Serving: Eastern Ohio and Northern and Central West Virginia
Enrollment in this Plan is limited. You must live or work in our Geographic
service area to enroll. See page 7 for requirements.
Enrollment codes for this Plan:
U41 Self Only U42 Self and Family
RI 73-553
For benefit changes see
page 8.
This Plan has an excellent accreditation from the NCQA. See the 2002 Guide
for
more information on accreditation.
RI 73-553 1
1 Page
2 3
Table of Contents
Introduction
..................................................................................................................................................................
4
Plain Language
..............................................................................................................................................................
4
Inspector General
Advisory...........................................................................................................................................
4
Section 1. Facts about this HMO plan
..........................................................................................................................
6
How we pay providers
.................................................................................................................................
6
Your
Rights..................................................................................................................................................
6
Service Area
................................................................................................................................................
7
Section 2. How we change for
2002.............................................................................................................................
8
Program-wide
changes.................................................................................................................................
8
Changes to this
Plan.....................................................................................................................................
8
Section 3. How you get care
.........................................................................................................................................
9
Identification cards
......................................................................................................................................
9
Where you get covered
care.........................................................................................................................
9
. Plan
providers........................................................................................................................................
9
. Plan facilities
.........................................................................................................................................
9
What you must do to get covered
care.........................................................................................................
9
. Primary care
..........................................................................................................................................
9
. Specialty care
........................................................................................................................................
9
. Hospital
care........................................................................................................................................
10
Circumstances beyond our
control.............................................................................................................
11
Services requiring our prior approval
........................................................................................................
11
Section 4. Your costs for covered services
.................................................................................................................
12
.
Copayments.........................................................................................................................................
12
. Deductible
...........................................................................................................................................
12
.
Coinsurance.........................................................................................................................................
12
Your out-of-pocket
maximum...................................................................................................................
12
Section 5. Benefits
......................................................................................................................................................
13
Overview
...................................................................................................................................................
13
(a) Medical services and supplies provided by physicians and other health
care professionals ........... 14
(b) Surgical and anesthesia services
provided by physicians and other health care professionals ....... 23
(c)
Services provided by a hospital or other facility, and ambulance services
..................................... 27
(d) Emergency services/
accidents.........................................................................................................
30
(e) Mental health and substance abuse
benefits....................................................................................
32
(f) Prescription drug benefits
...............................................................................................................
34
(g) Dental benefits
................................................................................................................................
37
(h) Non-FEHB benefits available to Plan
members..............................................................................
38
Section 6. General exclusions --things we don't cover
.............................................................................................
39
2002 The Health Plan HMO 2 Table of Contents 2
2 Page 3 4
Section 7. Filing a claim for covered services
............................................................................................................
40
Section 8. The disputed claims process
......................................................................................................................
41
Section 9. Coordinating benefits with other coverage
................................................................................................
43
When you have…
. Other health
coverage.........................................................................................................................
43
. Original
Medicare...............................................................................................................................
43
. Medicare managed care plan
..............................................................................................................
45
TRICARE/ Workers' Compensation/
Medicaid...........................................................................................
45
Other Government
agencies.......................................................................................................................
46
When others are responsible for
injuries....................................................................................................
46
Section 10. Definitions of terms we use in this brochure
...........................................................................................
47
Section 11. FEHB facts
..............................................................................................................................................
48
Coverage information
............................................................................................................................
…48
. No pre-existing condition
limitation...................................................................................................
48
. Where you get information about enrolling in the FEHB
Program.................................................... 48
. Types of
coverage available for you and your family
........................................................................ 48
. When benefits and premiums start
.....................................................................................................
49
. Your medical and claims records are
confidential..............................................................................
49
. When you retire
..................................................................................................................................
49
When you lose
benefits..............................................................................................................................
49
. When FEHB coverage
ends................................................................................................................
49
. Spouse equity coverage
......................................................................................................................
49
. Temporary Continuation of Coverage
(TCC).....................................................................................
49
. Converting to individual
coverage......................................................................................................
50
. Getting a Certificate of Group Health Plan Coverage
........................................................................ 50
Long Term Care is Coming Later in
2002...................................................................................................................
51
Index
................................................................................................................................................................
52
Summary of
benefits....................................................................................................................................................
55
Rates
..................................................................................................................................................
Back cover
2002 The Health Plan HMO 3 Table of Contents 3
3 Page 4 5
Introduction
The Health Plan of the Upper Ohio Valley Inc. (The
Health Plan HMO) 52160 National Road, East
St. Clairsville, Ohio 43950
This brochure describes the benefits of The Health Plan HMO under our
contract (CS 2616) 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 8. 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" means The Health Plan HMO.
. 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 us know. Visit OPM's "Rate US" feedback area at www. opm. gov/ insure or e-mail us at fehbwebcomments@ opm. gov.
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 800/ 624-6961 and
explain the situation.
. If we do not resolve the issue, call
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.
2002 The Health Plan HMO 4 Introduction/ Plain Language/ Advisory
4
4 Page 5 6
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.
2002 The Health Plan HMO 5 Introduction/ Plain Language/ Advisory
5
5 Page 6 7
Section 1. Facts about this HMO plan
This Plan is a health
maintenance organization (HMO). We require you to see specific physicians,
hospitals, and other providers that contract with us. These Plan providers
coordinate your health care services.
HMOs emphasize preventive care such as routine office visits, physical exams,
well-baby care, and immunizations, in addition to treatment for illness and
injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan
providers, you will not have to submit claim forms or pay bills. You only pay
the copayments and coinsurance described in this brochure. When you receive
emergency services from non-Plan
providers, you may have to submit claim
forms.
You should join an HMO because you prefer the plan's benefits, not
because a particular provider is available. You cannot change plans because a
provider leaves our Plan. We cannot guarantee that any one physician,
hospital, or other provider will be available and/ or remain under contract
with us.
