Ask your doctor about which hospital or clinic has the best care and results for your condition if you have more than one hospital or clinic to choose from to get the healthcare you need. PDF United States Department of the Interior - Indian Affairs State Law Authority for Premium Pay Program for Local Government Employees Tell the surgeon, anesthesiologist, and nurses about any allergies, bad reaction to anesthesia, and any medications or nutritional supplements you are taking. All offices hiring under this authority should adhere to the provisions of this pay plan. Medical Nutrition Therapy for medical conditions such as: Physical and occupational therapies are covered: Non-Plan Provider30% of eligible chargesand any difference between oureligible chargeand the actual charge. You may also visit our website at www.hmsa.com/federalplan. You may change your enrollment 31 days before to 60 days after that event. Box 32700Honolulu, Hawaii 96803-2700808-948-6499, For Prescription drug claimsCVS HealthP.O. Other plan benefits may also apply in addition to the emergency room benefit. Periodically review your claim history for accuracy to ensure we have not been billed for services you did not receive. Biden announces plans to give pay raises to federal employees in 2023 An assistance coordinator, working with a medical professional, can arrange a physician appointment or hospitalization, if necessary. If you are entitled to Medicare benefits, we will begin paying benefits after all Medicare benefits (including lifetime reserve days) are exhausted. List of changes: Section 13.6 - Exhibit 01 - Sets out the revised Pay Plan for Emergency Workers (Casuals) effective April 11, 2023. Contraceptive coverage is available at no cost to FEHB members. This helps ensure you do not receive double dosing from taking both a generic and a brand. Participants must obtain necessary specialty referrals if needed for symptom management. This amounts to an 84-day quantity since each package contains a 28-day quantity. You will owe the mail order copayment for a 90-day supply. The drug meets the medical necessity criteria and other criteria as established by HMSA. These programs and materials are the responsibility of the Plan, and all appeals must follow their guidelines. Healthcare FSA (HCFSA) Reimburses you for eligible out-of-pocket healthcare expenses (such as copayments, deductibles, physician prescribed over-the-counter drugs and medications, vision and dental expenses, and much more) for you, your tax dependents, and your adult children (through the end of the calendar year in which they turn 26). OPMs FEHB website. Suspended FEHB coverage to enroll in Medicaid or a similar state-sponsored program of medical assistance: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these state programs, eliminating your FEHB premium. Filing a Claim for Covered Services, Section 9. Coordinating Benefits with Medicare and Other Coverage, Section 10. For more information call (844) 847-8216. You must receive a written prescription from a recognized provider practicing within the scope of their license. Similarly, you cannot change to Self Plus One if the court/administrative order identifies more than one child. hospital, surgical center, etc.). This Plan's health coverage qualifies as minimum essential coverage and meets the minimum value standard for the benefits it provides. PDF Administratively Determined (Ad) Employees - Usuhs You can receive Plan dental benefits when you see a dental provider for covered services outside ofHawaii. Your primary care doctor will provide the necessary care, refer you to other Plan providers, or make arrangements with other providers. If you have questions or need more information, please call 808-948-6440 on Oahu or (1-800-792-4672) on the mainland or neighbor islands Monday through Friday, 8 a.m. to 5 p.m., or visit our website at www.hmsa.com/federalplan. To learn more about Medicare Advantage plans, contact Medicare at 800-MEDICARE (1-800-633-4227), (TTY: 877-486-2048) or at www.medicare.gov. You must: a) Write to us within 6 months from the date of our decision; and, b) Send your request to us at: Hawaii Medical Service Association, Attn: Member Advocacy and Appeals, P.O. The handbook will guide you through the items you should have in your emergency kit, including how to return home safely after a disaster, preparing your home and business for a disaster, making sure your flood insurance is adequate and up to date, how to stay informed, and how to recover after a disaster. Any claims that are not pre-service claims. Individual C gave birth on April 1, 2023, and wants to enroll herself and her child in Employer Z's plan. Important things you should keep in mind about these benefits: Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary. The programs offer services to help you and your physician manage your care and make informed health choices. Reimbursement means a carriers pursuit of a recovery if a covered individual has suffered an illness or injury and has received, in connection with that illness or injury, a payment from any party that may be liable, any applicable insurance policy, or a workers compensation program or insurance policy, and the terms of the carriers health benefits plan require the covered individual, as a result of such payment, to reimburse the carrier out of the payment to the extent of the benefits initially paid or provided. The eligible charge is the lower of either the providers actual charge or the amount we established as the, For participating facilities, we calculate our payment based on the. Note: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and you did not indicate that your claim was a claim for urgent care, then call our Medical Management Department at 808-948-6464 on Oahu or (1-800-344-6122) toll-free from the Neighbor Islands. Please contact our Medical Management Department at 808-948-6464 on Oahu, or (1-800-344-6122) toll free from the Neighbor Islands. At the discretion of your pharmacist, you may refill your prescriptions for maintenance drugs earlier if you need to synchronize such prescriptions to pick them up at the same time. Plan ProviderNothing(based on semiprivate room), Non-Plan Provider30% of eligible charges and any difference between our eligible charge and the actual charge(based on semiprivate room), Plan Provider30% of eligible charge (based on