SAMBA Health Benefit Plan
http:// www. samba-insurance. com
A fee-for-service plan with a
preferred provider organization
Sponsored and administered by: the Special Agents Mutual Benefit
Association
Who may enroll in this Plan: Active employees of the
Federal Bureau of Investigation (FBI), the Drug Enforcement Administration
(DEA), the Bureau of Alcohol, Tobacco, and Firearms (BATF), the
Naval
Investigative Service (NIS), the United States Marshals Service (USMS), the
Department of Justice Office of the Inspector General (IG), the Criminal
Investigation Division and the National
Treasury Inspector General for Tax
Administration (IRS), Civilian Employees of the Office of Special Investigations
of the Department of the Air Force (OSI), the Executive Office of the United
States
Attorneys (EOUSA), the Offices, Boards and Divisions of the
Department of Justice (OBD), the United States Customs Service (USCS), the
Financial Crimes Enforcement Network (FinCEN) and all
presidentially-appointed offices of the Inspectors General (IGs).
The
only annuitants who may enroll in this Plan are persons who retired from the DEA
on or after January 9, 1983, who retired from the BATF or the NIS on or after
January 5, 1986, who retired from
the USMS or the Department of Justice IG
on or after January 14, 1990, who retired from the National Treasury IG on or
after January 12, 1992, who retired from the OSI on or after January 10, 1993,
who
retired from the EOUSA or the OBD on or after January 8, 1995, who
retired from the USCS or the FinCEN on or after January 4, 1998, who will retire
from the presidentially-appointed offices of the IG
on or after January 14,
2001, and all retired employees of the FBI.
Membership dues: There
are no membership dues.
Enrollment codes for this Plan:
441 Self Only 442 Self and Family
RI 72-006
2002 SAMBA 2 Table of Contents
Table of Contents
Introduction.............................................................................................................................................................................................
4
Plain Language
.......................................................................................................................................................................................
4
Inspector General
Advisory....................................................................................................................................................................
5
Section 1. Facts about this fee-for-service plan
.....................................................................................................................................
6
Section 2. How we change for 2002
......................................................................................................................................................
7
Section 3. How you get care …………...
..............................................................................................................................................
8
Identification
cards................................................................................................................................................................
8
Where you get covered
care..................................................................................................................................................
8
Covered
providers.........................................................................................................................................................
9
Covered facilities
..........................................................................................................................................................
9
What you must do to get covered
care................................................................................................................................
10
How to get approval for
......................................................................................................................................................
11
Your hospital stay (precertification)
...........................................................................................................................
11
Other services
.............................................................................................................................................................
12
Section 4. Your costs for covered services
...........................................................................................................................................
14
Copayments
................................................................................................................................................................
14
Deductible...................................................................................................................................................................
14
Coinsurance
................................................................................................................................................................
14
Differences between our allowance and the bill
.........................................................................................................
15
Your out-of-pocket
maximum.............................................................................................................................................
16
When government facilities bill
us......................................................................................................................................
16
If we overpay you
...............................................................................................................................................................
16
When you are age 65 or over and you do not have
Medicare.............................................................................................
17
When you have
Medicare....................................................................................................................................................
18
Section 5. Benefits
...............................................................................................................................................................................
19
Overview.............................................................................................................................................................................
19
(a) Medical services and supplies provided by
physicians and other health care
professionals........................................ 20
(b) Surgical and anesthesia services provided by physicians and
other health care professionals .................................... 29
(c) Services provided by a hospital or other facility, and
ambulance services
.................................................................. 35
(d) Emergency services/
accidents......................................................................................................................................
39
(e) Mental health and substance abuse
benefits.................................................................................................................
40
(f) Prescription drug benefits
............................................................................................................................................
44
(g) Special
features............................................................................................................................................................
48
Flexible benefits option
Managed Care Advisor (MCA) Program 2
2
Page 3 4
2002 SAMBA 3 Table of Contents
Worldwide
Assistance Program
24-hour nurse line
Services for deaf and hearing impaired
High risk pregnancies
National
Transplant Program and Centers of Excellence for organ/ tissue transplants
Travel benefit/ services overseas
(h) Dental
benefits.............................................................................................................................................................
50
(i) Non-FEHB benefits available to Plan members
..........................................................................................................
52
Section 6. General exclusions – things we don't
cover
........................................................................................................................
53
Section 7. Filing a claim for covered services
.....................................................................................................................................
54
Section 8. The disputed claims
process................................................................................................................................................
56
Section 9. Coordinating benefits with other
coverage
.........................................................................................................................
58
When you have other health coverage
................................................................................................................................
58
Original Medicare
...............................................................................................................................................................
58
Medicare managed care
plan...............................................................................................................................................
61
TRICARE/ Workers Compensation/
Medicaid.....................................................................................................................
61
When other Government agencies are responsible for
your
care........................................................................................
62
When others are responsible for
injuries.............................................................................................................................
62
Section 10. Definitions of terms we use in this
brochure.....................................................................................................................
63
Section 11. FEHB
facts........................................................................................................................................................................
66
Coverage information
.......................................................................................................................................................
66
No pre-existing condition
limitation...........................................................................................................................
66
Where you get information about enrolling in the
FEHB
Program............................................................................
66
Types of coverage available for you and your family
................................................................................................
66
When benefits and premiums
start..............................................................................................................................
66
Your medical and claims records are
confidential......................................................................................................
67
When you retire
..........................................................................................................................................................
67
When you lose
benefits.....................................................................................................................................................
67
When FEHB coverage
ends.......................................................................................................................................
67
Spouse equity
coverage..............................................................................................................................................
67
Temporary Continuation of Coverage
(TCC)............................................................................................................
67
Converting to individual
coverage.............................................................................................................................
68
Getting a Certificate of Group Health Plan
Coverage................................................................................................
68
Long term care insurance is coming later in 2002
................................................................................................................................
69
Index
.....................................................................................................................................................................................................
70
Summary of
benefits.............................................................................................................................................................................
71
Rates
.......................................................................................................................................................................................
Back cover 3
3 Page
4 5
2002 SAMBA 4 Introduction/ Plain Language/ Advisory
Introduction
SAMBA Health Benefit Plan 11301 Old Georgetown
Road
Rockville, MD 20852-2800
This brochure describes the benefits of
the SAMBA Health Benefit Plan under our contract (CS 1074) with the Office of
Personnel Management (OPM), as authorized by the Federal Employees Health
Benefits law. This brochure is the official statement of benefits.
No oral
statement can modify or otherwise affect the benefits, limitations, and
exclusions of this brochure.
If you are enrolled in this Plan, you are
entitled to the benefits described in this brochure. If you are enrolled for
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, 2002, unless those benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes
are effective January 1, 2002, and changes are summarized on page 7. Rates are shown at the end of this brochure.
Plain Language
Teams of Government and health plans' staff worked
on all FEHB brochures to make them responsive, accessible, and understandable to
the public. For instance,
Except for necessary technical terms, we use common words. For instance,
"you" means the enrollee or family member, "we" or "us" means the SAMBA Health
Benefit Plan.
We limit acronyms to ones you know. FEHB is the Federal
Employees Health Benefits Program. OPM is the Office of Personnel Management. If
we use others, we tell you what they mean first.
Our brochure and other FEHB
plans' brochures have the same format and similar descriptions to help you
compare plans.
If you have comments or suggestions about how to improve the
structure of this brochure, let OPM know. Visit OPM's "Rate Us" feedback area at
www. opm. gov/ insure or e-mail OPM at
fehbwebcomments@ opm. gov. You may
also write to OPM at the Office of
Personnel Management, Office of Insurance Planning
and Evaluation Division, 1900 E Street, NW, Washington, DC 20415-3650. 4
4 Page 5 6
2002 SAMBA 5 Introduction/ Plain Language/ Advisory
Inspector General Advisory
Stop health care fraud! Fraud
increases the cost of health care for everyone. If you suspect that a physician,
pharmacy, or hospital 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. If the provider does not resolve the matter, call us at 1-800/ 638-6589
or 301/ 984-1440
(for TDD, use 301/ 984-4155) and explain the situation. If
we do not resolve the issue, call or write
THE HEALTH CARE FRAUD HOTLINE 202/ 418-3300
The United States
Office of Personnel Management Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400 Washington, DC 20415
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB
Program benefits can be prosecuted for fraud. Also, the Inspector General may
investigate anyone who uses an ID card if the
person tries to obtain
services for someone who is not an eligible family member, or is no longer
enrolled in the Plan and tries to obtain benefits. Your agency may also take
administrative action against you. 5
5 Page 6 7
2002 SAMBA 6 Section 1
Section 1. Facts about this
fee-for-service plan
This Plan is a fee-for-service (FFS) plan. You can
choose your own physicians, hospitals, and other health care providers.
We
reimburse you or your provider for your covered services, usually based on a
percentage of the amount we allow. The type and extent of covered services, and
the amount we allow, may be different from other plans. Read brochures
carefully.
We also have Preferred Provider Organizations (PPO):
Our
fee-for-service plan offers services through a PPO. When you use our PPO
providers, you will receive covered services at reduced cost. Contact us for the
names of PPO providers and to verify their continued participation. You can also
go to our webCould not acquire words on page 7 page, which
you can reach
through the FEHB web site, www. opm. gov/ insure. Do not call OPM or your agency
for our provider directory.
The non-PPO benefits are the standard benefits
of this Plan. PPO benefits apply only when you use a PPO provider. Provider
networks may be more extensive in some areas than others. We cannot guarantee
the availability of every specialty in all areas. If no
PPO provider is
available, or you do not use a PPO provider, the standard non-PPO benefits
apply.
How we pay providers
When you use a PPO provider or
facility, our Plan allowance is the negotiated rate for the service. You are not
responsible for charges above the negotiated amount.
Non-PPO facilities and providers do not have special agreements with the
Plan. When you use a non-PPO provider to perform the service or provide the
supply, there are two methods we use to determine the Plan allowance; 1) the
Plan uses the 75 th percentile factor
of claims data and fee information
gathered for specific geographic areas by Medical Data Research (MDR) or 2) in
geographic areas where access to a PPO provider was available but the patient
did not use a PPO provider, our allowance is based on the average PPO
negotiated rate for that region. You may be responsible for amounts over the
Plan allowance.
We also obtain discounts from some non-PPO providers. When
we obtain discounts through negotiations with providers (PPO or non-PPO), we
pass along the savings to you.
Your Rights
OPM requires all FEHB Plans to provide certain
information to their FEHB members. You may get information about us, our
networks, providers, and facilities. 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.
SAMBA was established in 1948
SAMBA is a non-profit employee association
If you want more information about us, call 1-800/ 638-6589 or 301/ 984-1440
(for TDD, use 301/ 984-4155), or write to SAMBA 11301 Old Georgetown Road,
Rockville, MD 20852-2800. You may also contact us by fax at 301/ 984-6224 or
visit our website at
www.
samba-insurance. com. 6
6 Page
7 8
2002 SAMBA 8 Section 3
Section 3. How you get care
Identification cards 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 (for annuitants), or your 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/ 638-6589 or
301/ 984-1440 (for TDD, use 301/ 984-4155).
Where you get covered care 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.
This Plan's PPOs We have entered into
arrangements (geographically) with CareFirst BlueCross BlueShield (CareFirst)
and First Health Group Corp. (First Health) to offer Preferred
Provider
Organization (PPO) Networks to SAMBA enrollees. See below to determine which PPO
Network services your area.
Enrollees who reside in the Washington, DC Metropolitan area, including the
District of Columbia, the Maryland counties of Calvert, Charles, Frederick,
Montgomery, Prince George's and St. Mary's, the Virginia counties of
Arlington, Fairfax, Loudoun, Prince William, Spotsylvania, and Stafford, and the
cities of
Alexandria, Fairfax, Falls Church, and Fredericksburg and those in
the Baltimore Metropolitan area including the city of Baltimore, and the
Maryland counties of
Anne Arundel, Baltimore, Carroll, Harford, and Howard
may utilize the CareFirst PPO Network. Call CareFirst customer service
toll-free, 1-877/ 691-5856, for
information concerning the PPO.
Enrollees outside the CareFirst service areas (listed above) may utilize the
First Health PPO Network. Call First Health's Referral Management/ Telephonic
Provider
Directory at 1-800/ 346-6755 to confirm provider participation and
identify Network providers.
– Managed Care Advisor (MCA) Program — Enrollees in the First Health
service areas lacking Network access (as determined by the Plan) may join the
Plan's
Managed Care Advisor (MCA) Program. Refer to Section 5( g) on page 48 for additional information.
PPO benefits apply only when you use a PPO provider. Provider networks may be
more extensive in some areas than others. The availability of every specialty in
all areas
cannot be guaranteed. If no PPO provider is available the standard
non-PPO benefits apply.
Note: Use of a participating Network doctor or hospital does not guarantee
that the associated ancillary providers such as specialists, emergency room
doctors,
anesthesiologists, radiologists, and pathologists participate in
the Network. Subject to the Plan's definitions, limitations and exclusions, the
Plan pays its PPO benefits as outlined
in this brochure when services are
provided by a doctor or other provider participating in the Plan's PPO Network.
If you use a non-PPO provider, the standard non-PPO benefits
will apply as
outlined in this brochure. When you phone for an appointment, please remember to
verify that the physician or facility is still a PPO Network provider. 8
8 Page 9 10
2002 SAMBA 9 Section 3
Covered providers
We consider the following to be covered providers when they perform services
within the scope of their license or certification:
doctor of medicine (M.
D.) doctor of osteopathy (D. O.)
doctor of podiatry (D. P. M.)
Other
covered providers include, but are not limited to: dentist (D. D. S., D. M. D.)
chiropractor qualified clinical psychologist
clinical social worker
optometrist
nurse midwife nurse practitioner/ clinical specialist
Christian Science practitioner listed in the Christian Science Journal
Medically underserved areas. Note: We cover any licensed medical
practitioner for any covered service performed within the scope of that license
in states OPM determines
are "medically underserved." For 2002, the states
are: Alabama, Georgia, Idaho, Kentucky, Mississippi, Missouri, Montana, New
Mexico, North Dakota, South Carolina,
South Dakota, Texas, Utah, and
Wyoming.
Covered facilities Covered facilities include:
Ambulatory surgical center — a facility that operates primarily for the
purpose of performing same-day surgical procedures.
Birthing center — a licensed or certified facility approved by the Plan, that
provides services for nurse midwifery and related maternity services.
Convalescent nursing home — an institution that: 1) is legally operated
2) mainly provides services for persons recovering from illness or injury.
The services are provided for a fee from its patients, and include both:
(a)
room and board; and (b) 24-hour-a-day nursing service.
3) provides the
services under the full-time supervision of a doctor or registered graduate
nurse (R. N.)
4) keeps adequate medical records, and 5) if not supervised by
a doctor, it has the services of one available under a fixed
agreement. But,
Convalescent nursing home does not include an institution or part of one that is
used mainly as a place of rest or for the aged.
Hospital — 1) An institution that is accredited under the hospital
accreditation program of the
Joint Commission on Accreditation of Healthcare
Organizations, or 2) Any other institution that is operated pursuant to law,
under the supervision of a
staff of doctors and with 24-hour-a-day nursing
service by a registered graduate nurse (R. N.) or a licensed practical nurse (L.
P. N.), and primarily engaged in
providing acute inpatient care and
treatment of sick and injured persons through medical, diagnostic and major
surgical facilities, all of which must be provided
on its premises or under
its control. Christian Science sanatoriums operated, or listed as certified, by
the First Church of
Christ, Scientist, Boston, Massachusetts, are included.