How we pay providers
We contract with individual
physicians, medical groups, and hospitals to provide the benefits in this
brochure. These Plan providers accept a negotiated payment from us, and you will
only be responsible for your copayments or
coinsurance. We pay our
physicians under a fee-for-service basis, meaning that our physicians get paid
only when they provide service to you.
Your Rights
OPM requires that all FEHB Plans 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.
We are considered an Individual Practice Association (IPA) type
of HMO, providing medical services by contracting with over 1,200 primary care
and specialty care physicians and 24 hospitals. We serve the residents of
Eastern Ohio
and Northern and Central West Virginia.
. We are a 501( c)(
4) Not-for-Profit organization .
We are federally-qualified and
state-certified . We hold Certificates of Authority in 20 West Virginia counties
and 8 Ohio counties
. We have commendable accreditation from the National Committee for Quality
Assurance (NCQA) .
We began operations in 1979
If you want more information about us, call 800/ 624-6961, or write to The
Health Plan, 52160 National Road, East, St.
Clairsville, Ohio 43950. You may also contact us by fax at 740/ 695-5297 or
visit our website at
www. healthplan. org
2002 The Health Plan HMO 6 Section 1 6
6 Page 7 8
Service Area
To enroll with us, you must live
in or work in our service area. This is where our providers practice. Our
service area is these counties:
In Ohio: Belmont, Guernsey, Harrison, Jefferson, Monroe, Muskingum,
Noble, and Washington.
In West Virginia: Barbour, Brooke, Doddridge,
Gilmer, Hancock, Harrison, Lewis, Marion, Marshall, Monongalia, Ohio, Pleasants,
Preston, Ritchie, Taylor, Tyler, Upshur, Wetzel, Wirt, and Wood.
Normally, you must get your care from providers who contract with us. If you
receive care outside our service area, we will pay only for emergency or urgent
care. We will not pay for any other health care service outside our service
area.
If you or a covered family member moves outside of our service
area, you can enroll in a new plan. If your dependents live out of the area (for
example, if you child goes to college in another state), you should consider
enrolling in a fee-for-service plan or an HMO that has agreements with
affiliates in other areas. If you or a family member move, you do not have to
wait until Open Season to change plans. Contact your employing or retirement
office.
2002 The Health Plan HMO 7 Section 1 7
7 Page 8 9
Section 2. How we change for 2002
Do not rely
on these change descriptions; this page is not an official statement of
benefits. For that go to Section 5 Benefits. Also, we edited and clarified
language throughout the brochure; any language change not shown here is a
clarification that does not change benefits.
Program-wide changes
. We removed the requirement that services must be needed to restore
functional speech from the speech therapy
benefit (Section 5 (a))
Changes to this Plan
. Your share of the non-postal premium will
increase 14.7 % for Self Only and 16.3 % for Self and Family.
. You will pay
30% of our allowance for Growth Hormone Therapy. Previously, we did not charge a
copayment
for Growth Hormone Therapy.
. We will limit Outpatient Rehabilitative Therapies to the greater of two
months or 20 visits per condition.
Previously, we limited Outpatient
Rehabilitative Therapy to two months per condition.
. For covered medications and supplies available for up to a 31-day supply
you will pay $10 per generic drug, $20
per formulary brand name drug and $35
per non-formulary name brand drug. See page 35. Previously, you paid $5 per
generic drug, or $10 per brand name drug.
. We now cover certain intestinal transplants (Section 5 (b))
2002 The Health Plan HMO 8 Section 2 8
8 Page 9 10
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 800/ 624-
6961.
Where you get covered care You get care from "Plan providers" and
"Plan facilities." You will only pay copayments, and/ or coinsurance, and you
will not have to file claims.
. Plan providers Plan providers are physicians and other health care
professionals in our
service area that we contract with to provide covered
services to our members. We credential Plan providers according to national
standards.
We list Plan providers in the provider directory, which we update
periodically. The list is also on our website. We have two provider lists,
one for the Ohio Valley Region and one for the Mountaineer Region. The Ohio
Valley Region provider list includes providers in the northern
panhandle of
West Virginia and Eastern Ohio. The Mountaineer Region provider list includes
providers in north and west central West Virginia.
. Plan facilities Plan facilities are hospitals and other facilities
in our service area that we
contract with to provide covered services to our
members. We list these in the provider directory, which we update periodically.
The list is also
on our website.
What you must do It depends on the type of care you need. First, you
and each family to get covered care member must choose a primary care
physician from our provider lists.
This decision is important since your
primary care physician provides or arranges for most of your health care. If you
do not select a primary care
physician, it may result in non-payment of
claims.
. Primary care Your primary care physician can be a family
practitioner, general practitioner, general internal medicine, or pediatrician.
Your primary
care physician will provide most of your health care, or give
you a referral to see a specialist.
If you want to change primary care physicians or if your primary care
physician leaves the Plan, call us. We will help you select a new one.
You
and each family member may change primary care physicians once per month.
. Specialty care Your primary care physician will refer you to a
specialist for needed care.
When you receive a referral from your primary
care physician, you must return to the primary care physician after the
consultation, unless your
primary care physician authorized a certain number of visits without addition
referrals. The primary care physician must provide or authorize
all
follow-up care. Do not go to the specialists for return visits unless your
primary care physician gives you a referral. However, you may see
2002 The Health Plan HMO 9 Section 3 9
9 Page 10 11
an OB/ GYN without a referral if you select one as
your secondary care physician.
Here are other things you should know about
specialty care:
. If you need to see a specialist frequently because of a
chronic,
complex, or serious medical condition, your primary care physician
will develop a treatment plan that allows you to see your specialist for
a certain number of visits without additional referrals. Your primary care
physician will use our criteria when creating your treatment plan
(the
physician may have to get an authorization or approval beforehand).
