AultCare Insurance Company

www.aultcare.com

Customer Service 1-800-344-8858 or 330-363-6360

2020

A Health Maintenance Organization (High Option) and a High

Deductible Health Plan

IMPORTANT

• Rates: Back Cover

• Changes for 2020: Page 17

• Summary of Benefits: Page 121

This plan's health coverage qualifies as minimum essential coverage

and meets the minimum value standard for the benefits it provides. See

pages 3 & 8 for details.

This plan is accredited. See page 13.

Serving:

Stark, Carroll, Holmes, Tuscarawas and Wayne counties and

the Canton Metropolitan area in Ohio

Enrollment in this plan is limited. You must live or work in our

geographic service area to enroll. See page 16 for requirements.

Enrollment codes for this Plan:

3A1 High Option– Self Only

3A3 High Option - Self Plus One

3A2 High Option – Self and Family

3A4 High Deductible Health Plan (HDHP) Option – Self Only

3A6 High Deductible Health Plan (HDHP) Option - Self Plus One

3A5 High Deductible Health Plan (HDHP) Option – Self and Family

RI 73-699

Important Notice from AultCare Health Plan About

Our Prescription Drug Coverage and Medicare

The Office of Personnel Management (OPM) has determined that the Aultcare Health Plan’s 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 is considered Creditable Coverage. This means you do not need to enroll in Medicare Part D and pay extra

for prescription drug coverage. If you decide to enroll in Medicare Part D later, you will not have to pay a penalty for late

enrollment as long as you keep your FEHB coverage.

However, if you choose to enroll in Medicare Part D, you can keep your FEHB coverage and your Aultcare Health plan will

coordinate 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 advised

If you lose or drop your FEHB coverage and go 63 days or longer without prescription drug coverage that’s at least as good

as Medicare’s prescription drug coverage, your monthly Medicare Part D premium will go up at least 1% per month for every

month that you did not have that coverage. For example, if you go 19 months without Medicare Part D prescription drug

coverage, your premium will always be at least 19 percent higher than what many other people pay. You will have to pay this

higher premium as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the next

Annual Coordinated Election Period (October 15 - December 7) to enroll in Medicare Part D.

Medicare’s Low Income Benefits

For 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 1-800-772-1213 (TTY 1-800-325-0778).

You can get more information about Medicare prescription drug plans and the coverage offered in your area from these

places:

•Visit www.medicare.gov for personalized help.

•Call 1-800-MEDICARE (1-800-633-4227), (TTY: 1-877-486-2048).

Table of Contents

Cover Page ....................................................................................................................................................................................1

Important Notice ...........................................................................................................................................................................1

Table of Contents ..........................................................................................................................................................................1

Introduction ...................................................................................................................................................................................3

Plain Language ..............................................................................................................................................................................3

Stop Health Care Fraud! ...............................................................................................................................................................3

Discrimination is Against the Law ................................................................................................................................................5

Preventing Medical Mistakes ........................................................................................................................................................6

FEHB Facts ...................................................................................................................................................................................8

Section 1. How this Plan Works ..................................................................................................................................................13

Section 2. Changes for 2020 .......................................................................................................................................................17

Section 3. How You Get Care .....................................................................................................................................................18

Section 4. Your Costs for Covered Services ...............................................................................................................................26

Section 5. Benefits ......................................................................................................................................................................29

Section 5(a). Medical Services and Supplies Provided by Physicians and Other Health Care Professionals ............................31

Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Health Care Professionals ........................41

Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services .......................................................48

Section 5(d). Emergency Services/Accidents .............................................................................................................................50

Section 5(e). Mental Health and Substance Use Disorder Benefits ............................................................................................52

Section 5(f). Prescription Drug Benefits .....................................................................................................................................54

Section 5(g). Dental Benefits ......................................................................................................................................................58

Section 5. High Deductible Health Plan Benefits .......................................................................................................................60

Section 5. High Deductible Health Plan Overview .....................................................................................................................62

Section 5. Savings – HSAs and HRAs ........................................................................................................................................65

If You Have an HSA ...................................................................................................................................................................69

If You Have an HRA ...................................................................................................................................................................70

Section 5. Preventive Care ..........................................................................................................................................................71

Section 5. Traditional Medical Coverage Subject to the Deductible ..........................................................................................74

Section 5(a). Medical Services and Supplies Provided by Physicians and Other Health Care Professionals ............................75

Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Health Care Professionals ........................83

Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services .......................................................90

Section 5(d). Emergency Services/Accidents .............................................................................................................................93

Section 5(e). Mental Health and Substance Use Disorder Benefits ............................................................................................95

Section 5(f). Prescription Drug Benefits .....................................................................................................................................97

Section 5(g). Dental Benefits ....................................................................................................................................................100

Section 5(h). Wellness and Other Special Features ...................................................................................................................101

Section 5(i). Health Education Resources and Account Management Tools ............................................................................102

Non-FEHB Benefits Available to Plan Members ......................................................................................................................104

Section 6. General Exclusions – Services, Drugs and Supplies We Do Not Cover ..................................................................105

Section 7. Filing a Claim for Covered Services ........................................................................................................................106

Section 8. The Disputed Claims Process ...................................................................................................................................109

Section 9. Coordinating Benefits with Medicare and Other Coverage .....................................................................................112

Section 10. Definitions of Terms We Use in this Brochure ......................................................................................................118

Index ..........................................................................................................................................................................................120

Summary of Benefits for the HMO AultCare Health Plan- 2020 .............................................................................................121

Summary of Benefits for the HDHP AultCare Health Plan-2020 .............................................................................................123

1 2020 AultCare Insurance Company Table of Contents

2020 Rate Information for AultCare Health Plan .....................................................................................................................126

2 2020 AultCare Insurance Company Table of Contents

Introduction

This brochure describes the benefits of AultCare Insurance Company under our contract (CS 2723) with the United States

Office of Personnel Management, as authorized by the Federal Employees Health Benefits law. Customer service may be

reached at (800) 344-8858 or through our website: www.aultcare.com. The address for AultCare Insurance Company

administrative office is:

AultCare Insurance Company

2600 Sixth Street SW

Canton, Oh 44710

This brochure is the official statement of benefits. No verbal statement can modify or otherwise affect the benefits,

limitations, and exclusions of this brochure. It is your responsibility to be informed about your health benefits.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self Plus One

or 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, 2020, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2020, and changes are

summarized on page 17. Rates are shown at the end of this brochure.

Plain Language

All FEHB brochures are written in plain language to make them easy to understand. Here are some examples,

•Except for necessary technical terms, we use common words. For instance, “you” means the enrollee or family member,

“we” means AultCare Health 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.

•Our brochure and other FEHB plans’ brochures have the same format and similar descriptions to help you compare plans.

Stop Health Care Fraud!

Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits 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 that you can do to prevent fraud:

•Do not give 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.

•Periodically review your claim history for accuracy to ensure we have not been billed for services you did not receive.

•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.

3 2020 AultCare Insurance Company Introduction/Plain Language/Advisory

- If the provider does not resolve the matter, call us at 1-800-344-8858 and explain the situation.

- If we do not resolve the issue:

CALL - THE HEALTH CARE FRAUD HOTLINE

1-877-499-7295

OR go to www.opm.gov/oig www.opm.gov/our-inspector-general/hotline-to-report-fraud-waste-or-abuse/

complaint-form/

The online reporting form is the desired method of reporting fraud in order to ensure accuracy, and a quicker

response time.

You can also write to:

United States Office of Personnel Management

Office of the Inspector General Fraud Hotline

1900 E Street NW Room 6400

Washington, DC20415-1100

•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);

- Your child age 26 or over (unless he/she was disabled and incapable of self-support prior to age 26).

A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the

enrollee’s FEHB

enrollment.

•If you have any questions about the 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 (TCC).

•Fraud or intentional misrepresentation of material fact is prohibited under the Plan. You can be prosecuted for fraud and

your agency may take action against you. Examples of fraud include, falsifying a claim to obtain FEHB benefits, trying to

or obtaining service or coverage for yourself or for someone else who is not eligible for coverage, or enrolling in the Plan

when you are no longer eligible.