9
9 Page 10 11
2002 SAMBA 10 Section 3
Rehabilitation
facility — an institution specifically engaged in the rehabilitation of persons
suffering from alcoholism or drug addiction which meets all of these
requirements: 1) It is operated pursuant to law.
2) It mainly provides
services for persons receiving treatment for alcoholism or drug addiction. The
services are provided for a fee from its patients, and include
both: (a)
room and board; and (b) 24-hour-a-day nursing service. 3) It provides the
services under the full-time supervision of a doctor or registered
graduate
nurse (R. N.). 4) It keeps adequate patient records which include: (a) the
course of treatment; and
(b) the person's progress; and (c) discharge
summary; and (d) follow-up programs.
Skilled nursing facility — an institution or that part of an institution that
provides skilled nursing care 24 hours a day and is classified as a skilled
nursing care facility
under Medicare.
What you must do to It
depends on the kind of care you want to receive. You can go to any provider you
want, get covered care but we must approve some care in advance.
Transitional care: Specialty care: If you have a chronic or disabling
condition and
lose access to your specialist because we drop out of the
Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB
Plan, or
lose access to your PPO specialist because we terminate our contract with
your specialist for other than cause,
you may be able to continue seeing
your specialist and receiving any PPO benefits 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 and
any PPO benefits
continue until the end of your postpartum care, even if it is beyond the 90
days.
Hospital care: We pay for 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/
638-6589 or 301/ 984-1440 (for TDD, use 301/ 984-4155).
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; or
The day your benefits from your former plan run
out; or
The 92 nd day after you become a member of this Plan, whichever
happens first.
These provisions apply only to the benefits of the
hospitalized person. 10
10 Page
11 12
2002 SAMBA 11 Section 3
How to Get Approval for…
Your hospital stay
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. Unless we are misled by the
information given to us, we won't change our decision on medical necessity.
In most cases, your physician or hospital will take care of precertification.
Because you are still responsible for ensuring that we are asked to precertify
your care, you should
always ask your physician or hospital whether they
have contacted us.
Warning: We will reduce our benefits for the inpatient hospital stay
by $500 if no one contacts us for precertification. If the stay is not medically
necessary, we will not pay any inpatient
benefits.
How to precertify
an admission:
You, your representative, your doctor, or your hospital
must call CareFirst or First Health before admission. If you live in the
Washington, DC/ Baltimore area, call
CareFirst at 1-800/ 553-8700 toll-free.
Call First Health from all other areas at 1-800/ 346-6755 toll-free.
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 doctor, 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.
Provide
the following information:
– Enrollee's name and Plan identification number;
– Patient's name, birth date, and phone number;
– Reason for
hospitalization, proposed treatment, or surgery;
– Name and phone number of
admitting doctor;
– Name of hospital or facility; and
– Number of
planned days of confinement.
We will then tell the doctor and/ or hospital
the number of approved inpatient days and we will send written confirmation of
our decision to you, your doctor, and the
hospital.
Maternity care
You do not need to precertify a maternity admission for a routine delivery.
However, if your medical condition requires you to stay more than 48 hours after
a vaginal delivery or
96 hours after a cesarean section, then your physician
or the hospital must contact us for precertification of additional days.
Further, if your baby stays after you are discharged,
then your physician or
the hospital must contact us for precertification of additional days for your
baby.
If your hospital stay If your hospital stay – including for maternity
care – needs to be extended, you, your needs to be extended:
representative, your doctor or the hospital must ask us to approve the
additional days. 11
11 Page
12 13
2002 SAMBA 12 Section 3
What happens when you When we precertified the admission but you
remained in the hospital beyond the do not follow the number of days we
approved and did not get the additional days precertified, then:
precertification rules – for the part of the admission that was
medically necessary, we will pay inpatient
benefits, but
– for the part
of the admission that was not medically necessary, we will only pay for medical
services and supplies otherwise payable on an outpatient basis and will
not
pay inpatient benefits.
If no one contacted us, we will decide whether the
hospital stay was medically necessary.
– If we determine that the stay was medically necessary, we will pay the
inpatient charges, less the $500 penalty.
– If we determine that it was not
medically necessary for you to be an inpatient, we will not pay inpatient
hospital benefits. We will only pay for any covered medical
supplies and
services that are otherwise payable on an outpatient basis.
If we denied the
precertification request, we will not pay inpatient hospital benefits. We will
only pay for any covered medical supplies and services that are otherwise
payable on an outpatient basis.
Exceptions: You do not need
precertification in these cases:
You are admitted to a hospital outside the
United States.
You have another group health insurance policy that is the
primary payer for the hospital stay.
Your Medicare Part A is the primary payer for the hospital stay. Note: If you
exhaust your Medicare hospital benefits and do not want to use your Medicare
lifetime reserve days, then we will become the primary payer and you do
need precertification.
Other services Some services require a referral, precertification, or
prior authorization.
Rental or purchase (at our option) of covered durable
medical equipment (DME) or orthopedic and prosthetic devices requires
preauthorization once accumulated rental
charges or single purchase price
exceeds $1,000. Call SAMBA at 1-800/ 638-6589 or 301/ 984-1440 (for TDD, use
301/ 984-4155) to obtain preauthorization
Private duty nursing services must be preauthorized by SAMBA; call 1-800/
638-6589 or 301/ 984-1440 (for TDD, use 301/ 984-4155).
Preauthorization is
required for covered outpatient services for the treatment of mental conditions
and substance abuse when treatment continues beyond 10 visits
per person,
per calendar year. Call 1-800/ 999-9849 in the Washington, DC and Baltimore
Metropolitan areas, in all other areas call 1-800/ 346-6755 to obtain
preauthorization. 12
12 Page 13 14
2002 SAMBA 13 Section 3
Warning: We will reduce our
benefits to 80% of the benefit otherwise payable if no one contacts us for
preauthorization. In addition, if the services are not medically
necessary,
we will not pay any benefits.
We cover Growth hormone therapy (GHT) drugs in
Section 5( f) when we preauthorize the treatment. Call
SAMBA at 1-800/ 638-6589 or 301/ 984-1440 (for
TDD, use 301/ 984-4155) for
preauthorization. If we determine GHT is not medically necessary, we will not
cover the GHT or related services and supplies.
Note: The precertification process for organ transplants is more extensive
than the normal precertification process. See Section 5( b) on
page 32. 13
13 Page
14 15
2002 SAMBA 14 Section 4
Section 4. Your costs for covered services
This is what you
will pay out-of-pocket for your covered care:
Copayments A copayment
is a fixed amount of money you pay to the provider, facility, pharmacy, etc.,
when you receive services.
Example: When you see your PPO physician you pay a copayment of $20 per
visit.
We also have a separate copayment for:
Inpatient hospital
confinement; PPO: $200 per admission, non-PPO: $300 per admission
Outpatient
services facility charge; PPO: $100 per facility, per day, non-PPO: $150 per
facility, per day
Deductible 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. Copayments, coinsurance
and prescription drug program charges do
not count toward any deductible.
The calendar year deductible is $300 per
person. Under a 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 $600.
We also have separate deductibles
for:
– Certain covered expenses for the treatment of mental health and
substance abuse. The calendar year deductible is $300 per person/$ 600 per
family.
– Expenses for dental treatment of an accidental injury to sound,
natural teeth; $100 per person, per accident.
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 pCould not acquire words on page 16 lans at another
time during the year, you must begin a new deductible under your new plan.
Coinsurance Coinsurance is the percentage of our allowance that you
must pay for your care. Coinsurance doesn't begin until you meet your
deductible.
Example: You pay 10% of our allowance for in-network or 30% of
our allowance for out of network laboratory services.
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 30% coinsurance, the actual charge is $70. We will pay $49
(70% of the actual
charge of $70). 14
14
Page 15 16
2002 SAMBA 15 Section 4
Differences between Our "Plan
allowance" is the amount we use to calculate our payment for covered services.
our allowance and Fee-for-service plans arrive at their allowances in
different ways, so their allowances
the bill vary. For more
information about how we determine our Plan allowance, see
the definition of Plan allowance in Section 10.
Often, the provider's bill is more than a fee-for-service plan's allowance.
Whether or not you have to pay the difference between our allowance and the bill
will depend on the
provider you use.
PPO providers agree to limit
what they will bill you. Because of that, when you use a preferred provider,
your share of covered charges consists only of your deductible
and
coinsurance or copayment. Here is an example about coinsurance: You see a PPO
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 --10% of our $100 allowance ($ 10). Because of the agreement, your PPO
physician
will not bill you for the $50 difference between our allowance and
his bill.
Non-PPO providers, on the other hand, have no agreement to
limit what they will bill you. When you use a non-PPO 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 a non-PPO
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 30% of
our $100 allowance ($ 30). Plus, because
there is no agreement between the
non-PPO physician and us, he can bill you for the $50 difference between our
allowance and his bill.
The following table illustrates the examples of how much you have to pay
out-of-pocket for services from a PPO physician vs. a non-PPO physician. The
table uses our example
of a service for which the physician charges $150 and
our allowance is $100. The table shows the amount you pay if you have met your
calendar year deductible.
EXAMPLE PPO provider Non-PPO provider Surgical charge $150 $150
Our allowance We set it at: 100 We set it at: 100 We pay 90% of our
allowance: 90 70% of our allowance: 70
You owe: Coinsurance 10% of our
allowance: 10 30% of our allowance: 30
+Difference up to charge? No: 0 Yes:
50
TOTAL YOU PAY $10 $80 15
15 Page 16 17
16 Page 17 18
2002 SAMBA 17 Section 4
When you are age
65 or over and you do not have Medicare
Under the FEHB law, we must
limit our payments for those benefits you would be entitled to if you had
Medicare. And, your physician and hospital must follow Medicare rules and cannot
bill you for more than they could bill you if you had Medicare. The
following chart has more information about the limits.
If you… are age 65 or over, and
do not have Medicare Part A, Part
B, or both; and
have this Plan as an annuitant or as a former spouse, or
as a family member of an annuitant or former spouse; and
are not
employed in a position that gives FEHB coverage. (Your employing office can tell
you if this applies.)
Then, for your inpatient hospital care, the law requires us to base
our payment on an amount – the "equivalent Medicare amount" – set by Medicare's
rules for
what Medicare would pay, not on the actual charge;
you are
responsible for your applicable deductibles, coinsurance, or copayments you owe
under this Plan;
you are not responsible for any charges greater than the
equivalent Medicare amount; we will show that amount on the explanation of
benefits (EOB) form that we send you; and
the law prohibits a hospital from collecting more than the Medicare
equivalent amount.
And, for your physician care, the law requires us
to base our payment and your coinsurance on… an amount set by Medicare and
called the "Medicare approved amount," or
the actual charge if it is lower than the Medicare approved amount.
If
your physician… Then you are responsible for…
Participates with Medicare
or accepts Medicare assignment for the claim and is a member of our
PPO
network,
your deductibles, coinsurance, and copayments;
Participates with Medicare and is not in our PPO network, your
deductibles, coinsurance, copayments, and any balance up to the Medicare
approved amount;
Does not participate with Medicare, your deductibles,
coinsurance, copayments, and any balance up to 115% of the Medicare approved
amount
It is generally to your financial advantage to use a physician who
participates with Medicare. Such physicians are permitted to collect only up to
the Medicare approved amount.
Our explanation of benefits (EOB) form will tell you how much the physician
or hospital can collect from you. If your physician or hospital tries to collect
more than allowed by law, ask the physician or hospital to reduce the charges.
If you have paid more than
allowed, ask for a refund. If you need further
assistance, call us. 17
17 Page
18 19
2002 SAMBA 18 Section 4
When you have the We limit our
payment to an amount that supplements the benefits that Medicare would
Original Medicare Plan pay under Medicare Part A (Hospital insurance) and
Medicare Part B (Medical
(Part A, Part B, or both) insurance),
regardless of whether Medicare pays. Note: We pay our regular benefits for
emergency services to an institutional provider, such as a hospital, that does
not
participate with Medicare and is not reimbursed by Medicare.
If you
are covered by Medicare Part B and it is primary, your out-of-pocket costs for
services that both Medicare Part B and we cover depend on whether your physician
accepts Medicare assignment for the claim.
If your physician accepts
Medicare assignment, then you pay nothing for covered charges.
If your physician does not accept Medicare assignment, then you pay the
difference between our payment combined with Medicare's payment and the charge.
Note: The physician who does not accept Medicare assignment may not bill you
for more than 115% of the amount Medicare bases its payment on, called the
"limiting
charge." The Medicare Summary Notice (MSN) that Medicare will send
you will have more information about the limiting charge. If your physician
tries to collect more than
allowed by law, ask the physician to reduce the
charges. If the physician does not, report the physician to your Medicare
carrier who sent you the MSN form. Call us if you need
further assistance.
When you have a Medicare A physician may ask you to sign a private
contract agreeing that you can be billed Private Contract with a directly
for services Medicare ordinarily covers. Should you sign an agreement,
physician Medicare will not pay any portion of the charges, and we
will not increase our payment. We will still limit our payment to the amount we
would have paid after Medicare's
payment.
Please see Section 9, Coordinating benefits with other coverage, for
more information about how we coordinate benefits with Medicare. 18
18 Page 19 20
2002 SAMBA 19 Section 5
Section 5. Benefits – OVERVIEW
(See page 7 for how our benefits changed this
year and page 71 for a benefits summary.)
NOTE: 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. To
obtain claim
forms, claims filing advice, or more information about our benefits, contact us at 1-800/
638-6589 or 301/ 984-1440 (for TDD, use 301/ 984-4155) or at our website at www.
samba-insurance. com.
(a) Medical services and supplies provided by physicians
and other health care
professionals.................................................... 20-28
Diagnostic and treatment services
Lab, X-ray, and other diagnostic tests
Preventive care, adult
Preventive care, children
Maternity care
Family planning
Infertility services
Allergy care
Treatment
therapies
Physical and occupational therapy
Speech therapy
Hearing services (testing, treatment, and supplies)
Vision services (testing, treatment, and supplies)
Foot care
Orthopedic and prosthetic devices
Durable medical equipment (DME)
Home health services
Chiropractic
Alternative treatments
Educational classes and programs
(b) Surgical and anesthesia services provided by physicians
and other health care professionals
................................................ 29-34
Surgical
procedures
Reconstructive surgery
Oral and maxillofacial surgery
Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and
ambulance
services..............................................................................
35-38
Inpatient hospital
Outpatient hospital or ambulatory surgical
center
Extended care benefits/ Skilled nursing care facility
benefits
Hospice care
Ambulance
Blood and plasma
(d) Emergency services/ Accidents
......................................................................................................................................................
39
Medical emergency
Accidental injury
Ambulance
(e) Mental health and substance abuse benefits
............................................................................................................................
40-43
(f) Prescription drug
benefits........................................................................................................................................................
44-47
(g) Special
features........................................................................................................................................................................
48-49
Flexible benefits option
Managed Care Advisor (MCA) Program
World
Wide Assistance Program
24-hour nurse line
Services for deaf and hearing impaired
High risk pregnancies
National
Transplant Program and Centers of
Excellence for organ/ tissue transplants
Travel benefit/ services overseas
(h) Dental
benefits.........................................................................................................................................................................
50-51
(i) Non-FEHB benefits available to Plan members
............................................................................................................................
52
SUMMARY OF
BENEFITS...................................................................................................................................................................
71 19
19 Page
20 21
2002 SAMBA 20 Section 5( a)
Section 5 (a). Medical services and
supplies provided by physicians and other health care professionals
I M
P O
R T
A N
T
Here are some important things you should keep in mind about these
benefits:
Please remember that all benefits are subject to the
definitions, limitations, and exclusions in this brochure and are payable only
when we determine they are medically necessary.
