Frequently Asked Questions

Frequently Asked Questions Table of Contents Eligibility & Enrollment... 2 Who can be covered?... 2 Are my parents eligible for coverage?... 2 My state recognizes same sex marriages; how do I add my domestic partner to my contract? 2 How and when can I add my new spouse to my coverage?... 2 How can I remove my former spouse from my contract and add my new spouse?... 2 What is TCC?... 2 What is spouse equity?... 2 How do I keep coverage for my disabled child at age 26?... 3 How do I add a newborn?... 3 How do I add an adopted child?... 3 How do I add a grandchild or foster child to my coverage?... 4 Enrollment Procedures Chart... 4 ID Cards and Care... 4 Overseas Care... 5 How do I file claims for services overseas?... 5 Medical... 5 Mail Service Pharmacy... 5 Retail Pharmacy... 5 Who can I call for information on services overseas?... 5 Nurse Line (Blue Health Connection)... 5 Online services... 6 Audio library... 6 How do I access nurse line services?... 6 Other Questions and Answers... 6 Please explain medical necessity. If my doctor ordered the care, isn t it medically necessary?... 6 When I call Customer Service, why does the representative ask me so many questions?... 6 What is the difference between?... 7 Is the FEHBP program a Medicare supplement plan?... 7 How do you coordinate benefits when Medicare is primary?... 7 What is the plan allowance?... 7 My Explanation of Benefits (EOB) for services from a preferred provider shows that I must pay a portion of the costs, even though it shows I don't owe any difference. How is this calculated?... 7 I already paid my calendar year deductible. Why aren't you showing it?... 8 013895 (11-2011) An Independent Licensee of the Blue Cross Blue Shield Association

Eligibility & Enrollment Who can be covered? The following people are eligible for coverage: Legal spouse Divorced spouses (see information below on the Spouse Equity Act and Temporary Continuation of Coverage, or TCC) Natural children up to age 26 Foster children/grandchildren when residing in the home of the enrollee in a parent-child relationship and whom the enrollee intends to raise to adulthood; includes but is not limited to a child in legal custody of the enrollee; grandchild; niece; or nephew. Please note that a child placed in the home by a welfare agency or social agency that retains control over the child or pays for maintenance does not qualify. Disabled children age 26 and older (incapable of self-support because of a mental or physical disability which existed before age 26) Are my parents eligible for coverage? No, they are not eligible, even if they are dependent upon you for financial support. My state recognizes same sex marriages; how do I add my domestic partner to my contract? Federal law supersedes state law, and federal law does not recognize same sex marriages or domestic partnerships. Therefore, FEHBP does not allow domestic partners to be added to coverage. How and when can I add my new spouse to my coverage? If you are currently covering only yourself, you may change to self and family coverage within 31 days before getting married or 60 days afterward. Please contact your personnel office to make this change on paper or electronically. Your new spouse will be covered as of the date of the marriage. If you already have family coverage, please call your local Plan at the number on the back of your ID card. There is no time limitation in which to add your new spouse to your policy and coverage will be effective as of the date of marriage. How can I remove my former spouse from my contract and add my new spouse? Call your local plan at 1-800-562-1011 and give the representative the date of divorce from the active spouse. Also provide the name, date of birth, sex, Social Security number and date of marriage for the new spouse. What is TCC? Temporary Continuation of Coverage (TCC) allows coverage for up to 18 months for former employees and retirees and up to 36 months for dependents after coverage would normally end. Contact your personnel office or the Office of Personnel Management (OPM) for eligibility requirements. What is spouse equity? Spouse equity allows former spouses to enroll in an FEHBP health benefit plan. For information about enrolling under the Spouse Equity Act, you can look at the guide for Temporary Continuation of Coverage and Former Spouse Enrollees on www.opm.gov/insure. Page 2 of 8