•If your enrollment continues after you are no longer eligible for coverage(i.e. you have separated from Federal service)

and premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not

paid. You may be billed for services received. You may be prosecuted for fraud for knowingly using health insurance

benefits for which you have not paid premiums. It is your responsibility to know when you or a family member is no

longer eligble to use your health insurance coverage.

4 2020 AultCare Insurance Company Introduction/Plain Language/Advisory

Discrimination is Against the Law

AultCare complies with all applicable Federal civil rights laws, to include both Title VII of the Civil Rights Act of 1964 and

Section 1557 of the Affordable Care Act. Pursuant to Section 1557, AultCare does not discriminate, exclude people, or treat

them differently on the basis of race, color, national origin, age, disability, or sex.

If a carrier is a covered entity, its members may file a 1557 complaint with HHS Office of Civil Rights, OPM, or FEHB

Program carriers. For purposes of filing a complaint with OPM, covered carriers should use the following:

You can also file a civil rights complaint with the Office of Personnel Management by mail at:

Office of Personnel Management

Healthcare and Insurance

Federal Employee Insurance Operations

Attention: Assistant Director, FEIO

1900 E Street NW, Suite 3400-S

Washington, D.C. 20415-3610

5 2020 AultCare Insurance Company

Preventing Medical Mistakes

Medical mistakes continue to be a significant cause of preventable deaths within the United States. 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. Medical mistakes and their consequences also add significantly to the overall cost

of healthcare. Hospitals and healthcare providers are being held accountable for the quality of care and reduction in medical

mistakes by their accrediting bodies. You can also improve the quality and safety of your own health care and that of your

family members by learning more about and understanding your risks. 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 feel comfortable talking.

•Take a relative or friend with you to help you take notes, ask questions, and understand answers.

2. Keep and bring a list of all the medications you take.

•Bring the actual medication or give your doctor and pharmacist a list of all the medications and dosage that you take,

including non-prescription (over-the-counter) medications and nutritional supplements.

•Tell your doctor and pharmacist about any drug, food, and other allergies you have, such as to latex.

•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.

•Make sure your medication is what the doctor ordered. Ask the pharmacist about your medicine if it looks different than

you expected.

•Read the label and patient package insert when you get your medication, including all warnings and instructions.

•Know how to use your medication. Especially note the times and conditions when your medication should and should not

be taken.

•Contact your doctor or pharmacist if you have questions.

•Understand both the generic and brand names of your medication. This helps ensure you do not receive double dosing

from taking both a generic and a brand. It also helps prevent you from taking a medication to which you are allergic.

3. Get the results of any test or procedure.

•Ask when and how you will get the results of tests or procedures. Will it be in person, by phone, mail, or through the Plan

or Provider’s portal?

•Don’t assume the results are fine if you do not get them when expected, be it in person, by phone, or by mail. Contact your

healthcare provider 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 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 health care you need.

•Be sure you understand the instructions you get about follow-up care when you leave the hospital or clinic.

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?”

6 2020 AultCare Insurance Company Introduction/Plain Language/Advisory

•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 reactions to anesthesia, and any medications or

nutritional supplements you are taking.

Patient Safety Links

For more information on patient safety, please visit:

•www.jointcommission.org/speakup.aspx. - The Joint Commission’s Speak Up™ patient safety program.

•www.jointcommission.org/topics/patient_safety.aspx- The Joint Commission helps health care organizations to improve

the quality and safety of the care they deliver.

•http://www.ahrq.gov/patients-consumers/ - 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 you receive.

•www.npsf.org. The National Patient Safety Foundation has information on how to ensure safer health care for you and

your family.

•www.bemedwise.org. The National Council on Patient Information and Education is dedicated to improving

communication about the 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.

Preventable Healthcare Acquired Conditions (“Never Events”)

When you enter the hospital for treatment of one medical problem, you do not expect to leave with additional injuries,

infections, or other serious conditions that occur during the course of your stay. Although some of these complications may

not be avoidable, patients do suffer from injuries or illnesses that could have been prevented if doctors or the hospital had

taken proper precautions. Errors in medical care that are clearly identifiable, preventable and serious in their consequences

for patients, can indicate a significant problem in the safety and credibility of a health care facility. These conditions and

errors are sometimes called “Never Events” or “Serious Reportable Events.”

We have a benefit payment policy that encourages hospitals to reduce the likelihood of hospital-acquired conditions such as

certain infections, severe bedsores, and fractures, and to reduce medical errors that should never happen. When such an

event occurs, neither you nor your FEHB plan will incur costs to correct the medical error.

7 2020 AultCare Insurance Company Introduction/Plain Language/Advisory

FEHB Facts

We will not refuse to cover the treatment of a condition you had before you enrolled in

this Plan solely because you had the condition before you enrolled.

No pre-existing condition

limitation

Please visit the Internal Revenue Service (IRS) website at www.irs.gov/uac/Questions-

and-Answers-on-the-Individual-Shared-Responsibility-Provision for more information on

the individual requirement for MEC.

Minimum essential

coverage (MEC)

Our health coverage meets the minimum value standard of 60% established by the ACA.

This means that we provide benefits to cover at least 60% of the total allowed costs of

essential health benefits. The 60% standard is an actuarial value; your specific out-of-

pocket costs are determined as explained in this brochure.

Minimum value standard

See www.opm.gov/healthcare-insurance for enrollment information as well as:

• Information on the FEHB Program and plans available to you

• A health plan comparison tool

• A list of agencies that participate in Employee Express

• A link to Employee Express

• Information on and links to other electronic enrollment systems

Also, your employing or retirement office can answer your questions, and give

you brochures for other plans and other materials you need to make an informed decision

about your FEHB coverage. These materials tell you:

• When you may change your enrollment;

• How you can cover your family members;

• What happens when you transfer to another Federal agency, go on leave without pay,

enter military service, or retire;

• What happens when your enrollment ends;

• When the next Open Season for enrollment begins.

We don’t determine who is eligible for coverage and, in most cases, cannot change your

enrollment status without information from your employing or retirement office. For

information on your premium deductions, you must also contact your employing or

retirement office.

Where you can get

information about

enrolling in the FEHB

Program

Self Only coverage is for you alone. Self Plus One coverage is an enrollment that covers

you and one eligible family member. Self and Family coverage is for you and one eligible

family member, or your spouse, and your dependent children under age 26, including any

foster children authorized for coverage by your employing agency or retirement office.

Under certain circumstances, you may also continue coverage for a disabled child 26

years of age or older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self Plus One or Self and Family

enrollment if you marry, give birth, or add a child to your family. You may change your

enrollment 31 days before to 60 days after that event. The Self Plus One or Self and

Family enrollment begins on the first day of the pay period in which the child is born or

becomes an eligible family member. When you change to Self Plus One or Self and

Family because you marry, the change is effective on the first day of the pay period that

begins after your employing office receives your enrollment form. Benefits will not be

available to your spouse until you are married. A carrier may request that an enrollee

verify the eligibility of any or all family members listed as covered under the enrollee’s

FEHB enrollment.

Types of coverage

available for you and

your family

8 2020 AultCare Insurance Company FEHB Facts

Your employing or retirement office will not notify you when a family member is no

longer eligible to receive benefits, nor will we. Please tell us immediately of changes in

family member status, including your marriage, divorce, annulment, or when your child

reaches age 26.

If you or one of your family members are enrolled in one FEHB plan, you or they

cannot be enrolled in or covered as a family member by another enrollee in another

FEHB plan.

If you have a qualifying life event (QLE) - such as marriage, divorce, or the birth of a

child - outside of the Federal Benefits Open Season, you may be eligible to enroll in the

FEHB Program, change your enrollment, or cancel coverage. For a complete list of

QLE's, visit the FEHB website at www.opm.gov/healthcare-insurance/life-events. If you

need assistance, please contact your employing agency, Tribal Benefits Officer, personnel/

payroll office, or retirement office.