The calendar year deductible is: $300 per person ($ 600 per family). The
calendar year deductible applies to almost all benefits in this Section. We
added "( No deductible)" to show when the
calendar year deductible does not
apply.
The non-PPO benefits are the standard benefits of this Plan. PPO
benefits apply only when you use a PPO provider. When no PPO provider is
available, non-PPO benefits apply.
Be sure to read Section 4, Your costs for covered services,
for valuable information about how cost sharing works,
with special sections for members who are age 65 or over.
Also read Section 9
about coordinating benefits with
other coverage, including with Medicare.
I M
P O
R T
A N
T
Benefit Description You pay After the calendar year deductible…
NOTE: The calendar year deductible applies to almost all benefits in
this Section. We say "( No deductible)" when it does not apply.
Diagnostic and treatment services
Professional services of
physicians
Office visits and consultations, including second surgical
opinion.
Note: We cover one routine physical exam and one routine gynecologic exam for
women age 18 and older, per calendar year.
PPO: $20 copayment per office visit (No deductible)
Non-PPO: 30% of the
Plan allowance and any difference between our allowance and the
billed
amount
Same day services performed and billed by the doctor in conjunction with the
office visit PPO: 10% of the Plan allowance (No deductible)
Non-PPO: 30% of
the Plan allowance and any difference between our allowance and the
billed
amount
Professional services of physicians
In an urgent care center
During a hospital stay
In a skilled nursing facility
Examination
during a hospital stay of a newborn child covered under a family enrollment
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount 20
20 Page
21 22
2002 SAMBA 21 Section 5( a)
Lab, X-ray and other diagnostic tests You pay
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
CAT Scans/ MRI
Ultrasound
Electrocardiogram and EEG
Note: We cover lab, X-ray and other diagnostic tests (also see Preventive
care, adult) related to one routine physical exam and
one routine
gynecologic exam for women age 18 and older, per calendar year. Non-routine or
more extensive tests as determined
by the Plan are not covered under this
benefit.
PPO: 10% of the Plan allowance (No deductible)
Non-PPO: 30% of the Plan
allowance and any difference between our allowance and the
billed amount
Note: If your PPO provider uses a non-PPO lab or radiologist, we will pay
non-PPO
benefits for any lab and X-ray charges.
Preventive care, adult
Cancer screenings, including:
Fecal
occult blood test for members age 40 and older
Prostate Specific Antigen
(PSA test) – one annually for men age 40 and older
Routine pap test
PPO: Nothing (No deductible)
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount
Sigmoidoscopy, screening – every five years starting at age 50 PPO: 10% of
the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference
between our allowance and the
billed amount
Routine screenings, limited to:
Total blood cholesterol
Chlamydial infections
PPO: 10% of the Plan allowance for other services (No deductible)
Non-PPO: 30% of the Plan allowance and any difference between our allowance
and the
billed amount
Routine mammogram – covered for women age 35 and
older, as follows:
From age 35 through 39, one during this five year period
From age 40
through 64, one every calendar year
At age 65 and older, one every two
consecutive calendar years
PPO: Nothing (No deductible)
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount
Preventive care, adult – continued on next page 21
21 Page 22 23
2002 SAMBA 22 Section 5( a)
Preventive care, adult
(continued) You pay
Routine immunizations, limited
to:
Tetanus-diphtheria (Td) booster – once every 10 years, ages 19 and over
(except as provided for under Childhood
immunizations)
Influenza/ Pneumococcal vaccines, annually
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount
Not covered:
Routine immunizations not listed above.
All
charges.
Preventive care, children
Childhood immunizations recommended by
the American Academy of Pediatrics for dependent children under age 22 PPO:
Nothing (No deductible)
Non-PPO: Nothing (No deductible)
The office visit for routine well-child care examinations,
Same day
services performed and billed by the doctor in conjunction with the office
visit.
PPO: $20 copayment per office visit (No deductible)
Non-PPO: 30% of the Plan allowance and any difference between our allowance
and the
billed amount
Laboratory tests, including blood lead level screenings PPO: 10% of the Plan
allowance (No deductible)
Non-PPO: 30% of the Plan allowance and any difference between our allowance
and the
billed amount
Maternity care
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:
You do not need to precertify
your normal delivery; see page 11 for other circumstances,
such as extended stays for you or your
baby.
You may remain in the hospital up to 48 hours after a regular
delivery and 96 hours after a caesarean delivery. We will cover
an extended stay if medically necessary, but you, your representative, your
doctor, or your hospital must precertify.
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount
Maternity care – continued on next page 22
22 Page 23 24
2002 SAMBA 23 Section 5( a)
Maternity care
(continued) You pay
We cover routine nursery care
of the newborn child during the covered portion of the mother's maternity stay.
We will cover
other care of an infant who requires non-routine treatment if
we cover the infant under a Self and Family enrollment.
We pay hospitalization and surgeon services (delivery) the
same as for illness and injury. See Hospital benefits (Section
5( c)) and Surgery benefits (Section 5( b)).
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount
Not covered:
Routine sonograms to determine fetal age, size or
sex
Stand-by doctor for caesarean section
Services before
enrollment in the Plan begins or after enrollment ends
All charges
Family planning
A broad range of voluntary family planning
services, limited to:
Voluntary sterilization
Surgically implanted
contraceptives (such as Norplant)
Injectable contraceptive drugs (such as
Depo provera)
Intrauterine devices (IUDs)
Diaphragms
Note: We cover
oral contraceptives under the prescription drug benefit.
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount
Not covered:
Reversal of voluntary surgical sterilization
Genetic counseling
All charges.
Infertility services
Diagnosis and treatment of infertility,
except as shown in Not covered.
Coverage is limited to – $5,000 per person, per
lifetime, including fertility drugs covered in Section 5( f).
PPO: 10%
of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference
between our allowance and the
billed amount
Infertility services – continued on next page 23
23 Page 24 25
2002 SAMBA 24 Section 5( a)
Infertility services
(continued) You Pay
Not covered:
Infertility services after voluntary sterilization
Fertility drugs
Assisted reproductive technology (ART)
procedures, such as:
– artificial insemination
– in vitro
fertilization
– embryo transfer and GIFT
– intravaginal
insemination (IVI)
– intracervical insemination (ICI)
–
intrauterine insemination (IUI)
Services and supplies related to
ART procedures
Cost of donor sperm
Cost of donor egg.
All charges.
Allergy care
Allergy injections, testing and treatment, including
materials (such as allergy serum) PPO: 10% of the Plan allowance
Non-PPO:
30% of the Plan allowance and any difference between our allowance and the
billed amount
Treatment therapies
Chemotherapy and radiation therapy
Dialysis – Renal dialysis, hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy – Home IV and antibiotic therapy
Transparenteral nutrition (TPN)
Growth hormone therapy (GHT)
Note:
Growth hormone is covered under the prescription drug benefit.
Note: – We only cover GHT when we preauthorize the treatment. Call 1-800/
638-6589 or 301/ 984-1440 (for TDD, use
301/ 984-4155) for preauthorization.
We will ask you to submit information that establishes that the GHT is medically
necessary.
See Other Services in Section 3.
Respiratory and inhalation therapies
Cardiac rehabilitation
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount 24
24 Page
25 26
2002 SAMBA 25 Section 5( a)
Physical and occupational therapies You pay
Physical therapy
–
Limited to:
$3,000 per person, per calendar year for the services of a
qualified physical therapist or physician
PPO: 10% of the Plan allowance
Non-PPO: 50% of the Plan allowance and any
difference between our allowance and the
billed amount
Occupational therapy PPO: 10% of the Plan allowance
Non-PPO: 30% of the
Plan allowance and any difference between our allowance and the
billed amount
Not covered:
Long-term rehabilitative therapy
Exercise programs
All charges.
Speech therapy
Speech therapy –
Note: Covered expenses are
limited to charges of a licensed speech therapist for speech loss or impairment
due to (a) congenital anomaly
or defect, whether or not surgically corrected or (b) due to any other
illness or surgery.
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount
Hearing services (testing, treatment, and supplies)
First hearing
aid and testing only when necessitated by accidental injury PPO: 10% of the Plan
allowance
Non-PPO: 30% of the Plan allowance and any difference between our
allowance and the
billed amount
Not covered:
Hearing testing
Hearing aids, testing and examinations for them, except for
accidental injury
All charges.
Vision services (testing, treatment, and supplies)
One pair of
eyeglasses or contact lenses to correct an impairment directly caused by
accidental ocular injury or
intraocular surgery (such as for cataracts)
Vision therapy, such as eye exercises or orthoptics
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount
Not covered:
Eyeglasses or contact lenses and examinations for
them except as noted above
Radial keratotomy, lasik and other refractive surgery
2002 SAMBA 26 Section 5( a)
Foot care You pay
Routine
foot care when you are under active treatment for a metabolic or peripheral
vascular disease, such as diabetes.
Removal of nail root
See Orthopedic and prosthetic devices for
information on podiatric shoe inserts.
PPO: $20 copayment for the office visit (No deductible) plus 10% of the Plan
allowance
for other services
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount
Not covered:
Cutting, trimming or removal of
corns, calluses, or the free edge of toenails, and similar routine treatment of
conditions of the
foot, except as stated above
Treatment of weak, strained or
flat feet or bunions; and of any instability, imbalance or subluxation of the
foot (unless the
treatment is by open cutting surgery)
All charges
Orthopedic and prosthetic devices
Artificial limbs and eyes; stump
hose
Orthopedic and corrective shoes, arch supports, foot orthotics, heel
pads and heel cups
Externally worn breast prostheses and surgical bras, including necessary
replacements following a mastectomy
Lumbosacral supports
Crutches,
surgical dressings, splints, casts, and similar supplies
Braces, corsets,
trusses, elastic stockings, support hose, and other supportive devices
Internal prosthetic devices, such as artificial joints, pacemakers, cochlear
implants, and surgically implanted breast implant
following mastectomy. Note: See 5( b) for coverage of the surgery to
insert the device.
Note: Certain services listed above require
precertification (refer to Section 3). Dental prosthetic appliances are
covered under Section
5( h).
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount 26
26 Page
27 28
2002 SAMBA 27 Section 5( a)
Durable medical equipment (DME) You
pay
Durable medical equipment (DME) is equipment and supplies that:
1. Are prescribed by your attending physician (i. e., the physician who is
treating your illness or injury);
2. Are medically necessary;
3. Are primarily and customarily used only
for a medical purpose;
4. Are generally useful only to a person with an
illness or injury;
5. Are designed for prolonged use; and
6. Serve a
specific therapeutic purpose in the treatment of an illness or injury.
We cover rental or purchase, at our option, including repair and adjustment,
of durable medical equipment, such as:
Oxygen equipment and oxygen
Hospital beds
Wheelchairs
Walkers
Note:
Certain services listed above require precertification (refer to Section 3).
PPO: 10% of the Plan allowance
Non-PPO: 50% of the Plan allowance and any
difference between our allowance and the
billed amount
Not covered:
Air conditioners, humidifiers, dehumidifiers,
purifiers
Other items that do not meet the definition of durable
medical equipment
All charges
Home health services
Home health aide services, limited to:
100 visits per person per calendar year for covered services of a home
health aide. Services must be furnished by a home health
care agency in accordance with a home health care plan as defined in Section 10, page 64.
Note: Each visit taking 4 hours or less is counted as one visit. If a visit
exceeds 4 hours, each 4 hours or fraction is counted as a
separate visit.
PPO: 10% and all charges after 100 visits
Non-PPO: 30% and all charges
after 100 visits
Private duty nursing care, limited to:
$10,000 per person, per calendar
year for covered services of a registered nurse (R. N.), licensed practical
nurse (L. P. N.),
licensed vocational nurse (L. V. N.), or Christian Science nurse.
Note: Private duty nursing requires precertification. Refer
to Section 3, Other services.
PPO: 10% and all charges after we pay $10,000
Non-PPO: 50% and all
charges after we pay $10,000
Home health services – continued on next page 27
27 Page 28 29
2002 SAMBA 28 Section 5( a)
Home health services
(continued) You Pay
Not covered:
Nursing care requested by, or for the convenience of, the patient or
the patient's family;
Services primarily for hygiene, feeding, exercising, moving the patient,
homemaking, companionship or giving oral medication.
All charges.
Chiropractic
Services of a chiropractor, such as manipulation and
X-rays
Note: Benefits are limited to $500 per person, per calendar year
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our allowance
and the billed
amount
Alternative treatments
Acupuncture by a doctor of medicine or
osteopathy for pain relief
Note: Benefits are limited to $500 per person, per calendar year
PPO: 10%
of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference
between our allowance and the
billed amount
Not covered:
Naturopathic practitioner
Massage therapist
(Note: benefits of certain alternative treatment providers may be covered
in medically underserved areas; see page 9)
All charges
Educational classes and programs
Coverage is limited to:
Smoking Cessation – Up to $100 for one smoking cessation program per member
per lifetime, including all related expenses
such as drugs.
Diabetes self management.
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount 28
28 Page
29 30
2002 SAMBA 29 Section 5( b)
Section 5 (b). Surgical and
anesthesia services provided by physicians and other health care professionals
I M
P O
R T
A N
T
Here are some important things you should keep in mind about these
benefits:
Please remember that all benefits are subject to the
definitions, limitations, and exclusions in this brochure and are payable only
when we determine they are medically necessary.
The calendar year deductible is: $300 per person ($ 600 per family). The
calendar year deductible applies to almost all benefits in this Section. We
added "( No deductible)" to show when the
calendar year deductible does not
apply.
The non-PPO benefits are the standard benefits of this Plan. PPO
benefits apply only when you use a PPO provider. When no PPO provider is
available, non-PPO benefits apply.
Be sure to read Section 4, Your costs for covered services,
for valuable information about how cost sharing works, with special sections
for members who are age 65 or over. Also read Section 9
about coordinating benefits with other coverage, including with
Medicare.
The amounts listed below are for the charges billed by a physician
or other health care professional for your surgical care. Look in Section 5( c) for charges associated with the facility (i. e.
hospital,
surgical center, etc.).
YOU MUST GET PRECERTIFICATION
OF SOME SURGICAL PROCEDURES. Please refer to Organ/ tissue transplants (page
32) for information regarding the National Transplant
Program/ Centers of Excellence.
I M
P O
R T
A N
T
Benefit Description You pay After the calendar year deductible…
NOTE: The calendar year deductible applies to almost all benefits in
this Section. We say "( No deductible)" when it does not apply
Surgical procedures
A comprehensive range of services, such as:
Operative procedures Treatment of fractures, including casting
Normal pre-and post-operative care by the surgeon Correction of amblyopia and
strabismus
Endoscopy procedures Biopsy procedures
Removal of tumors and
cysts Correction of congenital anomalies (see Reconstructive
surgery)
Surgical treatment of morbid obesity --a condition in which
an individual weighs 100 pounds or 100% over his or her normal
weight
according to current underwriting standards; eligible members must be age 18 or
over
Insertion of internal prosthetic devices. See 5( a) –
Orthopedic and prosthetic devices for device coverage
information
Voluntary sterilization,
Norplant (a surgically implanted contraceptive), and intrauterine devices
(IUDs)
Treatment of burns Assistant surgeons -we cover up to 20% of our
allowance for
the surgeon's charge
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount
Surgical procedures – continued on next page 29
29 Page 30 31
2002 SAMBA 30 Section 5( b)
Surgical procedures
(continued) You pay
When multiple or bilateral surgical
procedures performed during the same operative session add time or complexity to
patient care,
our benefits are:
For the primary procedure:
– PPO:
90% of the Plan allowance or
– Non-PPO: 70% of the Plan allowance
For the secondary procedure( s):
– PPO: 90% of one-half of the Plan
allowance or
– Non-PPO: 70% of one-half of the Plan allowance
Note: Multiple or bilateral surgical procedures performed through the same
incision are "incidental" to the primary surgery. That is,
the procedure
would not add time or complexity to patient care. We do not pay extra for
incidental procedures.
