Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2023 – 12/31/2023
: FEHB BASIC OPTION (HMO06071 / PHA04083) Coverage for: Self Only, Self Plus One or Self and Family | Plan Type: HMO
1 of 7
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would
share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.
This is only a summary. Please read the FEHB Plan brochure (RI 73-192) that contains the complete terms of this plan. All benefits are subject to the
definitions, limitations, and exclusions set forth in the FEHB Plan brochure. Benefits may vary if you have other coverage, such as Medicare. For general
definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary.
You can get the FEHB Plan brochure at https://www.deancare.com/members/federal-employee-members and view the Glossary at https://www.healthcare.gov/sbc-
glossary/. You can call 1-800-279-1301 (TTY: 711) to request a copy of either document.
Important Questions Answers Why This Matters:
What is the overall
deductible?
$0
Generally, you must pay all of the costs from providers up to the deductible amount before this
plan begins to pay. Copayments and coinsurance amounts do not count toward your deductible,
which generally starts over January 1. When a covered service/supply is subject to a deductible,
only the Plan allowance for the service/supply counts toward the deductible. If you have other
family members on the plan, each family member must meet their own individual deductible until
the total amount of deductible expenses paid by all family members meets the overall family
deductible.
Are there services
covered before you meet
your deductible?
Yes. Preventive care services are
covered before you meet your
deductible.
This plan covers some items and services even if you haven’t yet met the deductible amount. But
a copayment or coinsurance may apply. For example, this plan covers certain preventive services
without cost sharing and before you meet your deductible. See a list of covered preventive
services at https://www.healthcare.gov/coverage/preventive-care-benefits/.
Are there other
deductibles for specific
services?
No You don’t have to meet deductibles for specific services.
What is the out-of-pocket
limit for this plan?
$6,000 individual / $12,000 family
The out-of-pocket limit, or catastrophic maximum, is the most you could pay in a year for covered
services. If you have other family members in this plan, they have to meet their own out-of-
pocket limits until the overall family out-of-pocket limit has been met.
What is not included in
the out-of-pocket limit?
Premiums, balance billing
charges, and health care this plan
doesn‘t cover.
Even though you pay these expenses, they don’t count toward the out–of–pocket limit.
Will you pay less if you
use a network provider?
Yes. See deancare.com/find-a-
doc/ or call 800-279-1301 (TTY:
711) for a list of network providers.
This plan uses a provider network. You will pay less if you use a provider in the plan’s network.
You will pay the most if you use an out-of-network provider, and you might receive a bill from a
provider for the difference between the provider’s charge and what your plan pays (balance
2 of 7
For more information about limitations and exceptions, see the FEHB Plan brochure RI 73-192 at
deancare.com/members/federal-employee-members.
billing). Be aware, your network provider might use an out-of-network provider for some services
(such as lab work). Check with your provider before you get services.
Do you need a referral to
see a specialist?
No. You can see the specialist you choose without a referral.
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
Common
Medical Event
Services You May Need
What You Will Pay
Limitations, Exceptions, & Other Important
Information
Network Provider
(You will pay the least)
Out-of-Network Provider
(You will pay the most,
plus you may be balance
billed)
If you visit a health
care provider’s office
or clinic
Primary care visit to treat an
injury or illness
Not covered
No coverage for Chiropractic maintenance or
long-term therapy.
Specialist visit $80 copay/visit Not covered
Infertility services are covered at 100% up to
$2,000 policy life time maximum.
Preventive care/screening/
immunization
$0 copay/visit Not covered
Services under the Affordable Care Act (ACA)
guidelines will be covered as preventive.
Services may have a limit on number of visits
and/or specific age requirements. For
additional information please see the
Preventive Services section in your Member
Certificate. You may have to pay for services
that aren't preventive. Ask your provider if the
services needed are preventive. Then check
what your plan will pay for.
If you have a test
Diagnostic test (x-ray, blood
work)
$0 copay/visit Not covered None
Imaging (CT/PET scans, MRIs)
Not covered
None
3 of 7
For more information about limitations and exceptions, see the FEHB Plan brochure RI 73-192 at
deancare.com/members/federal-employee-members.