Family members covered under your Self and Family enrollment are your spouse

(including a valid common law marriage) and children as described in the chart below. A

Self Plus One enrollment covers you and your spouse, or one other eligible family

member as described in the chart below.

ChildrenCoverage

Natural children, adopted children, and

stepchildren

Natural, adopted children and stepchildren

are covered until their 26

birthday.

Foster children Foster children are eligible for coverage

until their 26

birthday if you provide

documentation of your regular and

substantial support of the child and sign a

certification stating that your foster child

meets all the requirements. Contact your

human resources office or retirement system

for additional information.

Children incapable of self-support Children who are incapable of self-support

because of a mental or physical disability

that began before age 26 are eligible to

continue coverage. Contact your human

resources office or retirement system for

additional information.

Married children Married children (but NOT their spouse or

their own children) are covered until their

26th birthday.

Children with or eligible for employer-

provided health insurance

Children who are eligible for or have their

own employer-provided health insurance are

covered until their 26th birthday.

Newborns of covered children are insured only for routine nursery care during the

covered portion of the mother’s maternity stay.

You can find additional information at www.opm.gov/healthcare-insurance.

Family member coverage

OPM has implemented the Federal Employees Health Benefits Children’s Equity Act of

2000. This law mandates that you be enrolled for Self Plus One or Self and Family

coverage in the FEHB Program, if you are an employee subject to a court or

administrative order requiring you to provide health benefits for your child(ren).

Children’s Equity Act

9 2020 AultCare Insurance Company FEHB Facts

If this law applies to you, you must enroll in Self Plus One or Self and Family coverage in

a health plan that provides full benefits in the area where your children live or provide

documentation to your employing office that you have obtained other health benefits

coverage for your children. If you do not do so, your employing office will enroll you

involuntarily as follows:

• If you have no FEHB coverage, your employing office will enroll you for Self Plus

One or Self and Family coverage, as appropriate, in the lowest-cost nationwide plan

option as determined by OPM.

• If you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves

the area where your children live, your employing office will change your enrollment

to Self Plus One or Self and Family, as appropriate, in the same option of the same

plan; or

• 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.

As long as the court/administrative order is in effect, and you have at least one child

identified in the order who is still eligible under the FEHB Program, you cannot cancel

your enrollment, change to Self Only, or change to a plan that does not serve the area in

which your children live, unless you provide documentation that you have other coverage

for the children. If the court/administrative order is still in effect when you retire, and you

have at least one child still eligible for FEHB coverage, you must continue your FEHB

coverage into retirement (if eligible) and cannot cancel your coverage, change to Self

Only, or change to a plan that does not serve the area in which your children live as long

as the court/administrative order is in effect. Similarly, you cannot change to Self Plus

One if the court/administrative order identifies more than one child. Contact your

employing office for further information.

The benefits in this brochure are effective January 1. If you joined this Plan during Open

Season, your coverage begins on the first day of your first pay period that starts on or after

January 1. If you changed plans or plan options during Open Season and you receive

care between January 1 and the effective date of coverage under your new plan or

option, your claims will be paid according to the 2020 benefits of your old plan or

option. However, if your old plan left the FEHB Program at the end of the year, you are

covered under that plan’s 2019 benefits until the effective date of your coverage with your

new plan. Annuitants’ coverage and premiums begin on January 1. If you joined at any

other time during the year, your employing office will tell you the effective date of

coverage.

If your enrollment continues after you are no longer eligible for coverage, (i.e., you have

separated from Federal service) and premiums are not paid, you will be responsible for all

benefits paid during the period in which premiums were not paid. You may be billed for

services received directly from your provider. You may be prosecuted for fraud for

knowingly using health insurance benefits for which you have not paid premiums. It is

your responsibility to know when you or a family member are no longer eligible to use

your health insurance coverage.

When benefits and

premiums start

When you retire, you can usually stay in the FEHB Program. Generally, you must have

been enrolled in the FEHB Program for the last five years of your Federal service. If you

do not meet this requirement, you may be eligible for other forms of coverage, such as

Temporary Continuation of Coverage (TCC).

When you retire

AultCare Insurance Company currently holds NCQA Accreditation. Our current status is

Accredited.

Accreditations

10 2020 AultCare Insurance Company FEHB Facts

When you lose benefits

You will receive an additional 31 days of coverage, for no additional premium, when:

• Your enrollment ends, unless you cancel your enrollment, or

• You are a family member no longer eligible for coverage.

Any person covered under the 31 day extension of coverage who is confined in a hospital

or other institution for care or treatment on the 31

day of the temporary extension is

entitled to continuation of the benefits of the Plan during the continuance of the

confinement but not beyond the 60

day after the end of the 31 day temporary extension.

You may be eligible for spouse equity coverage or Temporary Continuation of Coverage

(TCC).

When FEHB coverage

ends

If you are divorced from a Federal employee, or annuitant, you may not continue to get

benefits under your former spouse’s enrollment. This is the case even when the court has

ordered your former spouse to provide health coverage for you. However, you may be

eligible for your own FEHB coverage under either the spouse equity law or Temporary

Continuation of Coverage (TCC). If you are recently divorced or are anticipating a

divorce, contact your ex-spouse’s employing or retirement office to get information about

your coverage choices. You can also visit OPM's website at www.opm.gov/healthcare-

insurance/healthcare/plan-information/guides. A carrier may request that an enrollee verify

the eligibility of any or all family members listed as covered under the enrollee’s FEHB

enrollment.

Upon divorce

If you leave Federal service, Tribal employment, or if you lose coverage because you no

longer qualify as a family member, you may be eligible for Temporary Continuation of

Coverage (TCC). The Patient Protection and Affordable Care Act (ACA) did not eliminate

TCC or change the TCC rules. For example, you can receive TCC if you are not able to

continue your FEHB enrollment you turn 26, etc.

You may not elect TCC if you are fired from your Federal or Tribal job due to gross

misconduct. Enrolling in TCC. Get the RI 79-27, which describes TCC, from your

employing or retirement office or from www.opm.gov/healthcare-insurance . It explains

what you have to do to enroll. Alternatively, you can buy coverage through the Health

Insurance Marketplace where, depending on your income, you could be eligible for a new

kind of tax credit that lowers your monthly premiums. Visit www.HealthCare.gov to

compare plans and see what your premium, deductible, and out-of-pocket costs would be

before you make a decision to enroll. Finally, if you qualify for coverage under another

group health plan (such as your spouse’s plan), you may be able to enroll in that plan, as

long as you apply within 30 days of losing FEHB Program coverage.

Temporary Continuation

of Coverage (TCC)

You may convert to a non-FEHB individual policy if:

• Your coverage under TCC or the spouse equity law ends (If you canceled your coverage

or did not pay your premium, you cannot convert);

• You decided not to receive coverage under TCC or the spouse equity law; or

• You are not eligible for coverage under TCC or the spouse equity law.

If you leave Federal or Tribal service, your employing office will notify you of your right

to convert. You must contact us in writing within 31 days after you receive this notice.

However, if you are a family member who is losing coverage, the employing or retirement

office will not notify you. You must contact us in writing within 31 days after you are no

longer eligible for coverage.

Converting to Individual

Coverage

11 2020 AultCare Insurance Company FEHB Facts

Your benefits and rates will differ from those under the FEHB Program; however, you will

not have to answer questions about your health, a waiting period will not be imposed and

your coverage will not be limited due to pre-existing conditions. When you contact us, we

will assist you in obtaining information about health benefits coverage inside or outside

the Affordable Care Act’s Health Insurance Marketplace in your state. For assistance in

finding coverage, please contact us at 800-344-8858 or visit our website at www.aultcare.

com.

This plan no longer offers its own non-FEHB plan for conversion purposes. If you would

like to purchase health insurance through the Affordable Care Act's Health Insurance

Marketplace, please visit www.HealthCare.gov. This is a website provided by the U.S.

Department of Health and Human Services that provides up-to-date information on the

Marketplace.