PPO: 10% of the Plan allowance for the primary procedure and 10% of one-half
of the
Plan allowance for the secondary procedure( s)
Non-PPO: 30% of
the Plan allowance for the primary procedure and 30% of one-half of the
Plan
allowance for the secondary procedure( s); and any difference between our
payment and the billed amount
Not covered:
Reversal of voluntary sterilization
Services of a standby surgeon, except during angioplasty or other
high risk procedures when we determine standbys are medically necessary
Routine treatment of conditions of the foot; see Foot care
Eye
surgery, such as radial keratotomy, lasik and laser surgery when the primary
purpose is to correct myopia
(nearsightedness), hyperopia (farsightedness) or astigmatism (blurring)
All charges.
Reconstructive surgery
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
– the
condition produced a major effect on the member's appearance and
– the condition can reasonably be expected to be corrected by such surgery
Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form or norm.
Examples of congenital
anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks;
and webbed
fingers and toes.
All stages of breast reconstruction surgery
following a mastectomy, such as:
– surgery to produce a symmetrical appearance on the other breast;
–
treatment of any physical complications, such as lymphedemas;
– breast
prostheses; and surgical bras and replacements (see Orthopedic
and prosthetic devices for coverage)
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount
Reconstructive surgery – continued on next page 30
30 Page 31 32
2002 SAMBA 31 Section 5( b)
Reconstructive surgery
(continued) You pay
Note: We pay for internal breast prostheses as orthopedic and prosthetic
devices, see Section 5( a).
Note: If you need a mastectomy, you may choose to have the procedure
performed on an inpatient basis and remain in the
hospital up to 48 hours
after the procedure.
Not covered:
Cosmetic surgery – any
surgical procedure (or any portion of a procedure) performed primarily to
improve physical
appearance through change in bodily form, except repair of accidental
injury
Surgeries related to sex transformation or sexual dysfunction
All charges
Oral and maxillofacial surgery
Oral surgical procedures, limited
to:
Reduction of fractures of the jaws or facial bones
Surgical
correction of cleft lip, cleft palate or severe functional malocclusion
Removal of stones from salivary ducts
Excision of impacted teeth, bony
cysts of the jaw, torus palatinus, leukoplakia or malignancies
Excision of cysts and incision of abscesses not involving the teeth
Other
surgical procedures that do not involve the teeth or their supporting structures
Freeing of muscle attachments
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount
Not covered:
Oral implants and transplants
Procedures that involve the teeth or their supporting structures
(such as the periodontal membrane, gingiva, and alveolar bone)
All charges 31
31 Page 32 33
2002 SAMBA 32
Section 5( b)
Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Liver
Lung: Single;
Double
Pancreas
Bone marrow transplants as follows: Allogeneic (donor)
bone marrow transplants
Autologous bone marrow transplants (autologous stem cell support) and
autologous peripheral stem cell support for:
acute lymphocytic or
non-lymphocytic leukemia; advanced Hodgkin's lymphoma; advanced non-Hodgkin's
lymphoma;
advanced neuroblastoma; breast cancer; multiple myeloma;
epithelial ovarian cancer; and testicular, mediastinal,
retroperitoneal and
ovarian germ cell tumors.
Intestinal transplants (small intestine) and the
small intestine with the liver or small intestine with multiple organs such as
the
liver, stomach, and pancreas
Nothing when performed through the First Health National Transplant Program
or
CareFirst's Centers of Excellence, except for cornea and pancreas.
Note: When services are rendered outside the above programs, the standard
Plan benefits
apply and are limited to $100,000 per transplant.
National Transplant Program/ Centers of Excellence -The Plan pays 100% of
covered expenses for the organ transplants as listed
(except cornea and
pancreas) when performed through the First Health National Transplant Program or
CareFirst's Centers of
Excellence. Covered expenses are:
The
pretransplant evaluation;
Organ procurement;
The transplant procedure itself (hospital and doctor
fees); Transplant-related follow-up care for up to one year; and
Pharmacy costs for immunosuppressant and other transplant-related medication.
Note: As a potential candidate for an organ transplant procedure, you or
your doctor must contact the First Health National
Transplant Program at
1-800/ 346-6755 or CareFirst's Centers of Excellence (Washington, DC and
Baltimore area) at
1-800/ 553-8700 to initiate the pretransplant evaluation.
The clinical results of the evaluation will be reviewed to determine if the
proposed procedure meets the Plan's definition of medically necessary. A
case manager will assist the patient in accessing the
appropriate transplant
facility. This includes providing information to facilitate travel and lodging
arrangements and coordinating the
pretransplant evaluation.
Organ/
tissue transplants – continued on next page 32
32
Page 33 34
2002
SAMBA 33 Section 5( b)
Organ/ tissue transplants (continued)
You pay
Limited Benefits -
If you do not use either the First
Health National Transplant Program or a CareFirst Centers of Excellence
facility, standard Plan
benefits will be applied to your expenses. Total benefit payments, including
donor expenses, the transplant procedure itself (hospital
and doctor fees),
transplant-related follow-up care for one year, and pharmacy costs for
immunosuppressant and other transplant-related
medication will be limited to
a maximum payment of $100,000 per transplant. The travel and lodging allowance
will not be available.
Travel/ Lodging Benefit – If the recipient lives more than 50 miles from a
designated transplant facility, the Plan will provide an
allowance for
preapproved travel and lodging expenses up to $10,000 per transplant. The
allowance will provide coverage of
reasonable travel and temporary lodging
expenses for the recipient and one companion (two companions if the recipient is
a minor).
Travel and lodging to a designated facility for the pretransplant
evaluation is covered under this benefit even if the transplant is not
eventually certified as medically necessary.
Cornea and pancreas
transplants are not available through the above programs; therefore, the Travel/
Lodging Benefit is not available
and standard Plan benefits apply.
Note:
We cover related medical and hospital expenses of the actual donor when we cover
the recipient.
Not covered:
Donor screening tests and donor search expenses,
except those performed for the actual donor
Implants of artificial organs
Transplants and related services
not listed as covered
All charges
Anesthesia
Professional services provided in –
Hospital
(inpatient)
PPO: 10% of the Plan allowance (No deductible)
Non-PPO: 30% of the Plan allowance and any difference between our allowance
and the
billed amount (No deductible)
Note: If you use a PPO facility,
we pay PPO benefits if you receive treatment from an
anesthesiologist who is not a PPO provider.
Anesthesia – continued on
next page 33
33 Page
34 35
2002 SAMBA 34 Section 5( b)
Anesthesia (continued) You Pay
Professional
services provided in –
Hospital outpatient department
Skilled nursing
facility
Ambulatory surgical center
Office
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount
Note: If your PPO provider uses a non-PPO anesthesiologist,
we will pay non-PPO
benefits for any anesthesia charges. 34
34 Page 35 36
2002 SAMBA 35 Section 5( c)
Section 5 (c). Services provided by
a hospital or other facility, and ambulance services
I M
P O
R T
A N
T
Here are some important things you should keep in mind about these
benefits:
Please remember that all benefits are subject to the
definitions, limitations, and exclusions in this brochure and are payable only
when we determine they are medically necessary.
Unlike Sections 5( a) and 5( b), in this Section 5( c) the calendar year
deductible applies to only a few benefits. In that case, we added "( calendar
year deductible applies)". The calendar year deductible
is: $300 per person
$600 per family).
The non-PPO benefits are the standard benefits of this
Plan. PPO benefits apply only when you use a PPO provider. When no PPO provider
is available, non-PPO benefits apply.
Be sure to read Section 4, Your costs for covered services,
for valuable information about how cost sharing
works, with special sections for members who are age 65 or
over. Also read Section 9
about coordinating benefits
with other coverage, including with Medicare.
The amounts listed below are
for the charges billed by the facility (i. e. hospital or surgical center) or
ambulance service for your surgery or care. Any costs associated with the
professional charge
(i. e. physicians, etc.) are in Sections 5( a) or (b).
YOU MUST GET
PRECERTIFICATION OF HOSPITAL STAYS; FAILURE TO DO SO WILL RESULT IN A $500
PENALTY. Please refer to the precertification information shown in
Section 3 to be sure which services require
precertification.
I M
P O
R T
A N
T
Benefit Description You pay
NOTE: The calendar year deductible
applies ONLY when we say below: "( calendar year deductible applies)".
Inpatient hospital
Room and board, such as
ward, semiprivate,
or intensive care accommodations;
general nursing care; and
meals and
special diets.
Note: We only cover a private room when you must be isolated
to prevent contagion. Otherwise, we will pay the hospital's average
charge for semiprivate accommodations. If the hospital only has private
rooms, we base our payment on the lowest rate for a private
room.
Note:
When the non-PPO hospital bills a flat rate, we prorate the charges to determine
how to pay them, as follows: 30% room and
board and 70% other charges.
PPO: $200 copayment per confinement
Non-PPO: $300 copayment per
confinement and 30% of the Plan allowance
Note: A confinement is defined in Section 10, page 63.
Inpatient hospital -continued on next page. 35
35 Page 36 37
2002 SAMBA 36 Section 5( c)
Inpatient
hospital (continued) You pay
Other hospital services and
supplies, such as:
Operating, recovery, maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Blood or blood plasma, if not donated or replaced
Dressings, splints,
casts, and sterile tray services
Medical supplies and equipment, including
oxygen
Anesthetics
Note: We base payment on whether the facility or a health care professional
bills for the services or supplies. For example, when
the hospital bills for
anesthetic services, we pay Hospital benefits and when the anesthesiologist
bills, we pay Anesthesia benefits.
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance
Note: If you use a PPO facility, we pay PPO benefits if you receive treatment
from a
radiologist, pathologist, or anesthesiologist who is not a PPO
provider.
Not covered:
Any part of a hospital admission that is not
medically necessary (see definition), such as when you do not need acute
hospital
inpatient (overnight) care, but could receive care in some other setting
without adversely affecting your condition or the quality
of your medical
care. Note: In this event, we pay benefits for services and supplies other than
room and board and in-hospital
physician care at the level they would have
been covered if provided in an alternative setting
Custodial care; see definition.
Non-covered facilities or any
facility used principally for convalescence, for rest, for a nursing home, for
the aged, for
domiciliary or custodial care, or as a school,
Personal comfort
items, such as telephone, television, barber services, guest meals and beds
All charges.
Outpatient hospital or ambulatory surgical center
Operating,
recovery, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood, blood plasma, and other biologicals
Blood and
blood plasma, if not donated or replaced
Pre-surgical testing
Dressings,
casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia service
Note: We cover hospital services and supplies related to dental procedures
when necessitated by a non-dental physical impairment.
PPO: $100 copayment per outpatient facility charge and 10% of the Plan
allowance
(calendar year deductible applies)
Non-PPO: $150 copayment per
outpatient facility charge and 30% of the Plan allowance
and any difference
between our allowance and the billed amount (calendar year deductible
applies)
Note: You pay the copayment per facility per day 36
36 Page 37 38
2002 SAMBA 37 Section 5( c)
Extended
care benefits/ Skilled nursing care facility benefits You pay
Skilled
nursing facility (SNF)/ Convalescent nursing home (CNH): We cover services and
supplies in a SNF/ CNH for up to 60 days per
confinement when:
1) you
are admitted within 10 days after a precertified hospital stay of at least 3
consecutive days; and
2) your doctor recommends transfer to a SNF/ CNH in lieu of continued
hospitalization
Coverage limited to:
One-half of the standard semiprivate room rate of
the hospital in which the patient was confined (limited to 60 days)
Nothing
Note: You pay charges above the Plan's limit.
Not covered:
Custodial care
Personal comfort
services such as beauty and barber services
All charges.
Hospice care
Hospice is a coordinated program of maintenance and
supportive care for the terminally ill provided by a medically supervised team
under the direction of a Plan-approved independent hospice administration.
Note: A terminally ill person is a covered family member whose life
expectancy is six months or less, as certified by the primary
doctor.
Inpatient hospice care
We pay 60 days of inpatient care, up to $300 per
day until you incur $700 of out-of-pocket expenses. We then pay 100% of
covered charges during the remainder of the 60-day period of care.
You pay charges in excess of $300 per day, up to a $700 out-of-pocket
maximum, then
nothing until the 60 day limit is met.
Outpatient hospice care
We pay $2000 of covered outpatient services and
supplies for each period of hospice care.
Nothing until benefits stop at
$2000
Not covered:
Charges incurred during a period of remission.
Definition: A remission is a halt or actual reduction in the progression of
illness resulting in discharge from a hospice care
program with no further expenses incurred. A re-admission within 3 months
of a prior discharge is considered the same period of
care. A new period
begins 3 months after a prior discharge, with maximum benefits available
All charges. 37
37 Page 38 39
2002 SAMBA 38
Section 5( c)
Ambulance You pay
Local professional ambulance
service only to and from a hospital, when medically appropriate PPO: 10% of the
Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between
our allowance and the
billed amount
All other local ambulance service when medically
appropriate PPO: 10% of the Plan allowance (calendar year deductible applies)
Non-PPO: 30% of the Plan allowance and any difference between our allowance
and the
billed amount (calendar year deductible applies)
Blood and plasma
Blood and plasma to the extent not donated or
replaced when not otherwise payable under Inpatient hospital benefits.
Nothing 38
38 Page
39 40
2002 SAMBA 39 Section 5( d)
Section 5 (d). Emergency services/
accidents
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure.
The calendar year deductible is: $300 per person ($ 600 per family). The
calendar year deductible applies to almost all benefits in this Section. We
added "( No deductible)" to show when the
calendar year deductible does not
apply.
The non-PPO benefits are the standard benefits of this Plan. PPO
benefits apply only when you use a PPO provider. When no PPO provider is
available, non-PPO benefits apply.
Be sure to read Section 4, Your costs for covered services,
for valuable information about how cost sharing works, with special
sections for members who are age 65 or over. Also read Section 9
about coordinating benefits with other
coverage, including with Medicare.
I M
P O
R T
A N
T
What is an accidental injury?
An accidental injury is a bodily
injury sustained solely through violent, external, and
accidental means, such as broken bones, animal bites, and poisonings. See
Section 5( h) for dental care for accidental injury.
Benefit Description You pay After the calendar year deductible…
NOTE: The calendar year deductible applies to almost all benefits in
this Section. We say "( No deductible)" when it does not apply.
Accidental injury
If you receive care for your accidental injury
within 72 hours, we cover:
All medically necessary physician services and supplies
Related hospital
services
Note: Services received after 72 hours are considered the same as any other
illness and standard Plan benefits will apply.
PPO: Nothing (No deductible)
Non-PPO: Only the difference between our
allowance and the billed amount. (No
deductible)
Medical emergency
Medical emergencies are considered the same as
any other illness and standard Plan benefits apply. Standard benefits apply
Ambulance
Accidental injury –
Professional ambulance service,
including medically necessary air ambulance
We pay 100% when services are rendered within 72 hours of your accidental
injury.
