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Introduction This brochure describes the benefits of the Blue Cross and Blue Shield Service Benefit Plan under our contract (CS 1039) with the United States Office of Personnel Management, as authorized by the Federal Employees Health Benefits law. This Plan is underwritten by participating Blue Cross and Blue Shield Plans (Local Plans) that administer this Plan on behalf of the Blue Cross and Blue Shield Association (the Carrier). The address for the Blue Cross and Blue Shield administrative office is: Blue Cross and Blue Shield Service Benefit Plan This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure. It is your responsibility to be informed about your health care benefits. If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled for Self and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that were available before January 1, 2007, unless those benefits are also shown in this brochure. OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2007, and changes are summarized in Section 2 of this brochure. Rates are shown under the Quick Reference feature. Plain Language All FEHB brochures are written in plain language to make them responsive, accessible, and understandable to the public. For instance, • Except for necessary technical terms, we use common words. For instance, "you" means the enrollee or family member; "we" means the Blue Cross and Blue Shield Service Benefit Plan. • We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the United States Office of Personnel Management. If we use others, we tell you what they mean first. • Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you compare plans. If you have comments or suggestions about how to improve the structure of this brochure, let OPM know. Visit OPM's "Rate Us" feedback area at www.opm.gov/insure, or e-mail OPM at fehbwebcomments@opm.gov. You may also write to OPM at the US Office of Personnel Management, Insurance Services Programs, Program Planning & Evaluation Group, 1900 E Street, NW, Washington, DC 20415-3650. Stop Health Care Fraud! Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits (FEHB) Program premium. OPM's Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless 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: • Be wary of giving your plan identification (ID) number over the telephone or to people you do not know, except to your doctor, other provider, or authorized plan or OPM representative. • Let only the appropriate medical professionals review your medical record or recommend services. • Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to get it paid. • Carefully review explanations of benefits (EOBs) that you receive from us. • 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, or misrepresented any information, do the following: •• Call the provider and ask for an explanation. There may be an error. •• If the provider does not resolve the matter, call us at 1.800.FEP.8440 and explain the situation. • If we do not resolve the issue, call or write: The Health Care Fraud Hotline • 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 over age 22 (unless he/she is disabled and incapable of self support). • If you have any questions about eligibility of a dependent, check with your personnel office if you are employed, with your retirement office (such as OPM) if you are retired, or with the National Finance Center if you are enrolled under Temporary Continuation of coverage. • You can be prosecuted for fraud and your agency may take action against you if you falsify a claim to obtain FEHB benefits or try to obtain services for someone who is not an eligible family member or who is no longer enrolled in the Plan. Preventing Medical Mistakes An influential report from the Institute of Medicine estimates that up to 98,000 Americans die every year from medical mistakes in hospitals alone. That's about 3,230 preventable deaths in the FEHB Program a year. While death is the most tragic outcome, medical mistakes cause other problems such as permanent disabilities, extended hospital stays, longer recoveries, and even additional treatments. By asking questions, learning more and understanding your risks, you can improve the safety of your own health care, and that of your family members. 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 fell comfortable talking. • Take a relative or friend with you to help you ask questions and understand answers. 2. Keep and bring a list of all the medicines you take. • Bring the actual medicines or give your doctor and pharmacist a list of all the medicines that you take, including non-prescription (over-the-counter) medicines. • Tell them about any drug allergies you have. • Ask about any risks or side effects of the medication and what to avoid while taking it. Be sure to write down what your doctor or pharmacist says. • Read the label and patient package insert when you get your medicine, including all warnings and instructions. • Make sure your medicine is what the doctor ordered. Ask the pharmacist about your medicine if it looks different than what you expected. • Know how to use your medicine. Especially note the times and conditions when your medicine should and should not be taken. • Contact your doctor or pharmacist if you have any questions. 3. Get the results of any test or procedure. • Ask when and how you will get the results of tests or procedures. • Don't assume the results are fine if you do not get them when expected, be it in person, by phone or by mail. • Call your doctor and ask for your results. • Ask what the results mean for your care. 4. Talk to your doctor about which hospital is best for your health needs. • Ask your doctor about which hospital has the best care and results for your condition if you have more than one hospital to choose from to get the health care you need. • Be sure you understand the instructions you get about follow-up care when you leave the hospital. 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 manage my care when I am in the hospital?" • Ask your surgeon: •• Exactly what will you be doing? •• About how long will it take? •• What will happen after surgery? •• How can I expect to feel during recovery? • Tell the surgeon, anesthesiologist, and nurses about any allergies, bad reaction to anesthesia, and any medications you are taking. Visit these Web sites for more information about patient safety • www.ahrq.gov/path/beactive.htm. The Agency for Healthcare Research and Quality makes available a wide-ranging list of topics not only to inform consumers about patient safety but to help choose quality health care providers and improve the quality of care your receive. • www.npsf.org. The National Patient Safety Foundation has information on how to ensure safer health care for you and your family. • www.talkaboutrx.org. The National Council on Patient Information and Education is dedicated to improving communication about safe, appropriate use of medications. • www.leapfroggroup.org. The Leapfrog Group is active in promoting safe practices in hospital care. • www.ahqa.org. The American Health Quality Association represents organizations and health care professionals working to improve patient safety. • www.quic.gov/report. Find out what federal agencies are doing to identify threats to patient safety and help prevent mistakes in the nation's health care delivery system. |