In lieu of offering a non-FEHB plan for conversion purposes, we will assist you, as we

would assist you in obtaining a plan conversion policy, in obtaining health benefits

coverage inside or outside the Affordable Care Act's Health Insurance Marketplace. For

assistance in finding coverage, please contact us at 330-363-6360 or 1-800-344-8858 or

visit our website at www.aultcare.com.

Finding replacement

coverage

If you would like to purchase health insurance through the ACA's Health Insurance

Marketplace, please visit www.HealthCare.gov. This is a website provided by the U.S.

Department of Health and Human Services that provides up-to-date information on the

Marketplace.

Health Insurance

Marketplace

12 2020 AultCare Insurance Company FEHB Facts

Section 1. How this Plan Works

This Plan is a health maintenance organization (HMO) with a high deductible health plan (HDHP) option. The HMO will

require you to see specific physicians, hospitals, and other providers that contract with us. These plan providers coordinate

your health care services. We are solely responsible for the selection of these providers in your area. Contact us for a copy of

our most recent provider directory.

OPM requires that FEHB plans be accredited to validate that plan operations and/or care management meet nationally

recognized standards. AultCare holds the following accreditations: NCQA Accredited. To learn more about this plan’s

accreditation(s), please visit the following websites:

•Accreditation Association for Ambulatory Health Care (aaahc.org);

•National Committee for Quality Assurance (ncqa.org);

•URAC (URAC.org).

General features of our HMO (High Option)

HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in

addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any

course of treatment.

When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You pay only the

copayments described in this brochure. When you receive emergency services from Non-Participating providers, you may

have to submit claim forms.

Preventive care services

Preventive care services are generally covered with no cost-sharing and are not subject to copayments, deductibles, or annual

limits when received from a network provider.

Annual deductible

There is no Annual deductible for the High Option plan.

We have network providers

Our AultCare Health Care Plan offers services through a network. When you use our network providers, you will receive

covered services at reduced cost. AultCare is solely responsible for the selection of network providers in your area. Contact

us for the names of network providers and to verify their continued participation. You can also go to our Web page, which

you can reach through the FEHB website, www.opm.gov/healthcare-insurance. Contact AultCare to request a network

provider directory.

In-network benefits apply only when you use a network provider. Provider networks may be more extensive in some areas

than others. We cannot guarantee the availability of every specialty in all areas.

How we pay providers

HMO Providers: We contract with individual physicians, medical groups, and hospitals to provide the benefits in this

brochure. These Plan providers accept a negotiated payment from us, and you will only be responsible for your cost-sharing

(copayments, deductibles, coinsurance and non-covered services and supplies).

AultCare HMO is an IPA model HMO, whereby the HMO has individual agreements with select physicians who have agreed

to provide care for AultCare HMO enrollees. Each family member must select a primary care doctor who coordinates care

for the HMO enrollee. There are approximately 938 primary care physicians from which to choose and nearly 3,136

specialists in our network.

13 2020 AultCare Insurance Company Section 1

The first and most important decision each member must make is the selection of a primary care doctor. The decision is

important since it is through this doctor that all other health services, particularly those of specialists, are obtained. It is the

responsibility of your primary care doctor to obtain any necessary authorizations from this Plan before referring you to a

specialist or making arrangements for hospitalization. Services of other providers are covered only when their has been a

referral by the member’s primary care doctor with the following exception(s): a woman may see her Plan gynecologist for

her annual routine examination without a referral.

You should join an HMO because you prefer the plan’s benefits, not because a particular provider is available. You

cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician, hospital, or

other provider will be available and/or remain under contract with us.

General features of our High Deductible Health Plan (HDHP)

HDHPs have higher annual deductibles and annual out-of-pocket maximum limits than other types of FEHB plans. FEHB

Program HDHPs also offer health savings accounts or health reimbursement arrangements. Please see below for more

information about these savings features.

You can read additional information from the U.S. Department of Health and Human Services at www.healthcare.gov.

Preventive care services

Preventive care services are generally covered with no cost-sharing and are not subject to copayments, deductibles, or annual

limits when received from a network provider.

Annual deductible

The annual deductible of $2,000 for Self Only and $4,000 for Self Plus One or Self and Family for the High Deductible

Health Plan (HDHP) must be met before Plan benefits are paid for care other than preventive care services.

Health Savings Account (HSA)

You are eligible for a Health Savings Account (HSA) if you are enrolled in an HDHP, not covered by any other health plan

that is not an HDHP (including a spouse’s health plan, but does not include specific injury insurance and accident, disability,

dental care, vision care, or long-term care coverage), not enrolled in Medicare, not received VA (except for veterans with a

service-connected disability) or Indian Health Service (HIS) benefits within the last three months, not covered by your own

or your spouse's flexible spending account (FSA), and are not claimed as a dependent on someone else’s tax return.

•You may use the money in your HSA to pay all or a portion of the annual deductible, copayments, coinsurance, or other

out-of-pocket costs that meet the IRS definition of a qualified medical expense.

•Distributions from your HSA are tax-free for qualified medical expenses for you, your spouse, and your dependents, even

if they are not covered by a HDHP.

•You may withdraw money from your HSA for items other than qualified medical expenses, but it will be subject to income

tax and, if you are under 65 years old, an additional 20% penalty tax on the amount withdrawn.

•For each month that you are enrolled in an HDHP and eligible for an HSA, the HDHP will pass through (contribute) a

portion of the health plan premium to your HSA. In addition, you (the account holder) may contribute your own money to

your HSA up to an allowable amount determined by IRS rules. Your HSA dollars earn tax-free interest.

•You may allow the contributions in your HSA to grow over time, like a savings account. The HSA is portable – you may

take the HSA with you if you leave the Federal government or switch to another plan.

Health Reimbursement Arrangement (HRA)

If you are not eligible for an HSA, or become ineligible to continue an HSA, you are eligible for a Health Reimbursement

Arrangement (HRA). Although an HRA is similar to an HSA, there are major differences.

•An HRA does not earn interest.

•An HRA is not portable if you leave the Federal government or switch to another plan.

Catastrophic protection (HDHP)

14 2020 AultCare Insurance Company Section 1

We protect you against catastrophic out-of-pocket expenses for covered services. The IRS limits annual out-of-pocket

expenses for covered services, including deductibles and copayments, to no more than $6,900 for Self Only enrollment and

$13,800 for a Self Plus One or Self and Family. When you use network providers, your specific annual out-of-pocket plan

limits, including coinsurance and copayments, cannot exceed $4,000 for Self Only enrollment, or $8,000 for Self Plus One or

Self and Family enrollment. The out-of-pocket limit for this Plan may differ from the IRS limit, but cannot exceed that

amount.

We have network providers

Our AultCare Health Care Plan offers services through a network. When you use our network providers, you will receive

covered services at reduced cost. AultCare is solely responsible for the selection of network providers in your area. Contact

us for the names of network providers and to verify their continued participation. You can also go to our Web page, which

you can reach through the FEHB website, www.opm.gov/healthcare-insurance. Contact AultCare to request a network

provider directory.

In-network benefits apply only when you use a network provider. Provider networks may be more extensive in some areas

than others. We cannot guarantee the availability of every specialty in all areas.

How we pay providers

HMO Providers: We contract with individual physicians, medical groups, and hospitals to provide the benefits in this

brochure. These Plan providers accept a negotiated payment from us, and you will only be responsible for your copayments.

AultCare HMO is an IPA model HMO, whereby the HMO has individual agreements with select physicians who have agreed

to provide care for AultCare HMO enrollees. Each family member must select a primary care doctor who coordinates care

for the HMO enrollee. There are approximately 938 primary care physicians from which to choose and nearly 3,136

specialists in our network.

The first and most important decision each member must make is the selection of a primary care doctor. The decision is

important since it is through this doctor that all other health services, particularly those of specialists, are obtained. It is the

responsibility of your primary care doctor to obtain any necessary authorizations from this Plan before referring you to a

specialist or making arrangements for hospitalization. Services of other providers are covered only when their has been a

referral by the member’s primary care doctor with the following exception(s): a woman may see her Plan gynecologist for

her annual routine examination without a referral.