Note: See 5( c) for non-emergency service.
PPO: Nothing (no deductible)
Non-PPO: Only the difference between our
allowance and the billed amount (No
2002 SAMBA 40 Section 5( e)
Section 5 (e). Mental health and
substance abuse benefits
I M
P O
R T
A N
T
You may choose to get care Out-of-Network or In-Network. When you receive
In-Network care, you must get our approval for services and follow a treatment
plan we approve. If you do, cost-sharing and
limitations for In-Network
mental health and substance abuse benefits will be no greater than for similar
benefits for other illnesses and conditions.
Here are some important things to keep in mind about these benefits:
Services must be provided by an In-Network provider to receive PPO
benefits.
All benefits are subject to the definitions, limitations, and
exclusions in this brochure.
We have a separate $300 per person ($ 600 per
family) calendar year deductible which applies to almost all benefits for the
treatment of mental health and substance abuse. For example, doctors'
inpatient hospital visits for a physical illness or disease applies to the
Plan's standard calendar year deductible. If the services are rendered to treat
mental health or substance abuse, the separate
mental health and substance
abuse calendar year deductible applies. We added "( No deductible)" to show when
a deductible does not apply.
Be sure to read Section 4, Your costs for covered services,
for valuable information about how cost sharing works. Also read Section
9 about coordinating benefits with other coverage, including with
Medicare.
YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See
the instructions after the benefits descriptions below.
In-Network mental health and substance abuse benefits are below, then Out-of-Network benefits begin on page 42.
I M
P O
R T
A N
T
Benefit Description You pay After the calendar year deductible…
NOTE: The calendar year deductible applies to almost all benefits in
this Section. We say "( No deductible)" when it does not apply.
In-Network benefits
All diagnostic and treatment services
contained in a treatment plan that we approve. The treatment plan may include
services, drugs,
and supplies described elsewhere in this brochure.
Note: In-Network benefits are payable only when we determine the care is
clinically appropriate to treat your condition and only when
you receive the care as part of a treatment plan that we approve.
Your cost sharing responsibilities are no greater than for other illness or
conditions.
Outpatient professional services by providers such as psychiatrists,
psychologists, or clinical social workers including:
– individual or group
therapy
– collateral visits with members of the patient's immediate family
– convulsive therapy visits
Medication management
Note:
Preauthorization is required; see page 41.
$20 copayment per visit (no deductible)
In-Network mental health and substance abuse benefits – continued on next
page 40
40 Page
41 42
2002 SAMBA 41 Section 5( e)
In-Network benefits
(continued) You pay
Other outpatient care including:
Day or after care (partial hospitalization) in a hospital
Note:
Preauthorization is required; see below.
10% of the Plan allowance
Diagnostic tests 10% of the Plan allowance
Covered inpatient hospital and
rehabilitation facility charges including:
Room and board, including general nursing care, in semiprivate accommodations
Other charges for hospital services and supplies (other than professional
services) including but not limited to the use of
operating, treatment and
recovery rooms; X-rays; surgical dressings; and drugs and medicines
Note: Precertification is required for an inpatient confinement; see below.
$200 per confinement copayment, nothing for room and board and 10% of Plan
allowance
for other hospital services (no deductible)
Note: A
confinement is defined in Section 10, page 63.
Services of a doctor for inpatient hospital visits 10% of the Plan allowance
Not covered:
Services we have not approved.
Note: OPM will
base its review of disputes about treatment plans on the treatment plan's
clinical appropriateness. OPM will
generally not order us to pay or provide one clinically appropriate
treatment plan in favor of another.
All charges.
Preauthorization To be eligible to receive enhanced mental health and
substance abuse benefits you must obtain a treatment plan and follow all of the
authorization processes. These
include obtaining Plan certification for:
The medical necessity of your admission to a hospital or other covered
facility prior to admission. Emergency admissions must be reported within two
business days following the day of admission even if you have been
discharged. Otherwise, the benefits payable will be reduced by $500.
Outpatient treatment beyond 10 visits per person, per calendar year, and day
or aftercare treatment (partial hospitalization). If preauthorization is not
obtained,
benefits will be reduced to 80% of the benefit otherwise payable.
Note: To obtain preauthorization and to locate a Network provider, call
1-800/ 999-9849 in the Washington, DC and Baltimore Metropolitan areas. In all
other areas, call 1-800/ 346-6755.
Network limitation If you do not obtain an approved treatment plan, we
will provide only Out-of-Network benefits. 41
41
Page 42 43
2002 SAMBA 42 Section 5( e)
Out-of-Network benefits You pay
We will cover the office visit fee for therapy sessions rendered by
providers such as psychiatrists, psychologists, or clinical social
workers.
Therapy sessions include:
Office visits, group therapy, and collateral
visits with members of the patient's immediate family
Limited benefits:
$100 per visit and 50 visits per person per calendar
year – including visits you paid for while satisfying the mental health
and substance abuse calendar year deductible.
Other outpatient care
includes:
Convulsive therapy visits, and
Day or after care (partial
hospitalization) in a hospital
Note: Almost all benefits for the treatment
of mental health and substance abuse require precertification, see page 43. During the
precertification process, we may establish an approved treatment plan.
50% of the Plan allowance and any difference between our allowance and the
billed amount
Note: You pay any charges above the Plan's limits.
Covered inpatient hospital and rehabilitation facility charges include:
Room and board including general nursing care, in semiprivate accommodations
Other charges for hospital services and supplies (other than professional
services) including but not limited to the use of
operating, treatment and
recovery rooms; X-rays; surgical dressings; and drugs and medicines
Limited benefits:
Confinement in a rehabilitation facility is limited to
1) a maximum of 30 days per confinement and 2) two confinements per person per
lifetime.
Note: Precertification is required for an inpatient
confinement, see page 43.
$300 per confinement copayment plus 30% of the Plan allowance and any
difference
between our allowance and the billed amount (No deductible)
Note: You pay any charges above the Plan's limits
Services of a doctor for inpatient hospital visits 30% of the Plan allowance
and any difference between our allowance and the billed amount
Not
covered out-of-network:
The same exclusions contained in this
brochure that apply to other benefits apply to mental health and substance abuse
benefits. OPM's review of disputes about out-of-network treatment plans
will be based on the treatment plan's clinical
appropriateness. OPM will
generally not order one clinically appropriate treatment plan in favor of
another.
Marital counseling
Treatment for learning disabilities
All charges
Out-of-Network benefits – continued on next page 42
42 Page 43 44
2002 SAMBA 43 Section 5( e)
Out-of-Network benefits
(continued)
Lifetime maximum Out-of-Network inpatient care
for the treatment of alcoholism and drug abuse is limited to two treatment
programs (30-day each maximum) per lifetime.
Precertification To be eligible to receive mental health and substance
abuse benefits you must follow your treatment plan and all of our authorization
processes. These include obtaining
Plan certification for:
The medical
necessity of your admission to a hospital or other covered facility prior to
admission. Emergency admissions must be reported within two
business days following the day of admission even if you have been
discharged. Otherwise, the benefits payable will be reduced by $500. See Section 3 for
details.
Outpatient treatment beyond 10
visits per person, per calendar year and day or aftercare treatment (partial
hospitalization). If preauthorization is not obtained,
benefits will be reduced to 80% of the benefit otherwise payable.
To
obtain preauthorization, call 1-800/ 999-9849 toll-free in the Washington, DC
and Baltimore Metropolitan areas. In all other areas call 1-800/ 346-6755
toll-free.
See these sections of the brochure for more valuable information about these
benefits:
Section 3, How you get care, for
information about out-of-pocket maximums for these benefits.
Section 7, Filing a claim for covered services, for
information about submitting out-of-network claims. 43
43 Page 44 45
2002 SAMBA 44 Section 5( f)
Section 5 (f). Prescription drug
benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart
beginning on the next page.
All benefits are subject to the definitions,
limitations and exclusions in this brochure and are payable only when we
determine they are medically necessary.
The calendar year deductible is: $300 per person ($ 600 per family). The
calendar year deductible applies to almost all benefits in this Section. We
added "( No deductible)" to show when the
calendar year deductible does not
apply.
The non-PPO benefits are the standard benefits of this Plan. PPO
benefits apply only when you use a PPO provider. When no PPO provider is
available, non-PPO benefits apply.
Be sure to read Section 4, Your costs for covered services,
for valuable information about how cost sharing works, with special
sections for members who are age 65 or over. Also read Section 9
about coordinating benefits with other
coverage, including with Medicare.
I M
P O
R T
A N
T
There are important features you should be aware of. These include:
Who can write your prescription. A licensed physician must write the
prescription.
Where you can obtain them. You may fill the
prescription at a participating Plan network pharmacy, a non-network pharmacy,
or by mail. – To receive the Plan's maximum benefit, you must fill the
prescription at a plan
pharmacy, or by mail for a maintenance medication.
We use a formulary.
We have an open formulary. An open formulary is a voluntary program to help
control the cost of care by asking your doctor to prescribe from a list of
medications preferred for their clinical effectiveness
and opportunities to help contain your and SAMBA's costs. The list of
medications is available online at www. merckmedco. com. For more information
about the formulary, call 1-800/ 283-3478.
These are the dispensing limitations.
– You may purchase up to a
30-day supply of covered drugs or supplies through the PAID system available at
most pharmacies. Call toll-free 1-800/ 283-3478 to locate a Plan network
pharmacy in your area. For each
prescription drug, supply or refill purchased at the pharmacy there is a
copayment of $15 generic, $25 name brand single source (no generic substitute)
and $30 multisource name brand.
– You may purchase up to a 90-day supply of covered drugs or supplies through
the mail order program. You order your prescription or refill by mail from the
Merck-Medco Home Delivery Pharmacy service (formerly
referred to as the
Merck-Medco Rx Services Mail Order Program). The Home Delivery Pharmacy service
will fill your prescription. For each prescription drug, supply or refill
purchased at the pharmacy there is a
copayment of $15 generic, $25 name
brand single source (no generic substitute) and $30 multisource name brand.
Note: If your physician prescribes a medication that will be taken over an
extended period of time, you should request two prescriptions – one to be used
for the participating Plan network pharmacy and the other for the Home
Delivery Pharmacy service. You may obtain up to a 30-day supply right away
through the prescription card program, and up to a 90-day supply from the Home
Delivery Pharmacy service.
A generic equivalent will be dispensed if it is available, unless your
physician specifically requires a name brand. If you receive a name brand drug
when a Federally-approved generic drug is available, and your physician has not
specified "dispense as written" for the name brand drug, you have to pay the
difference in cost between the name brand drug and the generic.
Prescription drug benefits – continued on next page 44
44 Page 45 46
2002 SAMBA 45 Section 5( f)
Section 5
(f). Prescription drug benefits (continued)
Why use generic
drugs? Generic drugs are lower-priced drugs that are the therapeutic
equivalent to more expensive name brand drugs. They must contain the same active
ingredients and must be equivalent in strength and dosage to
the original
name brand product. Generics cost less than the equivalent name brand product.
The U. S. Food and Drug Administration sets quality standards for generic drugs
to ensure that these drugs meet the same standards of
quality and strength
as name brand drugs. Using the most cost-effective medication saves money.
To claim benefits.
– From a pharmacy – When you purchase
medication from a network pharmacy use your SAMBA Health Insurance
Identification Card, which serves as a PAID Identification Card. In most cases,
you simply present
the card, together with the prescription, to the pharmacist; the claim is
automatically filed through the PAID system.
If you do not use your identification card when purchasing your medication,
or you use a non-network pharmacy, you must complete a direct reimbursement
claim form to claim benefits. You may obtain these
forms by calling PAID
toll-free at 1-800/ 283-3478. Service is available 7 days a week, 24 hours a
day. Follow the instructions on the form and mail it to:
PAID Prescriptions, L. L. C. P. O. Box 2187
Lee's Summit, MO 64063-2187
Note: Reimbursement will be limited to SAMBA's cost had you used a
participating pharmacy minus the copayments described above.
– By mail – The Plan will send you information on the Merck-Medco Home
Delivery service (formerly referred to as the Merck-Medco Rx Services Mail Order
Program):
1. ask your doctor to give you a new prescription for up to a
90-day supply of your regular medication plus refills, if appropriate;
2.
complete the patient profile questionnaire the first time you order under the
program; and 3. complete a mail order envelope, enclose your prescriptions, and
mail them along with the required
copayment -$15 generic, $25 name brand
single source (no generic equivalent) and $30 multisource name brand – for each
prescription or refill to:
The Merck-Medco Home Delivery Pharmacy service P. O. Box 67006
Harrisburg, PA 17106-7006
You must pay your share of the cost by check,
money order, VISA, Discover, or MasterCard (complete the space provided on the
order envelope to use your charge card).
You will receive forms for refills and future prescription orders each time
you receive drugs or supplies under the Program. In the meantime, if you have
any questions about a particular drug or a prescription, and to request your
first order forms, you may call 1-800/ 283-3478 toll-free. Customer service
is available 7 days a week, 24 hours a day.
Note: As at your local pharmacy, if you request a name brand prescription but
your doctor has not required it, you will be responsible for the difference in
price between the name brand drug and its generic equivalent.
Prescription drug benefits – continued on next page 45
45 Page 46 47
2002 SAMBA 46 Section 5( f)
Section 5
(f). Prescription drug benefits (continued)
Coordinating with
other drug coverage.
If you have prescription drug coverage through
another insurance carrier, and SAMBA is secondary, follow the procedures
outlined below.
When another insurance carrier is primary you should use that carrier's
prescription drug benefits.
However, if you elect to use the Home Delivery
Pharmacy service, you will be billed directly for the full discounted cost of
the covered medication. Pay the Home Delivery Pharmacy service the amount billed
and
submit the bill to your primary insurance carrier. After their
consideration submit the claim and the explanation of benefits (EOB) directly to
the PAID office at:
PAID Prescriptions, L. L. C. P. O. Box 2187
Lee's Summit, MO 64063-2187
Should you elect to use a retail pharmacy, pay the full cost of the covered
medication (do not show your SAMBA Health Insurance Identification Card). Submit
the bill to your primary insurance carrier. After their
consideration,
submit the claim and the explanation of benefits (EOB) directly to the PAID
office at:
PAID Prescriptions, L. L. C. P. O. Box 2187
Lee's Summit, MO
64063-2187
Prescription drug benefits – continued on next page 46
46 Page 47 48
2002 SAMBA 47 Section 5( f)
Benefit Description You pay After
the calendar year deductible…
NOTE: The calendar year deductible applies
to almost all benefits in this Section. We say "( No deductible)" when it does
not apply.
Covered medications and supplies
Each enrollee will receive a
description of our prescription drug program, a combined prescription drug/ Plan
identification card, a
mail order form/ patient profile and a preaddressed
reply envelope. Your SAMBA Health Insurance Identification Card serves as your
drug program identification card.
You may purchase the following
medications and supplies prescribed by a physician from either a pharmacy or by
mail:
Drugs that by Federal law of the United States require a doctor's written
prescription for purchase
Insulin
Needles and syringes for the
administration of covered medications, such as insulin
Contraceptive drugs and devices
Growth hormone therapy (GHT)
Network Retail: $15 generic/$ 25 name brand single source (no generic
substitute)/
$30 multisource name brand copayment (no deductible)
Non-Network Retail: $15 generic/$ 25 name brand single source (no generic)/
$30 multisource name brand copayment, plus the difference in cost had you
used a
participating Plan network pharmacy (no deductible)
Network Mail Order: $15 generic/$ 25 name brand single source (no generic
substitute)/$ 30 multisource name brand copayment (no deductible)
Note: Medicare enrollees pay the same prescription drug copayments as listed
above.