Common
Medical Event
Services You May Need
What You Will Pay
Limitations, Exceptions, & Other Important
Information
Network Provider
(You will pay the least)
Out-of-Network Provider
(You will pay the most,
plus you may be balance
billed)
If you need drugs to
treat your illness or
condition
More information about
prescription drug
coverage is available at
deancare.com/members
/pharmacy-benefits
Generic drugs
(retail); Mail order
maintenance
prescriptions, a 90-day
Not covered (retail and mail
order)
None
Preferred brand drugs
(retail); Mail order
maintenance
prescriptions, a 90-day
Not covered (retail and mail
order)
None
Non-preferred brand drugs
(retail); Mail order
maintenance
prescriptions, a 90-day
Not covered (retail and mail
order)
None
Specialty drugs
prescription (retail); Mail
order maintenance
prescriptions not
covered.
50% coinsurance for
infertility
drugs/prescription
Not covered (retail and mail
order)
None
If you have outpatient
surgery
Facility fee (e.g., ambulatory
surgery center)
$1,000 copay Not covered None
Physician/surgeon fees
Not covered
None
If you need immediate
medical attention
Emergency room care $300 copay/visit $300 copay/visit
Initial emergency services are covered with
out-of-network providers. Copay is waived if
admitted for observation or inpatient.
Emergency medical
transportation
$300 copay $300 copay None
4 of 7
For more information about limitations and exceptions, see the FEHB Plan brochure RI 73-192 at
deancare.com/members/federal-employee-members.
Common
Medical Event
Services You May Need
What You Will Pay
Limitations, Exceptions, & Other Important
Information
Network Provider
(You will pay the least)
Out-of-Network Provider
(You will pay the most,
plus you may be balance
billed)
Urgent care $40 copay/visit $40 copay/visit
Initial urgent care services are covered with
out-of-network providers.
If you have a hospital
stay
Facility fee (e.g., hospital room)
Not covered
Maximum of 3 copays per admission.
Physician/surgeon fees $0 copay Not covered None
If you need mental
health, behavioral
health, or substance
abuse services
Outpatient services
visit
$40 copay/day for day
Not covered None
Inpatient services
Not covered
Maximum of 3 copays per admission.
If you are pregnant
Office visits
copay/visit; Specialist
Not covered
Home or intentional out of hospital deliveries
are not covered. Cost sharing does not apply
for preventive services. Depending on the
type of services, a copayment, coinsurance, or
deductible may apply. Maternity care may
include tests and services described
elsewhere in the SBC (i.e. ultrasound).
Childbirth/delivery facility services – Maximum
of 3 copays per admission.
Childbirth/delivery professional
services
$80 copay Not covered
Childbirth/delivery facility
services
$1,000 copay/day Not covered
If you need help
recovering or have
other special health
needs
Home health care
Not covered
None
Rehabilitation services
Services:
$1,000 copay/day
Physical, Occupational
and Speech Therapy:
Not covered
Maximum of 3 copays per admission.
Services for custodial care are a policy
exclusion.
Habilitation services $80 copay/therapy/day Not covered
Services for custodial care are a policy
exclusion.
Skilled nursing care
Not covered
30 days/confinement.
Durable medical equipment
Not covered
None
Hospice services
Not covered
None
5 of 7
For more information about limitations and exceptions, see the FEHB Plan brochure RI 73-192 at
deancare.com/members/federal-employee-members.
Common
Medical Event
Services You May Need
What You Will Pay
Limitations, Exceptions, & Other Important
Information
Network Provider
(You will pay the least)
Out-of-Network Provider
(You will pay the most,
plus you may be balance
billed)
If your child needs
dental or eye care
Children’s eye exam $40 copay/visit Not covered
Exams performed by an ophthalmologist will
incur the specialty office visit cost share.
Children’s glasses
Not covered
None
Children’s dental check-up
Not covered
None
Excluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your FEHB Plan brochure for more information and a list of any other excluded services.)
• Cosmetic services including surgery
• Dental care (Adult)
• Glasses (Adult)
•
Long-term care
• Non-emergency care when traveling outside the
U.S.
• Private-duty nursing
• Routine foot care
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your FEHB Plan brochure.)