. If you are seeing a specialist when you enroll in our Plan, talk to your
primary care physician. Your primary care physician will decide what
treatment you need. If he or she decides to refer you to a
specialist, ask if you can see your current specialist. If your current
specialist does not participate with us, you must receive treatment
from a
specialist who does. Generally, we will not pay for you to see a specialist who
does not participate with our Plan.
. If you are seeing a specialist and your specialist leaves the Plan, call
your primary care physician, who will arrange for you to see another
specialist. You may receive services from your current specialist
until we can make arrangements for you to see someone else.
. If you have
a chronic or disabling condition and lose access to your
specialist because
we:
-terminate our contract with your specialist for other than cause; or
-drop out of the Federal Employees Health Benefits (FEHB) Program and you
enroll in another FEHB Plan; or
-reduce our service area and you enroll in another FEHB Plan,
you may be
able to continue seeing your specialist for up to 90 days after you receive
notice of the change. Contact us, or if we drop out of
the program, contact
your new plan.
If you are in the second or third trimester of pregnancy and
you lose access to your specialist based on the above circumstances, you can
continue to see your specialist until the end of your postpartum care, even
if it is beyond the 90 days.
. Hospital care Your Plan primary care physician or specialist will
make necessary
hospital arrangements and supervise your care. This includes
admission to a skilled nursing or other type of facility.
If you are in the hospital when your enrollment in our Plan begins, call our
customer service department immediately at 800/ 624-6961. If you
are new to
the FEHB Program, we will arrange for you to receive care.
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
2002 The Health Plan HMO 10 Section 3 10
10 Page 11 12
. 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.
Circumstances beyond our control Under certain extraordinary
circumstances, such as natural disasters, we may have to delay your services or
we may be unable to provide them.
In that case, we will make all reasonable
efforts to provide you with the necessary care.
Services requiring our Your primary care physician has authority to
refer you for most services. prior approval For certain services,
however, your physician must obtain approval from
us. Before giving
approval, we consider if the service is covered, medically necessary, and
follows generally accepted medical practice.
We call this preauthorization. Your physician must obtain preauthorization
for services, such as, elective and extended hospital
stays, CAT Scans,
MRIs, outpatient surgeries, durable medical equipment, skilled nursing care,
home health services, outpatient
thearapies, and scheduled ambulance
transports.
We will review the requested service and our Medical Director
will either approve it or deny it. In the event of denial, your physician will
be
notified by phone within one business day and by mail. You will receive
notice by mail. If we do not authorize your services, you may request a
second review. If we uphold our denial, you may file a formal appeal with
us. See page 41 for the disputed claims process.
2002 The Health Plan HMO 11 Section 3 11
11 Page 12 13
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
.
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 primary care physician you pay a copayment of $10
per office visit.
. Deductible We do not have a deductible.
. Coinsurance
Coinsurance is the percentage of our negotiated fee that you must pay for
your care.
Example: In our Plan, you pay 20% of charges for durable medical equipment.
Your out-of-pocket After your copayments and/ or coinsurance total
$1,500 per person or maximum for coinsurance, $3,000 per family
enrollment in any calendar year, you do not have to pay
and copayments
any more for covered services. However, copayments/ coinsurance for the
following services do not count toward your out-of-pocket maximum, and
you
must continue to pay copayments/ coinsurance for these services:
.
Prescription Drugs .
Dental services (accidental in nature)
Be sure to keep accurate records of your copayments/ coinsurance since you
are responsible for informing us when you reach the maximum.
2002 The Health Plan HMO Section 4 12 12
12
Page 13 14
Section 5. Benefits --OVERVIEW (See page 8 for how our benefits
changed this year and page 55 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 claims forms, claims filing advice, or more information about
our benefits, contact us at 800/ 624-6961 or 740/ 695-3585 or at our website at
www. healthplan. org.
(a) Medical services and supplies provided by physicians and other health
care professionals 14-22
. 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
therapies
. 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....................... 23-26
. Surgical procedures .
Reconstructive surgery . Oral and maxillofacial surgery . Organ/ tissue
transplants . Anesthesia
(c) Services provided by a hospital or other facility, and ambulance
services..................................................... 27-29
.
Inpatient hospital
. Outpatient hospital or ambulatory surgical
center
. Extended care benefits/ skilled nursing care
facility benefits .
Hospice care
. Ambulance
(d) Emergency services/ accidents
........................................................................................................................
30-31 . Medical emergency . Ambulance
(e) Mental health and substance abuse benefits
...................................................................................................
32-33
(f) Prescription drug
benefits...............................................................................................................................
34-36
(g) Dental
benefits......................................................................................................................................................
37
(h) Non-FEHB benefits available to Plan members
...................................................................................................
38
Summary of
benefits....................................................................................................................................................
55
2002 The Health Plan HMO Section 5 13 13
13
Page 14 15
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 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.
. Plan physicians must provide or arrange your care.
. We have no
calendar year deductible:
. 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.
I M
P O
R T
A N
T
Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
. In physician's office
. In-office medical consultation
. In-office
surgical opinion
. At home
$10 per visit
Professional services of physicians
. In an urgent care center (see page
31 for urgent care benefit)
. During a hospital stay
. In a skilled
nursing facility
. Second surgical opinion while in a hospital
Nothing
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
Nothing, if you receive these services during your office visit;
otherwise, $10 per visit.
2002 The Health Plan HMO 14 Section 5( a) 14
14 Page 15 16
Preventive care, adult
Routine screenings,
such as
. Total Blood Cholesterol
. Colorectal Cancer Screening
Nothing, if you receive these services during your office visit;
otherwise, $10 per visit.
Prostate Specific Antigen (PSA test)
Routine pap test
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
Routine immunizations, such as:
. Tetanus-diphtheria (Td) booster – once
every 10 years, ages19 and
over (except as provided for under Childhood
immunizations)
. Influenza/ Pneumococcal vaccines
Not covered: Physical exams not necessary for medical reasons, such as
those required for obtaining or continuing employment or insurance,
attending schools or camp, or travel.