Not covered:
Drugs and supplies for cosmetic purposes, e. g.,
Retin A, Minoxidil, Rogaine
Nutritional supplements and vitamins (except injectable B-12)
Nonprescription medicines (over-the-counter medication)
The difference in cost between the name brand drug and the generic
substitute, if requested by you but not required by your
doctor, when a generic equivalent is available.
Drugs for
sexual dysfunction, e. g., Viagra, Muse, Caverject, etc.
Note: Drugs to aid
in smoking cessation are covered only under Educational
classes and programs (Section 5( a)).
2002 SAMBA 48 Section 5( g)
Section 5 (g). Special features
Special features Description
Flexible benefits option Under the flexible benefits option, we
determine the most effective way to provide services.
We may identify
medically appropriate alternatives to traditional care and coordinate other
benefits as a less costly alternative benefit.
Alternative benefits are subject to our ongoing review.
By approving an
alternative benefit, we cannot guarantee you will get it in the future.
The decision to offer an alternative benefit is solely ours, and we may
withdraw it at any time and resume regular contract benefits.
Our decision
to offer or withdraw alternative benefits is not subject to OPM review under the
disputed claims process.
Managed Care Advisor (MCA) Program Enrollees in the First Health
service area lacking Network access may join the Plan's Managed Care Advisor
(MCA) Program offered through First Health Group Corp. To determine eligibility
and to join the MCA Program, call
1-800/ 346-6755 and speak with a Referral
Management Coordinator. The coordinator will help you select a primary care
physician who will manage all
of your medical needs. If your primary care
physician recommends specialty care, you or your provider must contact a First
Health Referral Management
Coordinator at 1-800/ 346-6755 for a referral.
Enrollees who join and comply with the requirements of the MCA Program will
receive the Plan's enhanced
PPO benefits (subject to the Plan's definitions,
limitations, and exclusions).
Worldwide Assistance Program SAMBA has contracted with Worldwide
Assistance Services, Inc. to provide medical assistance, medical evacuation and
other covered services to our members and their eligible family members through
the Worldwide
Assistance Program. Each enrollee will receive a separate
brochure describing this program.
Note: Services provided under this benefit through Worldwide Assistance are
not subject to the FEHB disputed claims process.
24-hour nurse line Enrollees in the First Health service area (see page 8) may access Health Resource Line by calling First
Health Group Corp. at 1- 800/ 346-6755. Health Resource Line is a 24-hour,
seven-day-a-week nurse advisor line that
answers general medical questions,
provides educational materials, assists you in making health care decisions, and
assists in locating Network
providers.
Services for deaf and hearing impaired SAMBA has a TDD line for the
hearing-impaired: 301/ 984-4155 (TDD equipment is needed).
Special features – continued on next page 48
48 Page 49 50
2002 SAMBA 49 Section 5( g)
Special features Description
High risk pregnancies The precertification program will provide
maternity patients and their attending doctors with information that will assist
in effective management of prenatal care. This service includes monitoring of
prenatal care by a nurse,
identifying potential risk factors and providing
literature about important prenatal topics. To obtain this service, call the
precertification number for
your area when your pregnancy is confirmed.
(This portion of the program is not available to maternity patients in the
CareFirst Service Area.)
National Transplant Program and Centers of
Excellence for organ/
tissue transplants
The First Health National Transplant Program and the CareFirst Centers of
Excellence are available to patients requiring organ/ tissue transplants. See
page 32, Section 5( b).
Travel benefit/ services overseas For covered services rendered by a
hospital or by a doctor outside the United States and Puerto Rico, the Plan will
pay eligible charges at PPO benefit levels, limited to the Plan's allowance
established for the Washington, DC
Metropolitan area. The member is
responsible for the difference between the Plan's allowance and the provider's
charge. See page 54, Section 7 Filing a
claim for covered services. 49
49
Page 50 51
2002 SAMBA 50 Section 5( h)
Section 5 (h). Dental benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
The calendar year deductible is: $300 per person ($ 600 per family). The
calendar year deductible applies to almost all benefits in this Section. We
added "( No deductible)" to show when the
calendar year deductible does not
apply. In addition to the calendar year deductible, there is a $100 per accident
deductible, which applies to dental accidental injury benefits.
Be sure to read Section 4, Your costs for covered services,
for valuable information about how cost sharing works, with special
sections for members who are age 65 or over. Also read Section 9
about coordinating benefits with other
coverage, including with Medicare.
Note: We cover hospitalization for dental
procedures only when a non-dental physical impairment exists which makes
hospitalization necessary to safeguard the health of the patient. We do not
cover the dental procedure.
I M
P O
R T
A N
T
Benefit Description You pay
Accidental injury benefit
We cover
surgical and dental treatment of accidental injury to sound natural teeth.
Treatment must be rendered within 24 months
of the accident.
Definition:
A sound, natural tooth is a tooth that is whole or properly restored and is
without impairment, periodontal or other conditions and is
not in need of the treatment provided for any reason other than an accidental
injury.
Note: An injury to the teeth while chewing and/ or eating is not considered
to be an accidental injury.
PPO: $100 per accident deductible and 10% of the Plan allowance
Non-PPO:
$100 per accident deductible and 25% of the Plan allowance and any difference
between our allowance and the billed amount
Dental benefits
Orthodontic treatment
We cover charges of an
orthodontist for treatment after surgery for closure of a cleft palate or cleft
lip, or for correction of
prognathism or micrognathism.
Lifetime benefits per person are:
Cleft
palate or cleft palate with cleft lip limited to $2,500
Cleft lip,
prognathism or micrognathism limited to $1,000
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount
Note: You pay
charges above the Plan's limit.
Dental benefits – continued on next page 50
50 Page 51 52
2002 SAMBA 51 Section 5( h)
Dental
benefits (continued) You pay
Dental prosthetic appliances
We will pay covered charges for dental prosthetic appliances to treat
conditions due to a congenital anomaly or defect up to a
maximum lifetime benefit of $3,000 per person.
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount
Note: You pay
charges above the Plan's limit.
Not covered:
Dental appliances, study models, splints and other
devices or services associated with the treatment of temporomandibular
joint (TMJ) dysfunction.
All charges 51
51 Page 52 53
2002 SAMBA 52
Section 5( i)
Section 5 (i). Non-FEHB benefits available to Plan
members
The benefits on this page are not part of the FEHB contract or
premium, and you cannot file an FEHB disputed claim about them. Fees you
pay for these services do not count toward FEHB deductibles or out-of-pocket
maximums.
Terrorism Coverage SAMBA provides all its members, without charge, a
$125,000 accident policy payable upon death or dismemberment caused by an act of
terrorism within the United States and $75,000 if on official
assignment
overseas.
SAMBA's Below is a brief description of other group insurance plans
available through SAMBA. Plan Other Group provisions, certain exclusions,
eligibility requirements and underwriting guidelines apply for each plan.
Insurance Plans For more details, contact SAMBA toll-free at 1-800/
638-6589
Group Term Life This low-cost plan allows you to provide financial
protection for your family in the event of your untimely death. Plus, the plan
includes free accidental death and dismemberment coverage. The benefit
doubles in the event of a covered accidental death plus an additional 50% of
the original amount if the member is killed in the line of duty.
Dependents Group To help ease economic consequences of the loss of a
spouse or child, SAMBA offers this plan, which Term Life protects your
whole family for one low-cost premium.
Supplementary SAMBA offers you
additional protection at attractive group rates to members and spouses enrolled
in the Group Term Life basic Group Term Life Plan.
Disability
Income In the event of a long-term illness or disability, this plan provides
much-needed income for you and your Protection family. The plan pays up
to 65% of your insured salary tax-free. In addition, the plan pays 70% of your
insured salary for each day you or your spouse are hospitalized, and 35% for
hospitalized children. Benefits are payable in addition to paid sick leave and
supplement any other benefits to which you may
be entitled.
Long-Term Care Our customized plans help you cover the high cost of
long-term care. Members, spouses, parents, parents-in-law and children qualify
for benefits that help pay for nursing home care, home health care,
adult
day care and respite care.
Dental and Vision SAMBA offers you and your family a choice of two
comprehensive Dental and Vision Care Plans: Care Plan 1) The DMO
Dental Plan, for which you select a Primary Care dentist and receive a broad
range of
coverage and savings, or 2) The Alternate Dental Plan, which
provides flexibility to receive coverage for care from any licensed dentist.
Both plans provide coverage for a wide range of dental procedures
from basic
dental care to oral surgery and dentures, and include the same vision care
benefits for eye examinations, frames, and lenses (or contact lenses).
Dependent Children Your child's coverage under your Federal Employees
Health Benefits Program (FEHBP) plan generally Health Benefit Plan
terminates 31 days after your child turns 22, even if your child is a
full-time student. Available only to
members who are enrolled in the SAMBA
Health Benefit Plan, SAMBA offers you an affordable health plan for your
unmarried children ages 22 to 27. Your child does not have to be a student to be
eligible.
If you insure more than one child, the one low premium includes
coverage for all of them. The Dental and Vision Care Plan is also available. 52
52 Page 53 54
2002 SAMBA 53 Section 6
Section 6. General exclusions --things
we don't cover
The exclusions in this section apply to all benefits.
Although we may list a specific service as a benefit, we will not cover it
unless we determine it is medically necessary to prevent, diagnose, or treat
your illness, disease, injury, or condition. The
fact that one of our
covered providers has prescribed, recommended, or approved a service or supply
does not make it medically necessary or eligible for coverage under this Plan.
We do not cover the following:
Services, drugs, or supplies you receive
while you are not enrolled in this Plan;
Services, drugs, or supplies that
are not medically necessary;
Services, drugs, or supplies not required
according to accepted standards of medical, dental, or psychiatric practice in
the United States;
Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or supplies related to abortions, except when the life of
the mother would be endangered if the fetus were carried to term, or when the
pregnancy is the result of an act of rape or incest;
Procedures, services, drugs, and supplies related to sex transformations,
sexual dysfunction or sexual inadequacy;
Services, drugs, or supplies you
receive from a provider or facility barred from the FEHB Program;
Services
when no charge would be made if the covered individual had no health insurance
coverage;
Services furnished without charge (except as described on page 62); while in active military service; or required for
illness or injury sustained on or after the effective date of enrollment (1) as
a result of an act of war within the United States, its
territories, or possessions or (2) during combat;
Services and supplies
furnished by immediate relatives or household members, such as your parents,
your spouse, and your own and your spouse's children, brothers and sisters by
blood, marriage or adoption;
Noncovered facilities, except that medically necessary prescription drugs are
covered;
Services and supplies not specifically listed as covered;
Any
portion of a provider's fee or charge ordinarily due from the enrollee but that
has been waived. If a provider routinely waives (does not require the enrollee
to pay) a deductible, copayment or coinsurance, the Carrier will calculate the
actual
provider fee or charge by reducing the fee or charge by the amount waived;
Charges the enrollee or Plan has no legal obligation to pay, such as: excess
charges for an annuitant age 65 or older who is not covered by Medicare Parts A
and/ or B (see page 17), doctor charges exceeding the
amount specified by the Department of
Health and Human Services when benefits are payable under Medicare (limiting
charge) (see page 18), or State premium taxes however
applied;
Dental treatment, including X-rays and treatment by a dentist or oral surgeon
except to the extent shown in Section 5( h);
Dental
appliances, study models, splints and other devices or services associated with
the treatment of temporomandibular joint (TMJ) dysfunction;
Eyeglasses or hearing aids, or examinations for them, except as shown in Section 5( a);
Treatment of learning disabilities;
Marital counseling;
Practitioners who do not meet the definition of
covered provider on page 9, Section 3;
Charges for
services and supplies that exceed the Plan allowance;
Services in connection
with custodial care as defined on page 63;
Services in
connection with: corns; calluses; toenails; weak, strained, or flat feet; any
instability or imbalance of the foot; or any metatarsalgia or bunion, including
related orthotic devices, except as listed on page 26, Section
5( a);
Services by a massage therapist;
Services by a naturopathic practitioner;
Services and supplies for cosmetic purposes, e. g., Retin A, Minoxidil,
Rogaine;
Services and supplies for sexual dysfunction, e. g., Viagra, Muse,
Caverject; and
Fees for medical records not requested by the Plan. 53
53 Page 54 55
2002 SAMBA 54 Section 7
Section 7. Filing a claim for covered
services
How to claim benefits To obtain claim forms or other claims
filing advice or answers about our benefits, contact us at 1-800/ 638-6589 or 301/ 984-
1440 (for TDD, use 301/ 984-4155), or at our website at
www.
samba-insurance. com.
In most cases, providers and facilities file
claims for you. Your physician must file on the form HCFA-1500, Health Insurance
Claim Form. Your facility will file on the UB-92
form. For claims questions
and assistance, call us at 1-800/ 638-6589 or 301/ 984-1440 (for TDD, use 301/
984-4155).
When you must file a claim submit it on the HCFA-1500 or a claim form that
includes the information shown below. Bills and receipts should be itemized and
show:
Name of patient and relationship to enrollee;
Plan identification
number of the enrollee;
Name and address of person or firm providing the
service or supply;
Dates that services or supplies were furnished;
Diagnosis;
Type of each service or supply; and
The charge for each
service or supply.
Note: Canceled checks, cash register receipts, or balance
due statements are not acceptable substitutes for itemized bills.
In addition:
You must send a copy of the explanation of benefits (EOB)
from any primary payer (such as the Medicare Summary Notice (MSN)) with your
claim.
Bills for private duty nursing must show that the nurse is a registered or
licensed practical nurse.
Claims for rental or purchase of durable medical
equipment; private duty nursing; and physical, occupational, and speech therapy
require a written statement from the
physician specifying the medical
necessity for the service or supply and the length of time needed. Rental or
purchase of durable medical equipment costing in excess of
$1,000
and private duty nursing care must be preauthorized by SAMBA. See page 12,
Section 3.
Note: Claims for prescription drugs and supplies are addressed in Section 5( f), page 44.
Records Keep a separate record of
the medical expenses of each covered family member as deductibles and maximum
allowances apply separately to each person. Save copies of all
medical
bills, including those you accumulate to satisfy a deductible. In most instances
they will serve as evidence of your claim. We will not provide duplicate or
year-end
statements. 54
54 Page 55 56
2002 SAMBA 55
Section 7
Deadline for filing your claim Send us all of the
documents for your claim as soon as possible. You must submit the claim by
December 31 of the year after the year you received the service, unless timely
filing was prevented by administrative operations of Government or legal
incapacity, provided the claim was submitted as soon as reasonably possible.
Once we pay benefits,
there is a three-year limitation on the reissuance of
uncashed checks.
Overseas claims Claims for overseas (foreign) services should include
an English translation. Charges should be converted to U. S. dollars using the
exchange rate applicable at the time the
expense was incurred. Send itemized
bills for covered services provided by hospitals or doctors outside the United
States to SAMBA, 11301 Old Georgetown Road, Rockville,
MD 20852-2800.
When we need more information Please reply promptly when we ask for
additional information. We may delay processing or deny your claim if you do not
respond. 55
55 Page
56 57
2002 SAMBA 56 Section 8
Section 8. The disputed claims process
Follow this Federal
Employees Health Benefits Program disputed claims process if you disagree with
our decision on your claim or request for services, drugs, or supplies –
including a request for preauthorization/ prior approval:
Step Description
1 Ask us in writing to reconsider our initial
decision. You must: (a) Write to us within 6 months from the date of our
decision; and
(b) Send your request to us at: SAMBA, 11301 Old Georgetown Road, Rockville,
MD 20852-2800; and
(c) Include a statement about why you believe our initial
decision was wrong, based on specific benefit provisions in this brochure; and
(d) Include copies of documents that support your claim, such as physicians'
letters, operative reports, bills, medical records, and explanation of benefits
(EOB) forms.