PPO Providers: Allowable benefits are based upon charges and discounts which we or our PPO administrators have

negotiated with participating providers. PPO provider charges are always within our plan allowance.

Non-PPO providers: We determine our allowance for covered charges by using health care charge data prepared by the

Health Insurance Association of America (HIAA) or other credible sources, including our own data, when necessary.

Health education resources and accounts management tools

Your rights and responsibilities

OPM requires that all FEHB plans provide certain information to their FEHB members. You may get information about us,

our networks, and our providers. OPM’s FEHB Website (www.opm.gov/insure) lists the specific types of information that we

must make available to you. Some of the required information is listed below.

•AultCare has been in existence since 1985

•AultCare is a for-profit organization

You are also entitled to a wide range of consumer protections and have specific responsibilities as a member of this Plan. You

can view the complete list of these rights and responsibilities by visiting our website, www.aultcare.com/. You can also

If you want more information about us, call 1-800-344-8858 or visit our website at www.aultcare.com.

By law, you have the right to access your protected health information (PHI). For more information regarding access to PHI,

visit our website www.aultcare.com to obtain our Notice of Privacy Practices. You can also contact us to request that we mail

you a copy of that Notice.

15 2020 AultCare Insurance Company Section 1

Your medical and claims records are confidential

We will keep your medical and claims records confidential. 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.

Service Area

To enroll in this Plan, you must live or work in our service areas. This is where our network providers practice. Our Service

Areas are:

• Stark

• Carroll

• Holmes

• Tuscarawas

• Wayne Counties in Ohio

• Canton metropolitan area in Ohio

Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we will

pay only for emergency care benefits. We will not pay for any other health care services out of our service area unless the

services have prior plan approval.

If you or a covered family member move outside of our service area, you can enroll in another plan. If a dependent lives out

of the area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service plan

or another plan that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait

until Open Season to change plans. Contact your employing or retirement office.

16 2020 AultCare Insurance Company Section 1

Section 2. Changes for 2020

Do not rely only on these change descriptions; this Section is not an official statement of benefits. For that, go to Section 5

Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a

clarification that does not change benefits.

Changes to High Option (HMO) and High Deductible Health Plan (HDHP)

Telehealth Serviceshave been added as follows: (see pages 39, 53, 82 and 96)

High Option HMO plan would be a $15 copayment for

•Medical

•Behavioral Health

HDHP would be 20% of plan allowance in-network after deductible for

•Medical

•Behavioral Health

Prior Authorization - see page 20

•Prior authorization will now include total joint replacements (Elbow, Shoulder, Wrist, Hip, Knee, and Ankle), artificial disc

replacement of the lumber and cervical spine, scoliosis surgeries, and unicondylar knee replacements.

Prescription Drugs -see pages 54 and 97

•Addition of FreeStyle Libre to benefit for Continuous Blood Glucose Sensors and Readers: addition to covered items

under pharmacy benefit under Diabetic Supplies.

The sensors and readers would be: Retail- 2

tier $20.00 or 30% whichever is greater up to $350.00 max . Mail-2

tier

$55.00 or 25% whichever is greater up to $350.00 max

•Addition of Hepatitis B vaccination Heplisav B - covered at $0.00 cost share under medical benefit.

•Generic Market Alignment Program: This program helps to provide appropriate member movement to newer generic

medications. Any potential new generic approvals for coming year are identified in advance of program submission. No

action will be taken until the generic products are approved by the FDA and are available in the marketplace. A minimum

of 3 generic manufacturers is required for the next steps to be taken. Once there are 3 generic manufacturers available, a

timeline is established for member notification and eventual removal of the brand name product from the formulary

quarterly. Timeline would provide 60 days of notification to member that they will need to switch to the generic equivalent

if they have not already done so. Written correspondence would be included. An exception process is available for member

and prescriber to demonstrate medical necessity for continuation of brand name therapy.

17 2020 AultCare Insurance Company Section 2

Section 3. How You Get Care

We will send you an identification (ID) card when you enroll. You should carry your ID

card with you at all times. You must show it whenever you receive services from a Plan

provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use

your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment

confirmation letter (for annuitants), or your electronic enrollment system (such as

Employee Express) confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your

enrollment, or if you need replacement cards, call us at 1-800-344-8858 or write to us at

2600 Sixth Street SW, Canton, OH 44710. You may also request replacement cards

through our website: www.aultcare.com

Identification cards

HMO (High Option): You get care from “Plan providers” and “Plan facilities.” You will

only pay copayments, and you will not have to file claims.

HDHP Option: You will only pay deductibles and coinsurance and you will not have to

file claims.

You get care from "Plan providers" and "Plan facilities." You can also get care from non-

Plan providers but it will cost you more. If you use our Open Access program you can

receive covered services from a participating provider without a required referral from

your primary care physican or by another participating provider in the network.

Where you get covered

care

Plan providers are physicians and other health care professionals in our service area that

we contract with to provide covered services to our members. We credential Plan

providers according to national standards.

We list Plan providers in the provider directory, which we update periodically. The list is

also on our Website.

• Plan providers

Plan facilities are hospitals and other facilities in our service area that we contract with to

provide covered services to our members. We list these in the provider directory, which

we update periodically. The list is also on our Website.

• Plan facilities

Better Plan benefits are available when you use AultCare Providers. In order to receive

maximum Plan benefits, you must use the services of Aultman Hospital and the

Physicians within the AultCare network. If, on the other hand, you use a Non-AultCare

Provider, lesser benefit amounts may be payable. Should you be referred by an AultCare

Provider to a Non-AultCare Provider, and the referral is approved by AultCare, benefits

are payable as if provided by an AultCare Provider up to the Usual, Customary and

Reasonable (UCR) fee. If the referral is not approved by AultCare, you will be subject to a

reduction in benefits.

• Out-of-network

providers and

facilities

HMO (High Option): It depends on the type of care you need. First, you and each family

member must choose a primary care physician. This decision is important since your

primary care physician provides or arranges for most of your health care.

HDHP Option: You can get care from any “covered provider” or “covered facility.” How

much we pay – and you pay – depends on the type of covered provider or facility you use.

If you use our preferred providers, you will pay less.

What you must do to get

covered care

HMO (High Option) only: Your primary care physician can be a family practitioner,

internist, and pediatrician.Your primary care physician will provide most of your health

care, or give you a referral to see a specialist.

If you want to change primary care physicians or if your primary care physician leaves the

Plan, call us. We will help you select a new one.

• Primary care

18 2020 AultCare Insurance Company Section 3

HMO (High Option): Your primary care physician will refer you to a specialist for

needed care. When you receive a referral from your primary care physician, you must

return to the primary care physician after the consultation, unless your primary care

physician authorized a certain number of visits without additional referrals. The primary

care physician must provide or authorize all follow-up care. Do not go to the specialist for

return visits unless your primary care physician gives you a referral. However, you may

see

obstetrician/gynecologist without a referral.

Here are some other things you should know about specialty care:

• If you need to see a specialist frequently because of a chronic, complex, or serious

medical condition, your primary care physician will develop a treatment plan that allows

you to see your specialist for a certain number of visits without additional referrals.

Your primary care physician will use our criteria when creating your treatment plan. The

physician may have to get an authorization or approval beforehand. If you are seeing a

specialist when you enroll in our Plan, talk to your primary care physician. If he or she

decides to refer you to a specialist, ask if you can see your current specialist.

If your current specialist does not participate with us, you must receive treatment from a

specialist who does. Generally, we will not pay for you to see a specialist who does not

participate with our Plan.

• If you are seeing a specialist and your specialist leaves the Plan, call your primary care

physician, who will arrange for you to see another specialist. You may receive services

from your current specialist until we can make arrangements for you to see someone else.

• If you have a chronic and disabling condition and lose access to your specialist because

we:

– terminate our contract with your specialist for other than cause;

– drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in

another FEHB program plan; or

– reduce our service are and you enroll in another FEHB plan;

you may be able to continue seeing your specialist for up to 90 days after you receive

notice of the change. Contact us, or if we drop out of the Program, contact your new plan.