All charges.
2002 The Health Plan HMO 15 Section 5( a) 15
15 Page 16 17
Preventive care, children You pay
.
Childhood immunizations recommended by the American Academy
of Pediatrics
Nothing, if you receive these services during your office visit; otherwise, $10
per visit.
. Examinations, such as:
-Eye exams provided by PCP, through age 17 to
determine the need for vision correction.
-Ear exams through age 17 to determine the need for hearing correction
.
Well-child care charges for routine examinations, immunizations and
care up
to age 22
. Child health supervision services (review of physical and emotional
status, birth to age nine)
$10 per visit
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 10
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 cesarean delivery. We will extend your inpatient stay if
medically necessary.
. 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 only 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 5c) and Surgery benefits (Section 5b).
$10 for initial visit only
Not covered: Routine sonograms to determine fetal age, size or sex All
charges
2002 The Health Plan HMO 16 Section 5( a) 16
16 Page 17 18
Family planning You pay
A broad range of
voluntary family planning services, such as :
. Voluntary sterilization
. Surgically implanted contraceptives (such as Norplant)
. Injectable
contraceptive drugs, such as Depo Provera
. Contraceptive devices, such as
diaphragms and Intrauterine
devices (IUDs)
NOTE: We cover oral contraceptives under the prescription drug benefit
$10 per visit
Note: Depo Provera is $15 per injection in addition to the
office
visit copay.
Not covered: reversal of voluntary surgical sterilization, genetic
counseling, paternity testing, Estrogen & Androgen pellet implants. All
charges.
Infertility services
Diagnosis and treatment of
infertility, such as:
.
.
Artificial insemination:
-intravaginal insemination (IVI)
-intracervical insemination (ICI)
-intrauterine insemination (IUI)
Basic health care services such as diagnostic and exploratory procedures to
determine infertility including surgical procedures to
correct medically diagnosed diseases or conditions of the reproductive organs
$10 per visit
Not covered:
. Assisted reproductive technology (ART)
procedures, such as:
-in vitro fertilization
-embryo transfer, gamete
GIFT and zygote ZIFT
-surrogate parenting
.
.
.
.
.
Services and supplies related to excluded ART procedures
Cost of donor
sperm and sperm washing
Cost of donor egg
Fertility drugs (oral, topical
or injectible)
Experimental services
All charges.
2002 The Health Plan HMO 17 Section 5( a) 17
17 Page 18 19
Allergy care
Testing and treatment
Allergy injection
$10 per visit
Allergy serum Nothing
Not covered: sublingual allergy desensitization
All charges.
Treatment therapies You pay
. Chemotherapy and
radiation therapy
Note: High dose chemotherapy in association with
autologous bone marrow transplants is limited to those transplants listed under
Organ/ Tissue Transplants on page 25.
. Respiratory and inhalation
therapy
. Dialysis – Hemodialysis and peritoneal dialysis
. Intravenous
(IV)/ Infusion Therapy – Home IV and antibiotic
therapy
$10 per visit
. Growth hormone therapy (GHT)
Note: – We cover GHT under our medical
benefits. We will only cover GHT when we preauthorize the treatment. Call 800/
624-6961
for preauthorization. We will ask you to submit information that establishes
that the GHT is medically necessary. Ask us to authorize
GHT before you
begin treatment; otherwise, we will only cover GHT services from the date you
submit the information. If you do not ask
or if we determine GHT is not
medically necessary, we will not cover the GHT or related services and supplies.
See Services requiring our
prior approval in Section 3.
30% of our allowance
Physical and occupational therapies
. Outpatient (the greater of
two months or 20 visits per condition)
and inpatient (60 days per calendar
year) for the services of each of the following:
-qualified physical therapists and
-occupational therapists.
Note: We
only cover therapy to restore bodily function when there has been a total or
partial loss of bodily function due to
illness or injury.
$15 per outpatient visit
Nothing per inpatient visit
Cardiac rehabilitation following a heart transplant, bypass surgery or a
myocardial infarction, at a plan-approved facility for up to 12 weeks
or 36
visits per calendar year.
Nothing
Pulmonary rehabilitation at a plan-approved facility for up to 12 weeks or 36
visits per calendar year. Nothing
.
.
2002 The Health Plan HMO 18 Section 5( a) 18
18 Page 19 20
Rehabilitative therapies (Continued)
You pay
Not covered:
. long-term rehabilitative
therapy
. exercise programs
All charges.
Speech therapy
. Outpatient (the greater of two months or 20
visits per condition)
and inpatient (60 days per calendar year) $15 per
outpatient visit Nothing per inpatient visit
Hearing services (testing, treatment, and supplies)
. Hearing
exams are limited to one per calendar year to determine
the need for hearing
correction
. Hearing testing for children through age 17 (see Preventive care,
children)
. Hearing aids are limited to one hearing aid per lifetime
$10 per visit
Not covered: . All other hearing testing
. Replacement
or repair of hearing aids and batteries for them
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)
. Eye exam provided by PCP, to determine the need for vision
correction
for children through age 17 (see preventive care)
. Ophthalmologist visits for diagnosis and treatment of diseases of the
eye. (requires prior approval)
$10 per visit
Not covered:
. Eyeglasses, frames or contact lenses and
examinations for them,
after age 17,
. Eye exercises, vision therapy and orthoptics,
. Radial
keratotomy and other refractive surgery.
All charges.
Foot care
Routine foot care by a licensed Podiatrist, when you are
under active treatment for a metabolic or peripheral vascular disease, such as
diabetes.
See orthopedic and prosthetic devices for information on
podiatric shoe inserts.