How do I keep coverage for my disabled child at age 26? If your child s disability is eligible for continued coverage, your doctor can provide a statement with the needed information. Please contact your local Plan at the number on the back of your ID card for more information. How do I add a newborn? See info below on adding a grandchild or foster child Newborn with the same last name: o Self only policy: the enrollee must contact their Personnel Office to change to family coverage within 60 days after the birth of child. o Family policy: the enrollee can add the new child by calling the local Plan and providing the NAME, DATE OF BIRTH, SEX and SSN, if known. Newborn with different last name: o Self only policy: the enrollee must contact their Personnel Office to change to family coverage within 60 days after the birth of child. o Family policy: the enrollee must provide the following information in writing to the local Plan: EFFECTIVE DATE OF COVERAGE, NAME, DATE OF BIRTH, SEX, RELATIONSHIP TO ENROLLEE, CHILD S ADDRESS and the SSN, if known. FAX the information to: 425-918-5338 Or mail information to: The Federal Employee Program PO Box 33932 Seattle, WA 98133-0932 NOTES: Stepchildren must live in a Parent-Child relationship with the Contract Holder. The Contract Holder must be financially responsible for the child and intend to raise him/her to adulthood. If the stepchild temporarily lives elsewhere while attending school or for other reasons, the child is still considered to be an eligible family member if he/she is otherwise living with the policy holder in a regular parent-child relationship. If there is a court order requiring an ex-spouse who is now married to a federal employee to provide health insurance for their child from the former marriage, the child is not eligible for coverage under the federal policy unless a parent-child relationship is established between the stepchild and the contract holder. How do I add an adopted child? Self only policy: The enrollee must contact their Personnel Office to change to a family contract. Self and family policy: The enrollee must provide to the local Plan a letter of approval from the Contract Holder s Payroll/Agency/Personnel or a Court Order (Adoption Decree) regarding the adoption of the child (name, date of birth, effective date of coverage, and SSN). FAX the information to: 425-918-5338 Or mail information to: The Federal Employee Program PO Box 33932 Seattle, WA 98133-0932 Page 3 of 8

How do I add a grandchild or foster child to my coverage? Submit the child s name, date of birth, sex, Social Security number and a copy of the court order establishing guardianship to our enrollment area by fax to (202) 479-5511. Or, your agency may submit a Foster Child Status Form on your behalf. Enrollment Procedures Chart If you are currently enrolled in: Standard Option coverage - Blue Cross and Blue Shield Service Benefit Plan Standard Option coverage - Blue Cross and Blue Shield Service Benefit Plan Basic Option coverage - Service Benefit Plan Basic Option coverage - Service Benefit Plan Another FEHB plan And you want this coverage for next year: Standard Option coverage - Blue Cross and Blue Shield Basic Option coverage - Basic Option coverage - Standard Option coverage - Standard Option or Basic Option coverage Here is what you do: Do nothing. Your coverage will continue. Complete an SF 2809 and submit it to your health benefits officer or use the appropriate electronic enrollment process* to select Basic Option, enrollment codes 111 (Self Only) and 112 (Self and Family). Do nothing. Your coverage will continue. Complete an SF 2809 and submit it to your health benefits officer or use the appropriate electronic enrollment process* to select Standard Option, enrollment codes 104 (Self Only) and 105 (Self and Family) Complete an SF 2809 and submit it to your health benefits officer or use the appropriate electronic enrollment process* to select Standard Option, enrollment codes 104 and 105 (Self Only, Self and Family), or Basic Option, enrollment codes 111 and 112 (Self Only, Self and Family). * Some federal agencies use an electronic system, such as Employee Express, to handle Open Season enrollment transactions. In addition, all annuitants use an electronic process for enrollment changes. If you use an electronic system, active employees will not complete an SF 2809 to submit to your health benefits officer or annuitants to the US Office of Personnel Management (OPM). ID Cards and Care I have changed coverage and need my ID card right away; how do I speed up the process? If available, make a copy of your completed SF 2809 enrollment form (give the original to your health benefits office at your agency) or if you use an electronic enrollment system, make a copy of your confirmation form. Send or fax the copy to: CareFirst BlueCross BlueShield FEP Operations Center Attn: Expedited Enrollment 840 First Street NE Washington, DC 20065 Fax: 202-479-5511 If you use this expedited enrollment process, you will have your ID card within 14 days. Page 4 of 8

If I need medical care or prescription drugs before I receive my ID card, what do I do? Physician, hospital or dental care: Show the provider a copy of your SF 2809 enrollment form as proof of enrollment. Mail service pharmacy: Call 1-800-262-7890 for information (not available until your membership is processed). Retail pharmacy service: You must pay full retail price. Once you receive your ID card, submit a claim form for reimbursement. Claim forms are available on the web at www.fepblue.org. Call 1-800-624-5060 for more information. Overseas Care What resources do I have to help me with health care services while overseas? Outside the US and Puerto Rico, the worldwide Assistance Center can help you: find a physician refer you to a participating hospital or facility verify your enrollment make transportation arrangements to another health care setting Contact: Inside the U.S. and Puerto Rico 1-800-699-4337 Outside the U.S. and Puerto Rico (call collect) 1-804-673-1678 E-mail FEPOverseas@worldaccess.com You can also access information about benefits overseas on www.fepblue.org under the Benefits feature on the homepage. How do I file claims for services overseas? Visit www.fepblue.org for a copy of the overseas claim form and more information on submitting claims. Send claims for reimbursement as follows: Medical: CareFirst BlueCross BlueShield, P.O. Box 96242, Washington, DC 20090-6242 Mail Service Pharmacy: Caremark, P.O. Box 52056, Phoenix, AZ 85072 Retail Pharmacy: Service Benefit Plan, Retail Pharmacy Program, P.O. Box 52057, Phoenix, AZ 85072-2057 Who can I call for information on services overseas? Call 1-888-999-9862. Nurse Line (Blue Health Connection) What services does the nurse line provide? If you believe you are experiencing a life-threatening emergency, please call 9-1-1. For other health related questions and concerns, your benefits include access to a Nurse Line through Blue Health Connections by calling 888-258-3432. Registered nurses are available anytime day or night to thoroughly assess your symptoms and address your concerns. Page 5 of 8