If you are in the second or third trimester of pregnancy and you lose access to your

specialist based on the above circumstances, you can continue to see your specialist until

the end of your postpartum care, even if it is beyond the 90 days.

• Specialty care

HMO (High Option): Your Plan primary care physician or specialist will make necessary

hospital arrangements and supervise your care. This includes admission to a skilled

nursing or other type of facility.

• Hospital care

We pay covered services from the effective date of your enrollment. However, if you are

in the hospital when your enrollment in our Plan begins, call our customer service

department immediately at 1-800-344-8858. If you are new to the FEHB Program, we will

arrange for you to receive care and provide benefits for your covered services while you

are in the hospital beginning on the effective date of your coverage.

If you changed from another FEHB Plan to us, your former Plan will pay for the hospital

stay until:

• you are discharged, not merely moved to an alternative care center;

• the day your benefits from your former Plan run out; or

• the 92

day after you become a member of this Plan, whichever happens first.

• If you are hospitalized

when your enrollment

begins

19 2020 AultCare Insurance Company Section 3

These provisions apply only to the benefits of the hospitalized person. If your Plan

terminates participation in the FEHB Program in whole or in part, or if OPM orders an

enrollment change, this continuation of coverage provision does not apply. In such cases,

the hospitalized family member’s benefits under the new Plan begin on the effective date

of enrollment.

HDHP Option: We pay for covered services from the effective date of your enrollment.

However, if you are in the hospital when your enrollment in our HDHP begins, call our

Customer Service department immediately at 330-363-6360 or 1-800-344-8858.

Since your primary care physician arranges most referrals to specialists and inpatient

hospitalization, the pre-service claim approval process only applies to care shown under

Other services

You must get prior approval for certain services. Failure to do so may result in a

reduction of benefits.

Precertification - is the process by which – prior to your inpatient hospital admission –

we evaluate the medical necessity of your proposed stay and the number of days required

to treat your condition.

Prior Authorization - Your primary care physician has authority to refer you for most

services. For certain services, however, your physician must obtain prior approval from

us. Before giving approval, we consider if the service is covered, medically necessary,

and follows generally accepted medical practice.

• Abdominoplasty / panniculectomy

• Artificial disc replacement of the lumber and cervical spine

• Artificial intervertebral disc replacement – Cervical

• Audible prescription reading devices

• Auditory brainstem implant

• Autologous chondrocyte implantation

• Blepharoplasty and related procedures

• BRCA/BART testing

• Breast reduction

• Certain Drugs

• Certain MRIs;

• Certain radiology (X-rays) studies: (Call the AultCare Service center at

1-800-344-8858 or 330-363-6360 with questions)

• Certain Surgical Procedures including all non-emergency surgeries (Call the AultCare

Service center at 1-800-344-8858 or 330-363-6360 with questions)

• Cochlear Implants

• Continuous glucose monitors

• Cranial orthosis for plagiocephaly

• CT Angiogram

• Durable Medical Equipment in excess of $1,000 such as

• Endoscopic thoracic sympathectomy for treatment of hyperhidrosis

• External Defibrillators

• Gastric restrictive procedures for weight loss (Bariatric Surgery)

• Genetic/Molecular testing

• High frequency chest wall oscillation system

You need prior Plan

approval for certain

services

• Inpatient hospital

admission

• Other services

• Prior Authorization

• Services Requiring

Prior Authorization

20 2020 AultCare Insurance Company Section 3

• Home health care whether referred by in or out of network providers.

• Home PT / INR Monitoring devices

• Hospice Care;

• Hospital beds

• Implantable miniature telescope for end stage age related macular degeneration

treatment

• Implanted hearing related devices such as Bone Anchored Hearing Aids (BAHA)

• In Utero Fetal Surgery

• Insulin pumps

• Intensive outpatient programs provided in and out of network;

• Interspinious process decompression system

• Kyphoplasty

• Laser therapy for vitiligo

• Mastopexy

• Mental Health and Substance misuse disorder

• Non-emergent ambulance transportation

• Non-emergent surgeries

• Osteochondral allografts and auto grafts for treatment of focal articular cartilage

defects of the knee

• Otoplasty

• Partial hospitalization programs provided in and out of network;

• PET CT Scans;

• Phototherapy

• Physical, occupational, speech, cognitive and growth hormone therapies;

• Pneumatic compression devices

• Potentially experimental, investigational or unproven medical services, including

clinical trials

• Pressure reducing support surfaces

• Prosthetic devices including Artificial limbs and eyes

• Proton Beam Radiotherapy

• Radiofrequency volumetric tissue reduction

• Recombinant Human Bone Morphogenetic Protein -2 and Protein-7

• Reconstructive or cosmetic procedures

• Rehabilitation facility admissions;

• Rhinoplasty

• Scoliosis surgeries

• Sclerotherapy

• Septoplasty

• Skilled nursing facility admissions;

• Specialty Medications

• Speech generating devices

• Spinal Cord Stimulator

• Strabismus surgery if > 11 years of age

21 2020 AultCare Insurance Company Section 3

• Surgical repair of pectus deformities

• Surgical treatment for gynecomastia

• TMJ surgery

• Total ankle replacement

• Total joint replacements

• Trans catheter valve replacement/implantation

• Transcranial magnetic stimulation for treatment of depression

• Transgender Services

• Transplants

• Unicondylar knee replacements

• UPPP (Uvulopalatopharyngoplasty)

• Uvulectomy

• Vertebroplasty – Thoracic and Lumbar

• Wheel Chairs

HMO (High Option): Your primary care physician has authority to refer you for most

services. For certain services, however, your physician must obtain approval from us.

Before giving approval, we consider if the service is covered, medically necessary, and

follows generally accepted medical practice. Call 1-800-344-8858 or 330-363-6360.

Failure to obtain prior authorization may result in a claim denial. See Precertification

process above.

HDHP Option:The process known as pre-certification is an evaluation of your medical

case by your provider and AultCare medical professionals to determine the

appropriateness of your Hospital admission and expected length of stay. In some cases, an

alternative to Hospital admission, such as outpatient treatment, may be recommended.

If your medical professional is an AultCare Provider, the pre-certification process will be

handled for you by your provider when required. You are only responsible for alerting

your provider that you are an AultCare participant. However, if your medical professional

is not an AultCare Provider, you are responsible for seeing that utilization review

procedures are followed. Contact the Utilization Review Department or the Service Center

at 330-363-6360 or 1-800-344-8858. The Utilization Review Department will handle pre-

certification and tell you if a second opinion is necessary for the procedure being done and

encourages out patient surgery when medically necessary.

Depending on the circumstances and time constraints of your situation, you may be asked

to have a form completed. When possible, utilization requirements will be met with a

simple phone call by the Utilization Review Department to your Doctor. If you do not

receive confirmation please call us at 1-800-344-8858 or 330-363-6360.

Failure to meet pre-certification requirements for Non-Panel Hospital admissions will

result in a reduction of benefits.

• How to request

precertification

First, your physician, your hospital, you, or your representative, must call us at

330-363-6360 or 1-800-344-8858 before admission or services requiring prior

authorization are rendered.

Next, provide the following information:

• enrollee’s name and Plan identification number;

• patient’s name, birth date, identification number and phone number;

• reason for hospitalization, proposed treatment, or surgery;

• name and phone number of admitting physician;

How to request

precertification or give

prior authorization for

Other Services

22 2020 AultCare Insurance Company Section 3

• name of hospital or facility; and

• number of days requested for hospital stay

For non-urgent care claims, we will tell the physician and/or hospital the number of

approved inpatient days, or the care that we approve for other services that must have

prior authorization. We will make our decision within 15 days of receipt of the pre-

service claim. If matters beyond our control require an extension of time, we may take up

to an additional 15 days for review and we will notify you of the need for an extension of

time before the end of the original 15-day period. Our notice will include the

circumstances underlying the request for the extension and the date when a decision is

expected.

If we need an extension because we have not received necessary information from you,

our notice will describe the specific information required and we will allow you up to 60

days from the receipt of the notice to provide the information.

