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2025 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Table of Contents
Page 1

Table of Contents

Introduction - 4
Plain Language - 4
Stop Healthcare Fraud! - 4
Discrimination is Against the Law - 5
Preventing Medical Mistakes - 6
FEHB Facts - 9

Coverage information - 9

• No pre-existing condition limitation - 9
• Minimum essential coverage (MEC) - 9
• Minimum value standard - 9
• Where you can get information about enrolling in the FEHB Program - 9
• Enrollment types available for you and your family - 9
• Family member coverage - 10
• Children’s Equity Act - 10
• When benefits and premiums start - 11
• When you retire - 11

When you lose benefits - 12

• When FEHB coverage ends - 12
• Upon divorce - 12
• Temporary Continuation of Coverage (TCC) - 12
• Finding replacement coverage - 12
• Health Insurance Marketplace - 13

Section 1. How This Plan Works - 14

General features of FEP Blue Focus - 14
We have a Preferred Provider Organization (PPO) - 14
How we pay professional and facility providers - 14
Your rights and responsibilities - 15
Your medical and claims records are confidential - 15

Section 2. Changes for 2025 - 16
Section 3. How You Get Care - 17

Identification cards - 17
Where you get covered care - 17
Balance Billing Protection - 17

• Covered professional providers - 17
• Covered facility providers - 17

What you must do to get covered care - 19

• Transitional care - 19
• If you are hospitalized when your enrollment begins - 19

You need prior Plan approval for certain services - 20

• Inpatient hospital admission, inpatient residential treatment center admission - 20
• Other services - 20
• Special prior authorization situations related to coordination of benefits (COB) - 23
• Prior notification – Maternity care - 25

How to request precertification for an admission or get prior approval for Other services - 25

• Non-urgent care claims - 25
• Urgent care claims - 26
• Concurrent care claims - 26
• Emergency inpatient admission - 26

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