$15 per visit
2002 The Health Plan HMO 19 Section 5( a) 19
19 Page 20 21
Foot care (Continued) You pay
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 fallen arches, weak, strained or flat feet or bunions
or spurs; and of any instability, imbalance or subluxation of the foot
(unless the treatment is by open cutting surgery)
. Strapping or taping of the feet
. Hygienic and preventive
maintenance care such as, cleaning and
soaking the feet, the use of skin
creams to maintain skin tone of either ambulatory or bedfast patients and any
other service
performed in the absence of localized illness, injury or symptoms
involving the foot
All charges.
Orthopedic and prosthetic devices
. Artificial limbs and eyes;
stump hose
. Externally worn breast prostheses and surgical bras, including
necessary replacements, following a mastectomy
. Internal prosthetic devices, such as artificial joints, pacemakers,
cochlear implants, and surgically implanted breast implant following
mastectomy. Note: We pay internal prosthetic devices
as hospital benefits; see Section 5( c) for payment information. See 5( b)
for coverage of the surgery to insert the device.
. Foot orthotics
20% of charges
. Corrective orthopedic appliances for non-dental treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome. 30% of charges
Not covered:
. orthopedic and corrective shoes
.
arch supports
. heel pads and heel cups
. lumbosacral
supports
. corsets, trusses, elastic stockings, support hose, and
other supportive
devices
. Replacement of prosthetics provided prior to the end of their
expected life (except for replacement due to growth or development in
children up to age 18)
All charges.
2002 The Health Plan HMO 20 Section 5( a) 20
20 Page 21 22
Durable medical equipment (DME) You pay
Rental or purchase, at our option, including repair and adjustment, of
durable medical equipment prescribed by your Plan physician, such as
oxygen and dialysis equipment. Under this benefit, we also cover:
.
hospital beds;
. standard model wheelchairs;
. crutches;
. walkers;
. ostomy and catheter supplies; and
. insulin pumps.
Note: DME must be medically necessary and be pre-authorized by us prior to
dispensing. DME is limited to standard model only.
20% of charges
. blood glucose monitors
Note: We require the use of specific blood
glucose monitors.
Nothing
Not covered: . Replacement of DME prior to the end of its expected
life (except
for replacement due to growth or development in children up to
age 18)
. Batteries for DME items, such as batteries required for
hearing
aids, tens units, wheelchairs and glucometers . Equipment or
supplies primarily used for patient comfort or
convenience . Home modifications
. Supplies such as,
tape, alcohol, Q-tips/ swabs, gauze, bandages,
thermometers, aspirin,
diapers (adult or infant), heating pads, or ice bags
. Professional medical equipment such as, blood pressure units, or
stethoscopes
All charges.
Home health services
. Home health care ordered by a Plan
physician and provided by a
registered nurse (R. N.), licensed practical
nurse (L. P. N.), licensed vocational nurse (L. V. N.), or home health aide.
. Services include oxygen therapy, intravenous therapy and
medications.
Note: We must preauthorize Home health services prior to services being
rendered.
Nothing
2002 The Health Plan HMO 21 Section 5( a) 21
21 Page 22 23
Not covered:
. nursing care requested
by, or for the convenience of, the patient or
the patient's family;
. home care primarily for personal assistance that does not include
a
medical component and is not diagnostic, therapeutic, or rehabilitative
All charges.
Chiropractic
. Up to 20 visits per calendar year with approved
referral from your
PCP $15 per visit
Not covered:
. Non-subluxation services
All charges
Alternative treatments
Biofeedback Therapy (for incontinence only)
30% of charges
Not covered: . Acupuncture services
. Naturopathic services .
Hypnotherapy . Biofeedback
(except for incontinence)
. Massage therapy .
Christian Science Treatment . All
other alternative treatment services not listed as covered
All charges.
Educational classes and programs
Coverage is limited to:
. Work site Smoking Cessation classes – This program is available
when
requested by your employer. Our full time nurse provides classes. If you are
interested in these classes, please call us at 800/
624-6961 or 740/ 695-3585 for more information.
. Diabetes education – Up
to 8 group and 8 individual classes in a 12-
month period.
Nothing
2002 The Health Plan HMO 22 Section 5( a) 22
22 Page 23 24
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 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.
. Plan physicians must provide or arrange your care.
. We have no
calendar year deductible.
. 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.
. 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.).
. YOUR PHYSICIAN MUST GET PRECERTIFICATION OF SOME SURGICAL
PROCEDURES.
Please refer to the precertification information shown in Section 3 to be sure
which services require precertification and identify which surgeries require
precertification.
I M
P O
R T
A N
T
Benefit Description You pay
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% 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.
$10 per office visit; nothing for hospital visits
. Voluntary sterilization .
Treatment of burns Nothing
Not covered: . Reversal of voluntary sterilization
.
Routine treatment of conditions of the foot; see Foot care.
All charges.
2002 The Health Plan HMO 23 Section 5( b) 23
23 Page 24 25
Reconstructive surgery You pay . 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; birthmarks; webbed fingers; and webbed toes.
Nothing
. 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 Prosthetic devices)
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
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; .
Removal of stones
from salivary ducts; . Excision of leukoplakia or malignancies;
. Excision of cysts and incision of abscesses when done as independent
procedures; and . Other surgical procedures that do not involve the teeth or
their
supporting structures.
Nothing
2002 The Health Plan HMO 24 Section 5( b) 24
24 Page 25 26
Oral and maxillofacial surgery (Continued)
You pay
Not covered: . Oral implants and transplants
. Procedures that involve the teeth or their supporting structures (such
as the periodontal membrane, gingiva, and alveolar bone)
. Non-medical TMJ services
All charges.
Organ/ tissue transplants
Transplants must be approved by our
Medical Director and are limited to:
. Cornea
. Heart
. Heart/ lung
. Kidney
. Kidney/ Pancreas
. Liver
. Lung: Single –Double
. Pancreas
. Allogeneic (donor)
bone marrow transplants
. Autologous bone marrow transplants (autologous stem cell and
peripheral
stem cell support) for the following conditions: 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
Note: We cover actual acquisition costs of the donor when we cover the
recipient.