• Non-urgent care

claims

If you have an urgent care claim (i.e., when waiting for the regular time limit for your

medical care or treatment could seriously jeopardize your life, health, or ability to regain

maximum function, or in the opinion of a physician with knowledge of your medical

condition, would subject you to severe pain that cannot be adequately managed without

this care or treatment), we will expedite our review and notify you of our decision within

72 hours. If you request that we review your claim as an urgent care claim, we will review

the documentation you provide and decide whether or not it is an urgent care claim by

applying the judgment of a prudent layperson that possesses an average knowledge of

health and medicine.

If you fail to provide sufficient information, we will contact you within 24 hours after we

receive the claim to let you know what information we need to complete our review of the

claim.You will then have up to 48 hours from to provide the required information. We will

make our decision on the claim within 48 hours of (1) the time we received the additional

information or (2) the end of the time frame, whichever is earlier.

We may provide our decision orally within these time frames, but we will follow up with

written or electronic notification within three days of oral notification.

You may request that your urgent care claim on appeal be reviewed simultaneously by us

and OPM. Please let us know that you would like a simultaneous review of your urgent

care claim by OPM either in writing at the time you appeal our initial decision, or by

calling us at 1-800-344-8858. You may also call OPM's Health Insurance 3 at (202)

606-0755 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review. We

will cooperate with OPM so they can quickly review your claim on appeal. In addition, if

you did not indicate that your claim was a claim for urgent care, call us at

1-800-344-8858. If it is determined that your claim is an urgent care claim, we will

expedite our review (if we have not yet responded to your claim).

• Urgent Care Claims

A concurrent care claim involves care provided over a period of time or over a number of

treatments. We will treat reduction or termination of our pre-approved course of treatment

before the end of the approved period of time or number of treatments as an appealable

decision. This does not include reduction or termination due to benefit changes or if your

enrollment ends. If we believe a reduction or termination is warranted, we will allow you

sufficient time to appeal and obtain a decision from us before the reduction or termination

takes effect.

If you request an extension of an ongoing course of treatment at least 24 hours prior to the

expiration of the approval time period and this is also an urgent care claim, we will make

a decision within 24 hours after we receive the claim.

Concurrent care claims

23 2020 AultCare Insurance Company Section 3

If you have an emergency admission due to a condition that you reasonably believe puts

your life in danger or could cause serious damage to bodily function, you, your

representative, the physician, or the hospital must telephone us within two business days

following the day of the emergency admission, even if you have been discharged from the

hospital.

• Emergency inpatient

admission

You do not need to precertify your normal delivery. You may remain in the hospital for up

to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will extend

your inpatient stay if medically necessary. See Section 5(a) for more information.

• Maternity care

If you request an extension of an ongoing course of treatment at least 24 hours prior to the

expiration of the approved time period and this is also an urgent care claim, we will make

a decision within 24 hours after we receive the claim.

• If your treatment

needs to be extended

• Health Care FSA (HCFSA)–Reimburses you for eligible out-of-pocket health care

expenses (such as copayments, deductibles, physician prescribed over-the-counter

drugs and medications, vision and dental expenses, and much more) for you and your

tax dependents, including adult children(through the end of the calendar year in which

they turn 26).

• FSAFEDS offers paperless reimbursement for your HCFSA through a number of

FEHB and FEDVIP plans. This means that when you or your provider files claims

with your FEHB or FEDVIP plan, FSAFEDS will automatically reimburse your

eligible out-of-pocket expenses based on the claim information it receives from your

plan.

The Federal Flexible

Spending Account

Program -

FSAFEDS

What happens when you

do not follow the

precertification rules

when using non-network

facilities

Under certain extraordinary circumstances, such as natural disasters, we may have to

delay your services or we may be unable to provide them. In that case, we will make all

reasonable efforts to provide you with the necessary care.

• Circumstances

beyond our control

Upon occasion, it may be necessary for your AultCare Provider to refer you to a Physician

outside the AultCare Network. In order for you to receive the greatest benefit possible

from your AultCare Plan, the following procedure must be followed:

Your AultCare Provider must contact the pre-admission coordinator at the AultCare

Utilization Management Department to explain the circumstances of the referral.

This can be done by telephone or by completing a referral form available to the

Physician.

The completed referral request will be reviewed by the AultCare Medical Director. You

and your Physician will be contacted directly as to whether the referral has been approved.

If you do not receive written confirmation of your referral, please contact the AultCare

Utilization Management Department at 330-363-6360 or 1-800-344-8858 prior to your

appointment at the Non-AultCare Provider. When a referral is approved, benefits will be

payable as outlined for other AultCare Providers, subject to UCR limitation.

When a referral is not approved, or the above procedure is not followed, benefits are

payable as outlined for other Non-AultCare Providers.

• Services requiring our

prior approval

24 2020 AultCare Insurance Company Section 3

Case Management: The goal of AultCare's Medical Case Management is managing the

high cost of catastrophic illnesses while maintaining quality of care. Case management is

used to describe a number of different approaches to planning, coordinating, providing

and financing medical care. Case Management requires the simultaneous cooperation of

AultCare, the Physician, the patient, and the patient's family. Telephonic follow up is

provided to create and evaluate a goal oriented treatment plan. The focus of case

management can include, but is not limited to, chronic disease states such as diabetes,

COPD, or CHF, complex or catastrophic cases. Medical Case Management programs

develop an individual plan designed to coordinate and mobilize health care resources to

address specific medical problems and patient needs. The result should be a claim savings

through effective medical management.

If you have a pre-service claim and you do not agree with our decision regarding

precertification of an inpatient admission or prior approval of other services, you may

request a review in accord with the procedures detailed below.

If you have already received the service, supply, or treatment, then you have a post-

service claim and must follow the entire disputed claims process detailed in Section 8.

If you disagree with our

pre-service claim decision

Within 6 months of our initial decision, you may ask us in writing to reconsider our initial

decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this

brochure.

In the case of a pre-service claim and subject to a request for additional information, we

have 30 days from the date we receive your written request for reconsideration to

1. Precertify your hospital stay or, if applicable, arrange for the health care provider to

give you the care or grant your request for prior approval for a service, drug, or

supply; or

2. Ask you or your provider for more information and an extension of time to render our

decision.

You or your provider must send the information so that we receive it within 60 days of our

request. We will then decide within 30 more days.

If we do not receive the information within 60 days, we will decide within 30 days of the

date of the information was due. We will base our decision on the information we already

have. We will write to you with our decision.

3. Write to you and maintain our denial.

• To reconsider a non-

urgent care claim

In the case of an appeal of a pre-service urgent care claim, within 6 months of our initial

decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of

the disputed claims process detailed in Section 8 of this brochure.

Unless we request additional information, we will notify you of our decision within 72

hours after receipt of your reconsideration request. We will expedite the review process,

which allows oral or written requests for appeals and the exchange of information by

telephone, electronic mail, facsimile, or other expeditious methods.

• To reconsider an

urgent care claim

After we reconsider your pre-service claim, if you do not agree with our decision, you

may ask OPM to review it by following Step 3 of the disputed claims process detailed in

Section 8 of this brochure.

• To file an appeal with

OPM

25 2020 AultCare Insurance Company Section 3

Section 4. Your Costs for Covered Services

This is what you will pay out-of-pocket for covered care:

Cost-sharing is the general term used to refer to your out-of-pocket costs (e.g. deductible,

coinsurance, and copayments) for the covered care you receive.

Cost-sharing

HMO (High Option): A copayment is a fixed amount of money you pay to the provider,

facility, pharmacy, etc., when you receive certain services.

Example: When you see your primary care physician, you pay a copayment of $15 per

office visit, and $20 per office visit for specialty care physicians.

HDHP Option: See coinsurance below.

Copayments

HMO (High Option): There is no deductible under the HMO.

HDHP Option: A deductible is a fixed amount of covered expenses you must incur for

certain covered services and supplies before we start paying benefits for them.