semiprivate room)(deductible applies), Non-Plan Provider40% of eligible charges and any difference between our eligible charge and the actual charge (based on semiprivate room) (deductible applies), Not covered: Custodial care, rest cures, domiciliary or convalescent care. The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim about them. Do not give your plan identification (ID) number over the phone or to people you do not know, except for your healthcare providers, authorized health benefits plan, or OPM representative. In such cases, the total charge is often more than the eligible charge. Fax: 1-866-816-9532 or 505-563-7996, Hours of Operation: 9:00 a.m. to 7:00 p.m. Tony Reardon, president of the National Treasury Employees Union, said the increase would go a long way toward helping recruit and retain the public servants our government needs. However, he said his union would continue to push Congress for the 5.1% average increase proposed by some Democrats. Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals, Section 5(c). Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected. Adding to this confusion, "National Emergency" appears to be defined as both the National Emergency Concerning the Novel Coronavirus Disease (COVID19) Outbreak and the separate determination, under section 501(b) of the Robert T. Stafford Disaster Relief and Emergency Assistance Act. This Plan's health coverage qualifies as minimum essential coverage and meets the minimum value standard for the benefits it provides. Completed in person @ Dispatch, Financial Info Security Request (FS-6500-214) - Completed in person @ Dispatch, Driver Application for Authorization (R6-7100-184), Defensive Driving Certificate (every 4 years) Casual to complete online course, State DMV Driving Record (annual requirement) (Oregon: How to & Link), Employment Eligibility Verification (I-9), Financial Info Security Request (FS-6500-214). To donate, visit redcross.org, call 1-800-RED . Failure to provide requested information or failure to assist us in pursuit of our subrogation or recovery rights may result in you being personally responsible for reimbursing us for benefits paid relating to the injury, illness or condition as well as for our reasonable attorney fees and costs incurred in obtaining reimbursement from you. Thank you for your interest! Two years earlier, employees had received an average 4.8% raise. Be sure to read Section 4, Your Costs for Covered Services, for valuable information about how cost-sharing works. When such an event occurs, neither you nor your FEHB plan will incur costs to correct the medical error. All Plan providers and some non-Plan providers are recognized. You should join an HMO because you prefer the plans benefits, not because a particular provider is available. For instance, you means the enrollee and each covered family member, we means HMSA Plan. A member who is a dependent minor is covered when accompanied by an adult member. When you need covered services outside the state of Hawaii, you are encouraged to contact the Blue Cross and/or Blue Shield Plan in the area where you need services for information regarding specific Plan providers in their area. If you need assistance, please contact your employing agency, Tribal Benefits Officer, personnel/payroll office, or retirement office. Medical foods and low-protein modified food products for the treatment of inborn errors of metabolism in accord with Hawaii Law and Plan guidelines. Before making a final decision, please read this FEHB brochure. On March 29, 2023, in anticipation of the ends of both the National Emergency and Public Health Emergency, the Department of Labor, Health and Human Services, and the Treasury (the "Agencies") released new Frequently Asked Questions ("FAQs") to address how certain deadlines and . Please note that we may disclose your medical and claims information (including your prescription drug utilization) to any of your treating physicians or dispensing pharmacies or to administer this Plan. Those defined previously in Section 5(f) as covered when prescribed and dispensed by a healthcare professional practicing within the scope of their license and filled by a network pharmacy. Alternative benefits will be made available for a limited time period and are subject to our ongoing review. The claim form is available from us, the service center or online at, You can receive Plan dental benefits when you see a dental provider for covered services outside of Hawaii. FEDVIP coverage pays secondary to that coverage. If you do not agree with OPMs decision, your only recourse is to sue. Contact your employing office for further information. If you receive covered healthcare services under a Value-Based Program inside a Host Blues service area, you will not be responsible for paying any of the Provider Incentives, risk-sharing, and/or Care Coordinator Fees that are a part of such an arrangement, except when a Host Blue passes these fees to us through average pricing or fee schedule adjustments. Over the past week, there have also been reports the Department of Labor ("DOL") informally commented that it may maintain July 10, 2023, as the end of the Outbreak Period. Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance, and deductible. By accepting benefits (whether the payment of such benefits is made to you or made on your behalf to any healthcare provider) from us, you acknowledge that our recovery rights are a first priority claim and are to be paid to us before any other claim for your damages. Symptoms may include but are not limited to skin rash, anaphylaxis, or immediate hypersensitivity reaction. Before you leave home, look at the current weather forecast and check for updates hourly. He cited recruitment and retention challenges for federal positions as part of the reason for the proposed increases. PDF United States Department of the Interior - National Interagency Fire Center For more information or to make an inquiry about situations in which you are entitled to immediately appeal to OPM, including additional requirements not listed in Sections 3, 7 and 8 of this brochure, please call your plan's customer service representative at the phone number found on your enrollment card, plan brochure, or plan website. Note: Prescribed over-the-counter and prescription drugs approved by the FDA to treat tobacco dependence are covered under the