• Acupuncture (Limited to 10 visits per contract
period)
• Bariatric Surgery after written approval and
completion of Weight Management program.
• Chiropractic care
• Hearing aids (Limited to one aid per ear every 36
months)
• Infertility treatment
• Routine eye care (Adult)
• Weight Loss Programs as part of our
Comprehensive Weight Management Program
Your Rights to Continue Coverage: You can get help if you want to continue your coverage after it ends. See the FEHB Plan brochure, contact your HR
office/retirement system, contact your plan at 1-800-279-1301 (TTY: 711) or visit www.opm.gov.insure/health. Generally, if you lose coverage under the plan, then,
depending on the circumstances, you may be eligible for a 31-day free extension of coverage, a conversion policy (a non-FEHB individual policy), spouse equity
coverage, or temporary continuation of coverage (TCC). Other coverage options may be available to you, too, including buying individual insurance coverage through
the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.
Your Grievance and Appeals Rights: If you are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal. For information about
your appeal rights please see Section 3, “How you get care,” and Section 8 “The disputed claims process,” in your FEHB Plan brochure. If you need assistance, you
can contact: Dean Health Plan at deancare.com or 1-800-279-1301 (TTY: 711); Wisconsin Office of the Commissioner of Insurance at (800) 236-8517 or
http://oci.wi.gov/ or the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-EBSA (3272) or https://www.dol.gov/ebsa/healthreform.
Does this plan provide Minimum Essential Coverage? Yes
Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid,
CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.
6 of 7
For more information about limitations and exceptions, see the FEHB Plan brochure RI 73-192 at
deancare.com/members/federal-employee-members.
Does this plan meet the Minimum Value Standards? Yes
If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
Language Access Services:
Spanish (Español): Para obtener asistencia en Español, llame al 1-800-279-1301 (TTY: 711).
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-279-1301 (TTY: 711).
Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-800-279-1301 (TTY: 711).
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-279-1301 (TTY: 711).
To see examples of how this plan might cover costs for a sample medical situation, see the next section.
7 of 7
The plan would be responsible for the other costs of these EXAMPLE covered services.
Peg is Having a Baby
(9 months of in-network pre-natal care and a
hospital delivery)
Mia’s Simple Fracture
(in-network emergency room visit and follow
up care)
Managing Joe’s type 2 Diabetes
(a year of routine in-network care of a well-
controlled condition)
The plan’s overall deductible $0
Specialist copayment $80
Hospital (facility) copayment $1,000
Other coinsurance 0%
This EXAMPLE event includes services like:
Specialist office visits (prenatal care)
Childbirth/Delivery Professional Services
Childbirth/Delivery Facility Services
Diagnostic tests (ultrasounds and blood work)
Specialist visit (anesthesia)
Total Example Cost
$12,700
In this example, Peg would pay:
Cost Sharing
Deductibles
$0
Copayments
$1,200
Coinsurance
$0
What isn’t covered
Limits or exclusions
$60
The total Peg would pay is
$1,260
The plan’s overall deductible $0
Specialist copayment $80
Hospital (facility) copayment $1,000
Other coinsurance 0%
This EXAMPLE event includes services like:
Primary care physician office visits (including
disease education)
Diagnostic tests (blood work)
Prescription drugs
Durable medical equipment (glucose meter)
Total Example Cost
$5,600
In this example, Joe would pay:
Cost Sharing
Deductibles
$0
Copayments
$1,000
Coinsurance
$0
What isn’t covered
Limits or exclusions
$20
The total Joe would pay is
$1,020
The plan’s overall deductible $0
Specialist copayment $80
Hospital (facility) copayment $1,000
Other coinsurance 0%
This EXAMPLE event includes services like:
Emergency room care (including medical
supplies)
Diagnostic test (x-ray)
Durable medical equipment (crutches)
Rehabilitation services (physical therapy)
Total Example Cost
$2,800
In this example, Mia would pay:
Cost Sharing
Deductibles
$0
Copayments
$1,300
Coinsurance
$0
What isn’t covered
Limits or exclusions
$0
The total Mia would pay is
$1,300
About these Coverage Examples:
This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be
different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing
amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of
costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.