If you use PPO providers, the calendar year deductible is $2,000 for Self Only. Under a

Self Plus One or Self and Family enrollment, the deductible is satisfied for all family

members when the combined covered expenses applied to the calendar year deductible for

family members reach $4,000. If you use non-PPO providers, your calendar year

deductible increases to a maximum of $4,000 for Self Only and $8,000 for Self Plus One

or Self and Family.

Note: If you change plans during Open Season, you do not have to start a new deductible

under your old plan between January 1 and the effective date of your new plan. If you

change plans at another time during the year, you must begin a new deductible under your

new plan.

And, if you change from Self and Family to Self Only, or from Self Only to Self and

Family during the year, we will credit the amount of covered expenses already applied

toward the deductible of your old enrollment to the deductible of your new enrollment.

Note: If you change plans during Open Season, you do not have to start a new deductible

under your old plan between January 1 and the effective date of your new plan. If you

change plans at another time during the year, you must begin a new deductible under your

new plan.

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.

Deductible

HMO (High Option): See copayments above.

HDHP Option: Coinsurance is the percentage of our allowance that you must pay for

your care. Coinsurance does not begin until you have met your calendar year deductible.

Example: You pay 20% of our allowance for a Preferred Provider

Note: If your provider routinely waives (does not require you to pay) your copayments,

deductibles, or coinsurance, the provider is misstating the fee and may be violating the

law. In this case, when we calculate our share, we will reduce the provider’s fee by the

amount waived.

For example, if your physician ordinarily charges $100 for a service but routinely waives

your 20% coinsurance, the actual charge is $80. We will pay $64 (80% of the actual

charge of $80).

Coinsurance

26 2020 AultCare Insurance Company Section 4

In-network providers agree to limit what they will bill you. Because of that, when you

use a network provider, your share of covered charges consists of your copayments

(HMO High Option only) or your deductible and coinsurance (HDHP Option only).

HDHP Option: Here is an example about coinsurance: You see a network physician who

charges $150, but our allowance is $100. If you have met your deductible, you are only

responsible for your coinsurance. That is, you pay just – 20% of our $100 allowance

($20). Because of the agreement, your network physician will not bill you for the $50

difference between our allowance and his bill.

Out-of-network providers have no agreement to limit what they will bill you. When you

use an out-of-network provider, you will pay your deductible and coinsurance – plus any

difference between our allowance and charges on the bill. Here is an example: You see an

out-of-network physician who charges $150 and our allowance is again $100. Because

you’ve met your deductible, you are responsible for your coinsurance, so you pay 40% of

our $100 allowance ($40). Plus, because there is no agreement between the out-of-

network physician and us, the physician can bill you for the $50 difference between our

allowance and his bill.

Differences between our

Plan allowance and the

bill

HMO (High Option): After your out-of-pocket expenses, including any applicable

deductibles, copayments and coinsurance total $6,850 for Self Only, or $13,700 for a Self

Plus One or Self and Family enrollment in any calendar year, you do not have to pay any

more for covered services.

The maximum annual limitation on cost sharing listed under

Self Only of $6 ,850 applies to each individual, regardless of whether the individual is

enrolled in Self Only, Self Plus One, or Self and Family.

Be sure to keep accurate records of your copayments and coinsurance since you are

responsible for informing us when you reach the maximum.

Example Scenario: Your plan has a $6,850 Self Only maximum out-of-pocket limit and a

$13,700 Self Plus One or Self and Family maximum out-of-pocket limit. If you or one of

your eligible family members has out-of-pocket qualified medical expenses of $6,850 or

more for the calendar year, any remaining qualified medical expenses for that individual

will be covered fully by your health plan. With a Self and Family enrollment out-of-

pocket maximum of $13,700, a second family member, or an aggregate of other eligible

family members, will continue to accrue out-of-pocket qualified medical expenses up to a

maximum of $6,850 for the calendar year before their qualified medical expenses will

begin to be covered in full.

However, copayments and coinsurance, if applicable for the following services do not

count toward your catastrophic protection out-of-pocket maximum, and you must

continue to pay copayments and coinsurance for these services:

• Expenses in excess of our allowance or maximum benefit limitations

• Any amounts you pay because benefits have been reduced for non-compliance with

this Plan's cost containment requirements.

• Expenses in excess of Plan maximums

HDHP PPO benefit: Your out-of-pocket maximum is $4,000 for a Self Only and $8,000

for Self Plus One and Self and Family enrollment if you are using PPO providers. Only

eligible expenses for PPO providers count toward this limit.

Non-PPO benefit (Non-participating providers): Your out-of-pocket maximum is

$8,000 for a Self Only and $16,000 for a Self Plus One and Self and Family enrollment if

you are using Non-PPO providers. Eligible expenses for network providers also count

toward this limit. Your eligible out-of-pocket expenses will not exceed this amount

whether or not you use network providers.

Your catastrophic

protection out-of-pocket

maximum

27 2020 AultCare Insurance Company Section 4

HDHP Option: After your out-of-pocket expenses, including any applicable deductibles,

copayments and coinsurance total $4,000 for Self Only, or $8,000 for a Self Plus One or

Self and Family enrollment in any calendar year, you do not have to pay any more for

covered services.

The maximum annual limitation on cost sharing listed under Self Only

of $4,000 applies to each individual, regardless of whether the individual is enrolled in

Self Only, Self Plus One, or Self and Family.

Example Scenario: Your plan has a $4,000 Self Only maximum out-of-pocket limit and a

$8,000 Self Plus One or Self and Family maximum out-of-pocket limit. If you or one of

your eligible family members has out-of-pocket qualified medical expenses of $4,000 or

more for the calendar year, any remaining qualified medical expenses for that individual

will be covered fully by your health plan. With a Self and Family enrollment out-of-

pocket maximum of $8,000, a second family member, or an aggregate of other eligible

family members, will continue to accrue out-of-pocket qualified medical expenses up to a

maximum of $4,000 for the calendar year before their qualified medical expenses will

begin to be covered in full.

Out-of-pocket expenses for the purposes of this benefit are:

• The 20% you pay for PPO Inpatient hospital charges, Surgical, Maternity and Diagnostic

and treatment services

• The 40% you pay for non-PPO Inpatient hospital charges, Surgical, Maternity and

Diagnostic and treatment services; and

The following cannot be included in the accumulation of out-of-pocket expenses:

• Expenses in excess of our allowance or maximum benefit limitations

• Any amounts you pay because benefits have been reduced for non-compliance with this

Plan's cost containment requirements.

• Expenses in excess of Plan maximums

If you changed to this Plan during open season from a plan with a catastrophic protection

benefit and the effective date of the change was after January 1, any expenses that would

have applied to that plan’s catastrophic protection benefit during the prior year will be

covered by your old plan you have already met your old plan’s catastrophic protection

benefit level in full, it will continue to apply until the effective date of your coverage in

this Plan. If you have not met this expense level in full, your old plan will first apply your

covered out-of-pocket expenses until the prior year’s catastrophic level is reached and

then apply the catastrophic protection benefit to covered out-of-pocket expenses incurred

from that point until the effective date of your coverage in this Plan. Your old plan will

pay these covered expenses according to this year’s benefits; benefit changes are effective

January 1.

Note: If you change options in this Plan during the year, we will credit the amount of

covered expenses already accumulated toward the catastrophic out-of-pocket limit of your

old option to the catastrophic protection limit f your new option.

Carryover

Facilities of the Department of Veterans Affairs, the Department of Defense, and the

Indian Health Service are entitled to seek reimbursement from us for certain services and

supplies they provide to you or a family member. They may not seek more than their

governing laws allow. You may be responsible to pay for certain services and charges.

Contact the government facility directly for more information.

When Government

facilities bill us

28 2020 AultCare Insurance Company Section 4

Section 5. Benefits

HMO Option

This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning

of each subsection. Also read the general exclusions in Section 6; they apply to the benefits in the following subsections.

Make sure that you review the benefits that are available under the option in which you are enrolled.

To obtain claim forms,

claims filing advice, or more information about our benefits, contact us at 1-800-344-8858 or on our Website at www.

aultcare.com.