2 We have 30 days from the date we receive your request to: (a) Pay
the claim or approve your request for coverage; or
(b) Write to you and
maintain our denial – go to step 4; or
(c) Ask you or your provider for more
information. If we ask your provider, we will send you a copy of our request— go
to step 3.
3 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 the information was due. We will base our decision on the
information we already have.
We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
90 days after the date of our letter
upholding our initial decision; or
120 days after you first wrote to us – if
we did not answer that request in some way within 30 days; or
120 days after
we asked for additional information.
Write to OPM at: Office of Personnel
Management, Office of Insurance Programs, Contracts Division II, 1900 E Street,
NW, Washington, DC 20415-3620. 56
56 Page 57 58
2002 SAMBA 57
Section 8
The disputed claims process (continued)
Send
OPM the following information:
A statement about why you believe our
decision was wrong, based on specific benefit provisions in this brochure;
Copies of documents that support your claim, such as physicians' letters,
operative reports, bills, medical records, and explanation of benefits (EOB)
forms;
Copies of all letters you sent to us about the claim;
Copies of all
letters we sent to you about the claim; and
Your daytime phone number and
the best time to call.
Note: If you want OPM to review different claims, you must clearly identify
which documents apply to which claim.
Note: You are the only person who has
a right to file a disputed claim with OPM. Parties acting as your
representative, such as medical providers, must include a copy of your specific
written consent with the review request.
Note: The above deadlines may be extended if you show that you were unable to
meet the deadline because of reasons beyond your control.
5 OPM will review your disputed claim request and will use the
information it collects from you and us to decide whether our decision is
correct. OPM will send you a final decision within 60 days. There are no other
administrative appeals.
6 If you do not agree with OPM's decision, your only recourse is to
sue. If you decide to sue, you must file the suit against OPM in Federal court
by December 31 of the third year after the year in which you received the
disputed services, drugs,
or supplies or from the year in which you were
denied precertification or prior approval. This is the only deadline that may
not be extended.
OPM may disclose the information it collects during the review process to
support their disputed claim decision. This information will become part of the
court record.
You may not sue until you have completed the disputed claims
process. Further, Federal law governs your lawsuit, benefits, and payment of
benefits. The Federal court will base its review on the record that was before
OPM when OPM
decided to uphold or overturn our decision. You may recover
only the amount of benefits in dispute.
NOTE: If you have a serious or life threatening condition (one that
may cause permanent loss of bodily functions or death if not treated as soon as
possible), and
(a) We haven't responded yet to your initial request for care
or preauthorization/ prior approval, then call us at 1-800/ 638-6589 or 301/
984-1440 (for TDD, use 301/ 984-4155) and we will expedite our review; or
(b) We denied your initial request for care or preauthorization/ prior
approval, then:
If we expedite our review and maintain our denial, we will
inform OPM so that they can give your claim expedited treatment too, or
You can call OPM's Health Benefits Contracts Division II at 202/ 606-3818
between 8 a. m. and 5 p. m. eastern time. 57
57
Page 58 59
2002
SAMBA 58 Section 9
Section 9. Coordinating benefits with other
coverage
When you have other health coverage You must tell us if you are
covered or a family member is covered under another group health plan or have
automobile insurance that pays health care expenses without regard to
fault.
This is called "double coverage."
When you have double coverage, one plan
normally pays its benefits in full as the primary payer and the other plan pays
a reduced benefit as the secondary payer. We, like
other insurers, determine
which coverage is primary according to the National Association of Insurance
Commissioners' guidelines.
When we are the primary payer, we will pay the benefits described in this
brochure.
When we are the secondary payer, we will determine our allowance.
After the primary plan pays, we will pay either what is left of our allowance or
up to our regular benefit,
whichever is less. We will not pay more than our
allowance. The combined payments from both plans may not equal the entire amount
billed by the provider.
What is Medicare? Medicare is a Health Insurance Program for:
People 65 years of age and older.
Some people with disabilities, under
65 years of age.
People with End-Stage Renal Disease (permanent kidney
failure requiring dialysis or a transplant).
Medicare has two parts:
Part A (Hospital Insurance). Most people do not
have to pay for Part A. If you or your spouse worked for at least 10 years in
Medicare-covered employment, you
should be able to qualify for premium-free Part A insurance. (Someone who was
a Federal employee on January 1, 1983 or since automatically qualifies.)
Otherwise, if
you are age 65 or older, you may be able to buy it. Contact
1-800-MEDICARE for more information.
Part B (Medical Insurance). Most people pay monthly for Part B. Generally,
Part B premiums are withheld from your monthly Social Security check or your
retirement
check.
If you are eligible for Medicare, you may have choices
in how you get your health care. Medicare+ Choice is the term used to describe
the various health plan choices available to
Medicare beneficiaries. The
information in the next few pages shows how we coordinate benefits with
Medicare, depending on the type of Medicare+ Choice plan you have.
The Original Medicare Plan The Original Medicare Plan (Original
Medicare) is available everywhere in the United (Part A or Part B)
States. It is the way everyone used to get Medicare benefits and is the way
most people
get their Medicare Part A and Part B benefits now. You may go to
any doctor, specialist, or hospital that accepts Medicare. The Original Medicare
Plan pays its share and you pay
your share. Some things are not covered
under Original Medicare, like prescription drugs.
When you are enrolled in Original Medicare along with this Plan, you still
need to follow the rules in this brochure for us to cover your care. 58
58 Page 59 60
2002 SAMBA 59 Section 9
Claims process when you have the
Original Medicare Plan --You probably will never have to file a claim form
when you have both our Plan and the Original Medicare Plan.
We have
contracted with most Medicare Part B claims processors (also known as carriers)
to receive electronic copies of your claims after Medicare has paid their
benefits.
When Original Medicare is the primary payer, Medicare processes your claim
first. In most cases, your claims will be coordinated automatically and we will
pay the
balance of covered charges. You will not need to do anything. To
find out if you need to do something about filing your claims, call us at 1-800/
638-6589 or
301/ 984-1440 (for TDD, use 301/ 984-4155) or at our website at
www. samba-insurance. com.
When we are the primary payer, we process the claim first.
We waive
some costs when you have the Original Medicare Plan – When Original Medicare
is the primary payer, we will waive some out-of-pocket costs, as follows:
If you are enrolled in Medicare Part B, we will waive the deductibles,
copayments and coinsurances for:
– Surgery and anesthesia services
–
Mental health and substance abuse benefits
– Medical services and supplies
provided by physicians and other health care professionals
– Services by a hospital and other facilities and ambulance services
–
Dental benefits
Note: The prescription drug copayment is not waived.
If you are enrolled in Medicare Part A, we will waive the following:
–
the per confinement copayment for inpatient hospital confinements
– the
coinsurance for inpatient hospital benefits 59
59
Page 60 61
2002
SAMBA 60 Section 9
The following chart illustrates whether Original
Medicare or this Plan should be the primary payer for you according to your
employment status and other factors determined by Medicare. It is critical that
you tell us if you or a covered family member has
Medicare coverage so we
can administer these requirements correctly.
Primary Payer Chart
Then
the primary payer is… A. When either you --or your covered spouse --are age 65
or over and …
Original Medicare This Plan
1) Are an active employee with the
Federal government (including when you or a family member are eligible for
Medicare solely because of a
disability),
!
2) Are an annuitant, !
3) Are a reemployed annuitant with the Federal
government when
a) The position is excluded from FEHB, or !
b) The
position is not excluded from FEHB
(Ask your employing office which of these
applies to you.)
!
4) Are a Federal judge who retired under title 28, U. S. C., or a Tax Court
judge who retired under Section 7447 of title 26, U. S. C. (or if your
covered spouse is this type of judge), !
5) Are enrolled in Part B only,
regardless of your employment status, ! (for Part B services) ! (for other
services)
6) Are a former Federal employee receiving Workers' Compensation and the
Office of Workers' Compensation Programs has determined that you
are unable
to return to duty,
!
(except for claims related to Workers'
Compensation.)
B. When you --or a covered family member --have
Medicare based on end stage renal disease (ESRD) and…
1) Are within the first 30 months of eligibility to receive Part A benefits
solely because of ESRD, !
2) Have completed the 30-month ESRD coordination
period and are still eligible for Medicare due to ESRD, !
3) Become eligible
for Medicare due to ESRD after Medicare became primary for you under another
provision, !
C. When you or a covered family member have FEHB and…
1) Are eligible for Medicare based on disability, and
a) Are an
annuitant, or !
b) Are an active employee !
c) Are a former spouse of an annuitant !
d) Are a former spouse of an
active employee ! 60
60 Page
61 62
2002 SAMBA 61 Section 9
Medicare managed care plan If you
are eligible for Medicare, you may choose to enroll in and get your Medicare
benefits from another type of Medicare+ Choice plan – a Medicare managed care
plan.
These are health care choices (like HMOs) in some areas of the
country. In most Medicare managed care plans, you can only go to doctors,
specialists, or hospitals that
are part of the plan. Medicare managed care
plans provide all the benefits that Original Medicare covers. Some cover extras,
like prescription drugs. To learn more about
enrolling in a Medicare managed care plan, contact Medicare at
1-800-MEDICARE (1-800-633-4227) or at www. medicare. gov.
If you enroll in a Medicare managed care plan, the following options are
available to you:
This Plan and another plan's Medicare managed care
plan: You may enroll in another plan's Medicare managed care plan and also
remain enrolled in our FEHB plan.
We will still provide benefits when your
Medicare managed care plan is primary, even out of the managed care plan's
network and/ or service area, but we will not waive any of
our copayments,
coinsurance, or deductibles. If you enroll in a Medicare managed care plan, tell
us. We will need to know whether you are in the Original Medicare Plan or in a
Medicare managed care plan so we can correctly coordinate benefits with
Medicare.
Suspended FEHB coverage to enroll in a Medicare managed care
plan: If you are an annuitant or former spouse, you can suspend your FEHB
coverage to enroll in a Medicare
managed care plan, eliminating your FEHB
premium. (OPM does not contribute to your Medicare managed care plan premium.)
For information on suspending your FEHB
enrollment, contact your retirement
office. If you later want to re-enroll in the FEHB Program, generally you may do
so only at the next Open Season unless you involuntarily
lose coverage or
move out of the Medicare managed care plan's service area.
Private
Contract A physician may ask you to sign a private contract agreeing that
you can be billed with your physician directly for services ordinarily
covered by Original Medicare. Should you sign an
agreement, Medicare will
not pay any portion of the charges, and we will not increase our payment. We
will still limit our payment to the amount we would have paid after
Original
Medicare's payment.
If you do not enroll in If you do not have one or
both Parts of Medicare, you can still be covered under the Medicare Part A or
Part B FEHB Program. We will not require you to enroll in Medicare Part B
and, if you can't
get premium-free Part A, we will not ask you to enroll in
it.
TRICARE TRICARE is the health care program for eligible dependents of
military persons, and retirees of the military. TRICARE includes the CHAMPUS
program. If both TRICARE
and this Plan cover you, we pay first. See your
TRICARE Health Benefits Advisor if you have questions about TRICARE coverage.
Workers' Compensation We do not cover services that:
You need
because of a workplace-related illness or injury that the Office of Workers'
Compensation Programs (OWCP) or a similar Federal or State agency determines
they must provide; or
OWCP or a similar agency pays for through a third
party injury settlement or other similar proceeding that is based on a claim you
filed under OWCP or similar laws.
Once OWCP or similar agency pays its maximum benefits for your treatment, we
will cover your care.
Medicaid When you have this Plan and Medicaid, we pay first. 61
61 Page 62 63
2002 SAMBA 62 Section 9
DVA facilities,
DoD facilities Facilities of the Department of Veterans Affairs, the
Department of Defense, and the and Indian Health Service Indian Health
Service are entitled to seek reimbursement from the Plan for certain
services and supplies provided to you or a family member to the extent that
reimbursement is required under the Federal statutes governing such facilities.
When other Government agencies We do not cover services and supplies
when a local, State, or Federal Government are responsible for your care
agency directly or indirectly pays for them.
When others are
responsible Liability insurance and third party actions – Subrogation
applies when you are sick or for injuries injured as a result of the act
or omission of another person or party. If damages are
payable to you or any
member of your family as a result of injury or illness for which a claim is made
against a third party, the Plan, where cost effective, will take an assignment
of the proceeds of the claim and will assert a lien against such proceeds to
reimburse the Plan for the full amount of Plan benefits paid or payable to you
or any member of your
family. The Plan's lien will apply to any and all
recoveries for such claim whether by court order, out-of-court settlement, or
otherwise. The Plan will provide the necessary
forms and may insist on the
assignment before paying any benefits on account of the injury or illness.
Failure to notify the Plan promptly of a third party claim for damages
on
which the Plan has paid or may pay benefits may result in an overpayment by the
Plan subject to recoupment. If you need more information about subrogation, the
Plan will
provide you with its subrogation procedures. 62
62 Page 63 64
2002 SAMBA 63 Section 10
Section 10. Definitions of terms we
use in this brochure
Admission The period from entry (admission) into a
hospital or other covered facility until discharge. In counting days of
inpatient care, the date of entry and the date of discharge
are counted as
the same day.
Assignment An authorization by an enrollee or spouse for us to issue
payment of benefits directly to the provider. We reserve the right to pay the
member directly for all covered services.
Calendar year January 1 through December 31 of the same year. For new
enrollees, the calendar year begins on the effective date of their enrollment
and ends on December 31 of the same
year.
Coinsurance Coinsurance is the percentage of our allowance that you
must pay for your care. You may also be responsible for additional amounts. See
page 14.
Confinement An admission (or series of admissions separated by less
than 60 days) to a hospital as an inpatient, for which a full day's room and
board charge is made, for any one illness or
injury. There is a new
confinement when an admission is:
1) for a cause entirely unrelated to the
cause for the previous admission; or
2) for an enrolled employee who returns
to work for at least one day before the next admission; or
3) for a dependent or annuitant when admissions are separated by at least 60
days.
Congenital anomaly A condition existing at or from birth, which
is a significant deviation from the common form or norm. For purposes of this
Plan, congenital anomalies include protruding ear
deformities, cleft lips,
cleft palates, birthmarks, webbed fingers or toes, and other conditions that the
Carrier may determine to be congenital anomalies. In no event will
the term
congenital anomaly include conditions relating to teeth or intra-oral structures
supporting the teeth except for the Dental prosthetic
appliances benefit and Orthodontic
treatment covered under Section 5(
h); Dental benefits.
Copayment A copayment is a fixed amount of money
you pay when you receive covered services. See page 14.
Covered services Services we provide benefits for, as described in
this brochure.
Custodial care Treatment or services, regardless of
who recommends them or where they are provided, that could be rendered safely
and reasonably by a person not medically skilled, or that are
designed
mainly to help the patient with daily living activities. These activities
include but are not limited to:
1) personal care such as help in: walking; getting in and out of bed;
bathing; eating by spoon, tube or gastrostomy; exercising; dressing;
2)
homemaking, such as preparing meals or specials diets;
3) moving the
patient;
4) acting as companion or sitter;
5) supervising medication
that can usually be self administered; or
6) treatment or services that any
person may be able to perform with minimal instruction, including but not
limited to recording temperature, pulse, and respirations,
or administration and monitoring of feeding systems.
