized by the Federal Employees Health Benefits law. This Plan isunderwritten by Government Employees Health Association, Inc. Customer service may be reached at 800-821-6136 orthrough our website at www.geha.com. The address for the Government Employees Health Association, Inc. administrativeoffices is:Government Employees Health Association, Inc.P.O. Box 21542Eagan, MN 55121Thi
underwritten by Government Employees Health Association, Inc. Customer service may be reached at 800-821-6136 or through our website at www.geha.com. The address for the Government Employees Health Association, Inc. administrative offices is: Government Employees Health