Nothing
Not covered: . Donor screening tests and donor search expenses,
except those
performed for the actual donor . Implants of artificial
organs
. Transplants not listed as covered
All charges
2002 The Health Plan HMO 25 Section 5( b) 25
25 Page 26 27
Anesthesia
Professional services provided
in –
. Hospital (inpatient) .
Hospital outpatient department .
Ambulatory surgical center
. Skilled nursing facility
Nothing
Professional services provided in –
. Office
$10 per visit
2002 The Health Plan HMO 26 Section 5( b) 26
26 Page 27 28
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 to remember 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.
. Plan physicians must provide or arrange your care and you must be
hospitalized
in a Plan facility.
. We have no calendar year deductibles.
. 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.
. 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
covered in
Sections 5( a) or (b).
. YOUR PHYSICIAN MUST GET PRECERTIFICATION OF
ELECTIVE HOSPITAL STAYS. Please refer to Section 3 to be sure which services
require precertification
I M
P O
R T
A N
T
Benefit Description You pay
Inpatient hospital
Room and board,
such as . ward, semiprivate, or intensive care accommodations;
. general nursing care; and .
meals and special diets.
NOTE: If you want a private room when it is not medically necessary, you pay
the additional charge above the semiprivate room rate.
Nothing
2002 The Health Plan HMO Section 5( c) 27 27
27 Page 28 29
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 . Administration of blood
and blood products
. Blood or blood plasma, if not donated or replaced .
Dressings, splints,
casts, and sterile tray services . Medical supplies and equipment, including
oxygen
. Anesthetics, including nurse anesthetist services .
Medical supplies,
appliances, medical equipment, and any covered items billed by a hospital for
use at home
Nothing
Not covered: . Custodial care, rest cures, domiciliary or
convalescent care
. Non-covered facilities .
Personal
comfort items, such as telephone, television, barber services, guest meals and
beds
. Private nursing care
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 . 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.
We do not cover the
dental procedures.
Nothing
Extended care benefits/ skilled nursing care facility benefits
Skilled nursing facility (SNF): Up to 120 days per calendar year when
full-time nursing care and confinement to a SNF is medically
appropriate. All necessary services are covered, such as:
. Bed, board,
and general nursing care .
Drugs, biologicals, supplies and equipment
ordinarily provided or arranged by the SNF when prescribed by your physician
$25 per day
Not covered: custodial care or domicillary care, respite care, private
duty nursing, intermediate care, rest cure or other services
primarily to
assist in the activities of daily living and personal comfort items , such as
hygienic and convenience items and
telephones and televisions
All charges
2002 The Health Plan HMO Section 5( c) 28 28
28 Page 29 30
Hospice care You pay
Supportive and
palliative care for a terminally ill member, including home care and family
counseling.
Note: These services are provided when your physician certifies that the
member is in the terminal stages of illness, with a life expectancy
of
approximately six months or less.
Nothing
Not covered:
.
.
Independent nursing, homemaker
services
See "not covered" under SNF benefits
All charges
Ambulance
. Local professional ambulance service when medically
appropriate $25 per service
.
2002 The Health Plan HMO Section 5( c) 29 29
29 Page 30 31
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.
. We have no calendar year deductible .
. 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.
I M
P O
R T
A N
T
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or
an injury that you believe endangers your life or could result in serious injury
or disability, and requires immediate medical or
surgical care. Some problems are emergencies because, if not treated
promptly, they might become more serious; examples include deep cuts and broken
bones. Others are emergencies because they are
potentially life threatening,
such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability
to breathe. There are many other acute conditions that we may determine are
medical
emergencies – what they all have in common is the need for quick
action.
What to do in case of emergency:
In extreme emergencies, contact
the local emergency system (e. g., 911-telephone system). If you are in an
emergency situation, you should follow these steps:
.
.
.
First: When practical, call your PCP day or night. He or she can
direct you to the appropriate care and can assure the proper follow-up to that
care.
If your PCP cannot be reached, call our 24-hour emergency
number, 800/ 624-6961 or 740/ 695-3585. You will be put in contact with our
nurse on call for directions on what to do.
In a situation when a
telephone call is impractical or impossible, go directly to one of our
nearest participating hospital emergency rooms, if possible. Identify yourself
as a Health Plan
member. You or a family member must contact us within 48
hours of the visit, unless it was not reasonably possible to do so. It is your
responsibility to ensure that we have been timely notified.
You should also
inform your physician of the situation, that way your care can be better
coordinated.
Emergencies within our service area: If you are in an emergency
situation within our service area, please follow the above steps under "What to
do in case of emergency". If you need to be
hospitalized, we must be
notified within 48 hours or on the first working day following the admission,
unless it was not reasonably possible to notify us within that timeframe. If you
are hospitalized in non-Plan
facilities and your physician believes care can
be better provided in a Plan facility, you will be transferred when medically
feasible with any ambulance charges covered in full. Benefits are available
for care from non-Plan providers in a medical emergency only if delay in
reaching a Plan provider would result in death, disability or significant
jeopardy to your condition. Any follow-up care
recommended by non-Plan
providers must be approved by us or provided by Plan providers.
Emergencies outside our service area: If you are in an emergency
situation outside our service area, please follow the above steps under "What to
do in case of emergency". If you need to be
hospitalized, we must be notified within 48 hours or on the first working day
following the admission, unless it was not reasonably possible to notify us
within that timeframe. If your physician believes care
can be better
provided in a Plan hospital, you will be transferred when medically feasible
with any ambulance charges covered in full. Any follow-up care recommended by
non-Plan providers must be
approved by us or provided by Plan providers.