The Plan determines
which services are custodial care. 63
63 Page 64 65
2002 SAMBA 64 Section 10
Deductible A deductible is a fixed
amount of covered expenses you must incur for certain covered services and
supplies before we start paying benefits for those services. See page 14.
Experimental or A drug, device, or
biological product is experimental or investigational if the drug,
investigational services device, or biological product cannot be lawfully
marketed without approval of the U. S.
Food and Drug Administration (FDA)
and approval for marketing has not been given at the time it is furnished.
Approval means all forms of acceptance by the FDA.
A medical treatment or procedure, or a drug, device, or biological product is
experimental or investigation if 1) reliable evidence shows that it is the
subject of ongoing phase I, II,
or III clinical trials or under study to
determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or
its efficacy as compared with the standard means of treatment or
diagnosis;
or 2) reliable evidence shows that the consensus of opinion among experts
regarding the drug, device, or biological product or medical treatment or
procedure is that
further studies or clinical trials are necessary to
determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or
its efficacy as compared with the standard means of
treatment or diagnosis.
Reliable evidence shall mean only published reports and articles in the
authoritative medical and scientific literature; the written protocol or
protocols used by the treating
facility or the protocol( s) of another
facility studying substantially the same drug, device or medical treatment or
procedure; or the written informed consent used by the treating
facility or
by another facility studying substantially the same drug, device or medical
treatment or procedure.
Group health coverage Health care coverage that a member is eligible
for because of employment by, membership in, or connection with, a particular
organization or group that provides
payment for hospital, medical, or other
health care services or supplies, or that pays a specific amount for each day or
period of hospitalization if the specified amount exceeds
$200 per day,
including extension of any of these benefits through COBRA.
Home Health Care Plan A home health care program, prescribed in
writing by a patient's doctor, for the care and treatment of the patient's
illness or injury in the patient's home. In the plan, the doctor
must
certify that an inpatient stay (for which a room and board charge would be made)
in a hospital, convalescent nursing home or skilled nursing facility would be
required by
that patient if there were no home health care. The home health
care plan must be established in writing no later than 14 days after the start
of the home health care. After
each sixty days the written plan must be
renewed.
Medical necessity Services, drugs, supplies or equipment provided by a
hospital or covered provider of health care services that we determine:
1)
are appropriate to diagnose or treat the patient's condition, illness or injury;
2) are consistent with standards of good medical practice in the United
States;
3) are not primarily for the personal comfort or convenience of the
patient, the family, or the provider;
4) are not a part of or associated with the scholastic education or
vocational training of the patient; and
5) in the case of inpatient care,
cannot be provided safely on an outpatient basis.
The fact that a covered
provider has prescribed, recommended, or approved a service, supply, drug or
equipment does not, in itself, make it medically necessary. 64
64 Page 65 66
2002 SAMBA 65 Section 10
Plan allowance Our Plan allowance
is the amount we use to determine our payment and your coinsurance for covered
services. Fee-for-service plans determine their allowances in different ways.
We determine our allowance as follows:
PPO benefits: For services
rendered by a covered provider who participates in the Plan's PPO network, our
allowance is based on a negotiated rate agreed to under the
providers'
network agreement.
Note: You will not be responsible for any amount above
the providers' negotiated rate; PPO providers accept the Plan's allowance as
payment in full.
Non-PPO benefits: When you do not use a PPO provider to perform the service
or provide the supply, there are two methods we use to determine the Plan
allowance; 1)
the Plan uses the 75 th percentile factor of claims data and
fee information gathered for specific geographic areas by Medical Data Research
(MDR) or 2) in geographic areas
where access to a PPO provider was available
but the patient did not use a PPO provider, our allowance is based on the
average PPO negotiated rate for that region.
Note: We will not consider any fee charged above the Plan's allowance. You
will be responsible for the difference between our allowance and the bill.
For more information, see Differences between our
allowance and the bill in Section 4.
Us/ We Us and we refer to
SAMBA.
You You refers to the enrollee and each covered family member.
65
65 Page 66 67
2002 SAMBA 66 Section 11
Section 11. FEHB facts
No
pre-existing condition We will not refuse to cover the treatment of a
condition that you had before you enrolled limitation in this Plan solely
because you had the condition before you enrolled.
Where you can get information See www. opm. gov/ insure. Also, your employing
or retirement office can answer your about enrolling in the questions, and
give you a Guide to Federal Employees Health Benefits Plans, brochures
FEHB Program for other plans, and other materials you need to make an
informed decision about:
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;
When your enrollment ends; and
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.
Types of coverage available Self Only coverage is for you alone. Self
and Family coverage is for you, your spouse, for you and your family and
your unmarried dependent children under age 22, including any foster children or
stepchildren your employing or retirement office authorizes coverage for.
Under certain circumstances, you may also continue coverage for a disabled child
22 years of age or
older who is incapable of self-support.
If you have a
Self Only enrollment, you may change to a 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 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 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 marry.
Your employing or retirement
office will not notify you when a family member is no longer eligible to
receive health benefits, nor will we. Please tell us immediately when
you
add or remove family members from your coverage for any reason, including
divorce, or when your child under age 22 marries.
If you or one of your family members is enrolled in one FEHB plan, that
person may not be enrolled in or covered as a family member by another FEHB
plan.
When benefits and The benefits in this brochure are effective
on January 1. If you joined this Plan during premiums start Open Season,
your coverage begins on the first day of your first pay period that starts on
or after January 1. 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. 66
66
Page 67 68
2002 SAMBA 67 Section 11
Your medical and claims We will
keep your medical and claims information confidential. Only the following will
records are confidential have access to it:
OPM, this Plan, and
subcontractors when they administer this contract;
This Plan and appropriate
third parties, such as other insurance plans and the Office of Workers'
Compensation Programs (OWCP), when coordinating benefit payments
and subrogating claims;
Law enforcement officials when investigating and/
or prosecuting alleged civil or criminal actions;
OPM and the General Accounting Office when conducting audits;
Individuals
involved in bona fide medical research or education that does not disclose your
identity;
OPM, when reviewing a disputed claim or defending litigation about a claim.;
As part of its administration of the prescription drug benefits, the Plan
may disclose information about a member's prescription drug utilization,
including the names of
prescribing physicians, to any treating physicians or dispensing pharmacies.
When you retire 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 lose benefits
When FEHB coverage ends 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.
You may be eligible for
spouse equity coverage or Temporary Continuation of Coverage.
Spouse
equity If you are divorced from a Federal employee or annuitant, you may not
continue to get coverage benefits under your former spouse's enrollment.
But, you may be eligible for your own
FEHB coverage under the spouse equity law. If you are recently divorced or
are anticipating a divorce, contact your ex-spouse's employing or retirement
office to get
RI 70-5, the Guide to Federal Employees Health Benefits
Plans for Temporary Continuation of Coverage and Former Spouse Enrollees, or
other information about your
coverage choices.
Temporary continuation
If you leave Federal service, or if you lose coverage because you no longer
qualify as a of coverage (TCC) family member, you may be eligible for
Temporary Continuation of Coverage (TCC).
For example, you can receive TCC
if you are not able to continue your FEHB enrollment after you retire, if you
lose your Federal job, if you are a covered dependent child and
you turn 22
or marry, etc.
You may not elect TCC if you are fired from your Federal job
due to gross misconduct.
Enrolling in TCC. Get the RI 79-27, which
describes TCC, and the RI 70-5, the Guide to Federal Employees Health
Benefits Plans for Temporary Continuation of Coverage
and Former Spouse
Enrollees, from your employing or retirement office or from www. opm. gov/ insure. It explains what you
have to do to enroll. 67
67 Page 68 69
2002 SAMBA 68 Section 11
Converting to You may convert to a
non-FEHB individual policy if: individual coverage
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 orCould not acquire words on
page 69 the spouse equity law.
If you leave Federal service, your employing
office will notify you of your right to convert. You must apply in writing to us
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 apply in writing to us
within 31 days
after you are no longer eligible for coverage.
Your
benefits and rates will differ from those under the FEHB Program; however, you
will not have to answer questions about your health, and we will not impose a
waiting
period or limit your coverage due to pre-existing conditions.
Getting a Certificate of The Health Insurance Portability and
Accountability Act of 1996 (HIPAA) is a Federal Group Health Plan Coverage
law that offers limited Federal protections for health coverage availability
and continuity
to people who lose employer group coverage. If you leave the
FEHB Program, we will give you a Certificate of Group Health Plan Coverage that
indicates how long you have
been enrolled with us. You can use this
certificate when getting health insurance or other health care coverage. Your
new plan must reduce or eliminate waiting periods,
limitations, or
exclusions for health related conditions based on the information in the
certificate, as long as you enroll within 63 days of losing coverage under this
Plan. If you
have been enrolled with us for less than 12 months, but were
previously enrolled in other FEHB plans, you may also request a certificate from
those plans.
For more information get OPM pamphlet RI 79-27, Temporary Continuation of Coverage (TCC) under
the FEHB Program. See also the FEHB web site (www. opm. gov/ insure/
health); refer to the "TCC and HIPAA" frequently asked questions. These
highlight HIPAA rules, such as the requirement that Federal employees must
exhaust any TCC
eligibility as one condition for guaranteed access to
individual health coverage under HIPAA, and have information about Federal and
State agencies you can contact for more
information. 68
68 Page 69 70
2002 SAMBA 70 Index
Index
Do not rely on this page; it
is for your convenience and may not show all pages where the terms appear.
Accidental injury 39 Allergy tests
24
Alternative treatment 28 Allogenetic (donor) bone marrow
transplant 32 Ambulance 38, 39
Ambulatory surgical center 9, 36 Anesthesia 33, 34
Autologous bone marrow transplant 32
Biopsies 29 Birthing centers 9
Blood and blood plasma 36, 38
Cancer screening 21
Casts 26, 36 Catastrophic protection 16
Changes for 2002 7 Chemotherapy 24
Chiropractic 28 Claims 54
Coinsurance 14, 63 Congenital anomalies 63
Contraceptive
devices and drugs 23, 29, 47
Coordination of benefits 58, 59 Covered services 63
Covered
providers 9 Crutches 26
Deductible 14 Definitions 63-65
Dental care 31, 50, 51 Diagnostic services 20, 21
Disputed claims review 56, 57 Donor expenses (transplants) 32, 33
Dressings 26, 36 Durable medical equipment 12, 27
Educational classes and programs 28 Effective date of enrollment 66
Emergency 39 Experimental or
investigational 53,
64 Eyeglasses 25, 53
Family planning 23 Fecal occult blood test 21
Flexible benefits option 48 Foot
care 26
General Exclusions 53
Hearing
services 25 Home health services 27
Home nursing care 27 Hospital 9
Immunizations 22 Infertility 23
Inhospital physician care 20 Inpatient Hospital
Benefits 35, 36
Insulin 47
Laboratory and pathological services 21
Magnetic Resonance Imaging (MRI) 21
Mail Order Prescription Drugs 44-47 Mammograms 21
Maternity Benefits 22
Medicaid 61
Medically necessary
64 Medically underserved areas 9
Medicare 18, 58 Mental Conditions/ Substance Abuse
Benefits 40-43
Newborn care 20, 23 Non-FEHB Benefits 52
Nurse Licensed Practical Nurse 27
Nurse Midwife 9
Nurse Practitioner 9
Registered
Nurse 27 Nursery charges 23
Obstetrical care 22 Occupational
therapy 25
Ocular injury 25 Office visits 20
Oral and maxillofacial
surgery 31 Orthopedic devices 26
Out-of-pocket
expenses 16 Outpatient facility care 36
Overseas
claims 55 Oxygen 27
Pap test 21 Physical examination 20
Physical therapy 25 Precertification 11-13
Preferred Provider Organization (PPO) 6, 8
Prescription drugs 44-47
Preventive care, adult 21, 22
Preventive care, children 22
Prior approval 11, 12
Prostate
cancer screening 21 Prosthetic devices 26
Psychologist 9, 40, 42 Psychotherapy 40, 42
Radiation therapy 24 Renal dialysis 24
Room and board 35,
41, 42
Second surgical opinion 20 Skilled nursing facility care 10, 37
Smoking cessation 28 Social Worker 9
40, 42
Speech therapy 25 Splints 26
Sterilization procedures 23
Subrogation 62
Substance abuse
40-43 Surgery 29-34
Anesthesia 33, 34 Assistant surgeon 29
Multiple procedures 30 Oral 31
Reconstructive 30, 31 Syringes 47
Temporary continuation of coverage 67
Transplants 32, 33 Treatment therapies 24
Vision services 25
Well child
care 22 Wheelchairs 27
Workers' compensation 61
X-rays
21 70
70 Page 71
72
2002 SAMBA 71 Summary
Summary of benefits for the SAMBA
Health Benefit Plan – 2002
Do not rely on this chart alone. All
benefits are subject to the definitions, limitations, and exclusions in this
brochure. On
this page we summarize specific expenses we cover; for more
detail, look inside. If you want to enroll or change your enrollment in this
Plan, be sure to put the correct enrollment code from the cover on your
enrollment form. Below, an asterisk (*) means the item is subject to the $300
calendar year deductible. And, after we pay, you generally pay any
difference between our allowance and the billed amount if you use a Non-PPO
physician or other health care professional.
Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment
services provided in the office........................
PPO: $20 copayment
per office visit
Non-PPO: 30%* of the Plan allowance 20
Services provided by a hospital:
Inpatient
..................................................................................................
Outpatient
...............................................................................................
PPO: $200 copayment per confinement, nothing for room & board and 10%
for other
hospital services
Non-PPO: $300 copayment per confinement and
30% of the Plan allowance
PPO: $100 per facility charge and 10%* of the Plan allowance
Non-PPO:
$150 per facility charge and 30%* of the Plan allowance
35
36
Emergency benefits:
Accidental
injury.....................................................................................
Medical emergency
.................................................................................
Nothing within 72 hours
Standard benefits apply
39
39
Mental health and substance abuse
treatment............................................... In-Network: Regular
cost sharing.
Out-of-Network: Benefits are limited.
40
42
Prescription drugs
.........................................................................................
$15 generic, $25 name brand single source (no generic substitute) or $30 name
brand
copayment
44
Dental Care
...................................................................................................
PPO: 10%* of the Plan allowance (dental accident; $100 deductible and 10%)
Non-PPO: 30%* of the Plan allowance (dental accident; $100 deductible and
25%)
50
Special features: Flexible benefits option; Managed Care Advisor (MCA)
Program; Worldwide Assistance Program; 24-hour nurse line; Services for deaf and
hearing impaired; High risk pregnancies; National Transplant and
Centers of
Excellence for organ/ tissue transplants; Travel benefit/ services overseas
48
Protection against catastrophic costs (your out-of-pocket maximum)
.................................................................... PPO:
Nothing after $3,000/ Self-Only or $4,000/ Family enrollment per year
Non-PPO: Nothing after $4,500/ Self Only or $5,500/ Family enrollment per
year
Some costs do not count toward this protection
16 71
71 Page 72
2002 SAMBA
2002 Rate
Information for SAMBA Health Benefit Plan
FEHB Benefits of the Plan are
described in this brochure.
The 2002 rates for this Plan follow. If you are
in a special enrollment category, refer to an FEHB Guide or contact the agency
that maintains your health benefits enrollment.
Biweekly Premium Monthly Premium
Type of Enrollment Code Gov't Share Your
Share Gov't Share Your Share
Self Only 441 $97.86 $66.97 $212.03 $145.10
Self and Family 442 $223.41
$164.76 $484.06 $356.98 72