Nurses: Help you make informed decisions regarding the most appropriate time and place for care; give selfcare instructions to help you start feeling better while awaiting any additional care; or if no other care is recommended, will call back to see how you re doing. Provide long-term health counseling for chronic conditions or long illnesses, working with your doctor to help you understand tests, treatments and surgical options so you are able to make informed decisions; answer any general health questions; and explain procedures or tests you are considering or planning. Help you find information about providers in the network; select specialists to meet your needs; and point to resources, such as seminars and support groups, that are close to home. Online services: You may e-mail a nurse counselor, or research the health library of more than 1,100 topics if a situation does not require an immediate response. Audio library: You may listen to more than 450 recordings on a variety of health topics 24 hours a day. If you wish, you may order printed information. How do I access nurse line services? The Blue Health Connection number appears on the back of your ID card. Call 1-888-BLUE-432 (1-888-258-3432) 24 hours a day, 7 days a week. You can also access Blue Health Connection online at www.fepblue.org. The Blue Health Connection web site allows you to access ask-a-nurse via e-mail. A nurse will respond to your question(s) within 24 hours. There is also a helpful resource to learn more about medical conditions, tests and other medical terms. Hearing or speech impaired enrollees contact your local Telecommunications Relay Services (TRS) or 1-800-877-8339, Monday-Friday 8 a.m.-8 p.m. Eastern Standard Time Other Questions and Answers Please explain medical necessity. If my doctor ordered the care, isn t it medically necessary? The fact that a covered provider has prescribed, recommended or approved a service, drug, supply or equipment does not, in itself, make it medically necessary or covered. To be medically necessary, the services: Must be appropriate to prevent, diagnose or treat the patient s condition, illness or injury Must be consistent with standards of good medical practice in the U.S. Cannot be primarily for the personal comfort or convenience of the patient, the family or the provider Cannot be a part of, or associated with, the scholastic education or vocational training of the patient Cannot be provided safely on an outpatient basis, in the case of inpatient care When I call Customer Service, why does the representative ask me so many questions? First, to protect your privacy we ask questions that will help us determine who is calling. Second, we ask questions so we can answer you completely and accurately. Page 6 of 8

It is our responsibility to protect your privacy. Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the Gramm-Leach-Bliley Act, and other state and federal privacy laws, we must take measures to protect the privacy of your personal information your name, Social Security number, address, telephone number, account number, employment, medical history, health records, claims information, etc. The first step is validating who is calling. We are dedicated and committed to ensuring we provide you with excellent customer service and answering your questions accurately. To provide this service, Customer Service staff may need to ask for more information to assist them with their research. It helps if you have your ID card number and the following information available when you call. Claim questions Date of service Total submitted charges Provider s name Benefits Type of services Reason for your visit Provider s name, if known What is the difference between? Blue Cross originally was an insurance program for hospitalizations, while Blue Shield was an insurance program for doctors services. Today, the licensees contract with both doctors and hospitals. Is the FEHBP program a Medicare supplement plan? No, it is not. However, we do coordinate benefits with Medicare. How do you coordinate benefits when Medicare is primary? After Medicare pays its portion of the bill, we pay the Medicare copayments, coinsurance and deductibles for any covered services. For any services that Medicare denies as patient responsibility, we pay at 100% of our allowance for covered services What is the plan allowance? The plan allowance is a contracted amount that the plan will cover for a certain service. For more details on the plan allowance, please see the Service Benefit Plan. My Explanation of Benefits (EOB) for services from a preferred provider shows that I must pay a portion of the costs, even though it shows I don't owe any difference. How is this calculated? When you use a preferred provider, you are not responsible for the difference between the billed amount (the provider s charge) and the allowable charge (the amount our preferred providers accept for the service). Once this difference has been calculated, you are responsible for any deductible, coinsurance and copayments for the services, depending on your plan (Standard or Basic Option). Your EOB also shows you if there are any charges for non-covered services, which are also your responsibility to pay. Page 7 of 8

I already paid my calendar year deductible. Why aren't you showing it? Any amount that you pay to the provider at the time of services will not show in our system until the claim has been processed and pays. This includes your calendar year deductible, copayments and coinsurance. Page 8 of 8