2002 The Health Plan HMO 30 Section 5( d) 30
30 Page 31 32
Benefit Description You pay
Emergency within
our service area
. Emergency care at a doctor's office $10 per visit
. Emergency or urgent care at an urgent care center $25 per visit
Emergency care as an outpatient or inpatient at a hospital, including
doctors' services $50 per visit
Note: Waived if admitted
Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area
. Emergency care or urgent
care at an urgent care center $25 per visit
. Emergency care as an outpatient or inpatient at a hospital, including
doctors' services $50 per visit
Note: Waived if admitted
Not covered:
. Elective care or non-emergency care
. Emergency care
provided outside the service area if the need for
care could have been
foreseen before leaving the service area . Medical and hospital costs
resulting from a normal full-term
delivery of a baby outside the service
All charges.
Ambulance
Professional ambulance service when medically
appropriate.
See 5( c) for non-emergency service.
$25 per service
.
2002 The Health Plan HMO 31 Section 5( d) 31
31 Page 32 33
Section 5 (e). Mental health and substance abuse
benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
. All benefits are subject to the definitions, limitations, and
exclusions in this brochure.
. We have no calendar year deductible.
. 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 description below.
I M
P O
R T
A N
T
Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider and
contained in a treatment plan that we approve. The treatment plan
may include services, drugs, and supplies described elsewhere in this
brochure.
Note: Plan 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.
. Professional services, including individual or group therapy by
providers such as psychiatrists, psychologists, or clinical social workers
. Medication management
$10 per visit
Mental health and substance abuse benefits -Continued on next page
2002 The Health Plan HMO 32 Section 5( e) 32
32 Page 33 34
Mental health and substance abuse benefits
(Continued) You pay
. Diagnostic tests Nothing
. Services provided by a hospital or other facility
. Services in
approved alternative care settings such as partial
hospitalization, half-way
house, residential treatment, full-day hospitalization, facility based intensive
outpatient treatment
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 these benefits you must
obtain a treatment plan and follow all the following authorization processes:
Contact our Behavioral Health Administrator toll free at (877) 221-9295 for
mental health and substance abuse services
Limitation We may limit your benefits if you do not obtain a treatment
plan.
2002 The Health Plan HMO 33 Section 5( e) 33
33 Page 34 35
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.
. We have no calendar year deductible.
. 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.
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, licensed
dentist or oral surgeon, nurse
practitioner, optometrist, or physician's
assistant must write the prescription.
. Where you can obtain them. You must fill the prescription at a plan
pharmacy.
. We use a formulary. Drugs are prescribed and dispensed in
accordance with our drug formulary. A
drug formulary is a list of brand name
drugs that we cover. We cover non-formulary drugs prescribed by a Plan doctor.
If your physician believes a name brand product is necessary or there is
no generic available, your physician may prescribe a name brand drug from our
formulary list. This list of name brand drugs is a preferred list of drugs that
we selected to meet patient needs at a lower
cost. To order a prescription
drug brochure or drug formulary, call 800/ 624-6961. You may also choose to
receive a non-formulary prescription and pay the higher third tier copay.
. These are the dispensing limitations. Generally, we allow dispensing
of FDA-approved drugs up
to a 31-day supply per copay. Limits may be applied
to assure that dispensing of medication conforms to the approved Federal
labeling of the formulary drug. Furthermore, if you have your
prescription filled too early, it will not be allowed. You must use
three-fourths of the days supplied before a refill will be allowed.
. Why use generic drugs? Generic drugs are lower-priced drugs that are
the therapeutic equivalent
to more expensive brand-name drugs. They must
contain the same active ingredients and must be equivalent in strength and
dosage to the original brand name product. Generics cost less than the
equivalent brand-name 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 brand-name
drugs.
You can save
money by using generic drugs. You and your physician have the option to request
a name brand even if a generic is available. However, using the most
cost-effective medication saves
money.
When you have to file a claim. If you are in a situation outside our
service area, for which you cannot go to a plan pharmacy and a physician has
prescribed covered medication that is urgently needed,
please go to any
pharmacy and purchase the medication. Return your receipt to The Health Plan and
you will be reimbursed in full, less the applicable copay amount.
2002 The Health Plan HMO 34 Section 5( f) 34
34 Page 35 36
Benefit Description You pay
Covered medications
and supplies
We cover the following medications and supplies prescribed
by a Plan physician and obtained from a Plan for up to a 31-day supply:
. Drugs for which a prescription is required by law .
Diabetic supplies,
including insulin, glucose test tablets and test tape, Benedict's solution or
equivalent and acetone test tablets
. Disposable needles and syringes for the administration of covered
medications . Intravenous fluids and medications for home use, some
injectible drugs
(such as Depo Provera) are covered under medical services and supplies
.
Contraceptive drugs and devices (devices are covered under medical
services
and supplies) . Prenatal vitamins
. Sexual dysfunction drugs have dispensing limitations. Contact the
Plan
for details.
$10 per prescription unit or refill for generic drugs.
$20 per
prescription unit or refill for formulary brand name drugs
$35 per
prescription unit or refill for non-formulary brand name
drugs
Note: If there is no generic equivalent available, you will still have to pay
the
applicable brand name copay.
2002 The Health Plan HMO 35 Section 5( f) 35
35 Page 36 37
Covered medications and supplies (Continued)
You pay
Not covered:
. Drugs and supplies for
cosmetic purposes
. Drugs obtained at a non-Plan pharmacy except for
out-of-area
emergencies
. Medical supplies such as dressings and antiseptics
. Drugs to
enhance athletic performance
. Smoking cessation drugs and
medications, including nicotine
patches
. Drugs for weight control
. Infertility drugs
.
Vitamins and nutritional substances that can be purchased without a
prescription
. Nonprescription medicines
All Charges
2002 The Health Plan HMO 36 Section 5( f) 36
36 Page 37 38
Section 5 (g). 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.
. Plan dentists must provide or arrange your care.
. We have no calendar
year deductible.