TobaccoCessation benefit. The eligible charge for most medical services, is the amount we use to determine our payment and your coinsurance for covered services. We cover prescribed drugs that are FDA approved, as described in the chart beginning on page 70. If you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate,in the lowest-cost nationwide plan option as determined by OPM. We will keep your medical and claims records confidential. The new pay plan, he added, would allow the federal government to better compete with the private sector. For subsequent refills, the Plan pharmacist may dispense a maximum 90-day supply or fraction thereof after confirming that: Routine care associated with clinical trials is covered in accord with criteria established by us. 1) Have FEHB coverage on your own as an active employee, 2) Have FEHB coverage on your own as an annuitant or through your spouse who is an annuitant, 3) Have FEHB through your spouse who is an active employee, 4) Are a reemployed annuitant with the Federal government and your position is excluded from the FEHB (your employing office will know if this is the case) and you are not covered under FEHB through your spouse under #3 above. You, and your legal representatives, shall fully cooperate with our efforts to recover our benefits paid. Every region of the United States has the threat of a natural or man-made hazard; therefore, the concept of preparedness should not be an afterthought. See Section 5(c) for inpatient hospital benefits. If you change options in this Plan during the year, we will credit the amount of covered expenses already applied toward the deductible of your old option to the deductible of your new option. Under the BlueCard Program, when you receive covered healthcare services within the geographic area served by a Host Blue, HMSA will remain responsible for doing what we agreed to in the contract. If you have questions or need more information about our dental plans, please call 808-948-5555 on Oahu or (1-800-620-4672) toll-free on the Neighbor Islands Monday through Friday, 8 a.m. to 5 p.m., or visit our website www.hmsa.com/federalplan. Research costs costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes. To help you prepare your appeal, you may arrange with us to review and copy, free of charge, all relevant materials and Plan documents under our control relating to your claim, including those that involve any expert review(s) of your claim. Please call us at 808-538-8900 for more information. When you receive care outside of our service area, you will receive it from one of two kinds of providers. Forest Service Refer to Other services in Section 3 for prior approval procedures. Hawaii's emergency siren warning system was silent during Maui - CNN Note: Air ambulance services to the continental US requires prior approval. Protect Yourself From Fraud Here are some things that you can do to prevent fraud: CALL- THE HEALTHCARE FRAUD HOTLINE 877-499-7295OR go to www.opm.gov/our-inspector-general/hotline-to-report-fraud-waste-or-abuse/complaint-form/. If your medical treatment is accepted by the Dept. If no professional standards of care exists or if they exist but are outdated or contradictory, then by expert opinion. Medical services provided by physicians:Other diagnosticand treatment services provided in the office, 30% of eligible charges for laboratory and pathology services; 30% of eligible charges for X-rays*, Services provided by a hospital: Inpatient, Services provided by a hospital: Outpatient, $20 copayment for physician visit; 30% of eligible charges for emergency room facility copay*; 30% of eligible charges for laboratory tests*; and 30% of eligible charges for other emergency services*, $20 copayment for professional services and medication management; 30% of eligible charges for diagnostictests, psychological testing, and laboratory tests*; 30% eligible charges for inpatient services*; and 30% of eligible charges for partial hospitalization and outpatient facility*, $7 copayment for Tier 1 (preferred generic drugs), 40% of eligible charges (up to $100) for Tier 2 (non-preferred generic and preferred brand drugs)*, 40% of eligible charges (up to $600) for Tier 3 (other brand drugs)*, $200 copayment for Tier 4 (preferred specialty drugs)*, 40% of eligible charges (up to $1,200) for Tier 5 (non-preferred specialty drugs)*, 30% of eligible charges for Accidental Injury Benefits only, 30% of eligible charges for an annual vision exam*. All benefits are subject to the definitions, limitations, and exclusions in this brochure. Your cell phone is usually equipped to receive emergency alerts, including WEA (Wireless Emergency Alerts). The Diabetes Prevention Program is a structured health behavior change intervention that provides practical training in long-term dietary change, increased physical activity, and problem-solving strategies for overcoming challenges to sustaining weight loss and a healthy lifestyle. Our reconsideration will not take into account the initial decision. Mini-transplants performed in a clinical trial setting(non-myeloablative, reduced intensity conditioning or RIC)for memberswith a diagnosis listed below are subject to medical necessity reviewby the Plan. If you are a participant in a clinical trial, this health plan will provide related care as follows, if it is not provided by the clinical trial: For more detailed information on What is Medicare? and Should I Enroll in Medicare? please contact Medicare at 1-800-MEDICARE (1-800-633-4227), (TTY 877-486-2048) or at www.medicare.gov. This is called double coverage. All claim types are eligible to be processed through Inter-Plan Arrangements, as described above, except for all Dental Care Benefits except when paid as medical claims/benefits, and those Prescription Drug Benefits or Vision Care Benefits that may be administered by a third party contracted by us to provide the specific service or services. for more information on the individual requirement for MEC. This section provides information to help those involved in the payroll process for Casuals, including Casual Pay Specialists. Note: If you need home healthcare services for more than 30 days, a physician must certify that there is further need for the services and provide a continuing plan of treatment at the end of each 30-day period of care.

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