. We cover hospitalization days for oral surgical
procedures only when certified by the PCP
as being medically necessary to
safeguard your life and approved by us. We do not cover dental procedures.
. 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.
I M
P O
R T
A N
T
Accidental injury benefit You pay
We cover restorative services
and supplies necessary to promptly repair (but not replace) sound natural teeth.
The need for these services must
result from an accidental injury.
Nothing.
Dental benefits
We have no other dental benefits.
2002 The Health Plan HMO 37 Section 5( g) 37
37 Page 38 39
Section 5 (h). Non-FEHB benefits available to Plan members
The
benefits described on this page are neither offered nor guaranteed under the
contract with the FEHB Program, but are made available to all enrollees and
family members who are members of this Plan. The cost of the bene
described
on this page is not included in the FEHB premium; any charges for these services
do not count toward any FEHB deductible, out-of-pocket maximum copay charges,
etc. These benefits are not subject to the FEHB disputed
claims procedures.
fits
h control pills.
om
Medicare+ Choice product-This Plan offers Medicare recipients the
opportunity to enroll in its Medicare+ Choice product. The Plan's service area
for Medicare+ Choice is different then its FEHB program service area. You must
have Medicare part A & B to enroll in the Medicare+ Choice product. For
more information about the Medicare+ Choice product, please contact us at 740/
695-7656, or 800/ 624-6961.
Vision One eyecare program -The Plan is pleased to offer its FEHB
members savings on your eyecare needs... frames, lenses, contacts, and exams.
Operated in conjunction with Cole Vision, you may now obtain
substantial
savings on a wide range of vision services at any of the 1600 participating
Sears, JC Penny, Montgomery Wards, or Pearle Vision Express Departments
nationwide. To take advantage of these savings, simply show your
Health Plan
ID card at the above participating eyecare centers. Your savings are applied
directly to your purchase. There is no paperwork to fill out or claim forms to
submit.
Merck-Medco Mail Service Pharmacy – The Plan is now offering a
voluntary mail order prescription drug program administered by Merck-Medco Mail
Service Pharmacy. The Merck-Medco Mail Service Pharmacy is a
convenient,
safe and cost effective way to obtain prescription medications for chronic
conditions such as diabetes, asthma or high blood pressure as well as
prescriptions taken on a long-term basis such as birt
If you or a covered family member take medications on a long-term basis, the
mail order prescription drug program may save you money. The mail order copay is
twice the cost of the 31-day retail copay for a 90-day supply, as
follows:
$20 for a generic prescription $40 for a preferred (formulary)
prescription
$70 for a non-preferred (non-formulary) prescription
If you
would like more information about this program, please contact us at 740/ 695-3585 or 800/ 624- 6961. You may
also contact Merck-Medco Customer Service at 800/ 988-2262 or visit them at www.
merckmedco. c .
2002 The Health Plan HMO 38 Section 5( h) 38
38 Page 39 40
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 your
Plan doctor determines it is medically necessary to prevent, diagnose, or
treat your illness or condition and we agree, as discussed under What
Services Require Our Prior Approval on page 11.
We do not cover the following:
. Care by non-Plan providers except for
authorized referrals or emergencies (see Emergency
Benefits);
. 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;
. 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;
. Services, drugs, or supplies related to sex transformations; or
.
Services, drugs, or supplies you receive from a provider or facility barred from
the FEHB Program.
2002 The Health Plan HMO 39 Section 6 39
39 Page 40 41
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and
facilities, or obtain your prescription drugs at Plan pharmacies, you will not
have to file claims. Just present your identification card and pay your
copayment or
coinsurance.
You will only need to file a claim when you
receive emergency services from non-plan providers. Sometimes these providers
bill us directly. Check with the provider. If you need to file the claim, here
is the process:
Medical, hospital and prescription drug benefits In most cases,
providers and facilities file claims for you. Physicians
must file on the
form HCFA-1500, Health Insurance Claim Form. Facilities will file on the UB-92
form. For claims questions and
assistance, call us at 800/ 624-6961.
When you must file a claim --such as for out-of-area care --submit it on the
HCFA-1500 or a claim form that includes the information shown
below. Bills
and receipts should be itemized and show:
. Covered member's name and ID
number;
. Name and address of the physician or facility that provided the
service or supply;
. Dates you received the services or supplies;
. Diagnosis;
. Type of
each service or supply;
. The charge for each service or supply;
. A
copy of the explanation of benefits, payments, or denial from any
primary
payer --such as the Medicare Summary Notice (MSN); and
. Receipts, if you paid for your services.
Submit your claims to: The
Health Plan Attn: Claims Department
52160 National Road, East St.
Clairsville, Ohio 43950
Other supplies or services Same as above.
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.
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.
2002 The Health Plan HMO 40 Section 7 40
40 Page 41 42
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:
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: 52160 National Road, East, St.
Clairsville, Ohio 43950; 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 arrange for the health care provider to give you the care); 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 3, 1900 E Street, NW, Washington, DC 20415-3630.
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.
2002 The Health Plan HMO 41 Section 8 41
41 Page 42 43
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 800/ 624-6961 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 3 at 202/ 606-0755
between 8 a. m. and 5 p. m.
eastern time.
2002 The Health Plan HMO 42 Section 8 42
42 Page 43 44
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 what is left of our allowance, up
to our
regular benefit. We will not pay more than our allowance.
. 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.
. Part B (Medical Insurance). Most people pay
monthly for Part B.
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 managed care plan you have.
. The Original Medicare
plan The Original Medicare Plan is available everywhere in the United
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 the Original Medicare Plan along with this Plan, you
still need to follow the rules in this brochure for us to cover
your care.
Your care must continue to be authorized by your Plan PCP and prior authorized
as required.
We will not waive any of our copayments or coinsurance.
(Primary payer
chart begins on next page.)
2002 The Health Plan HMO 43 Section 9 43
43 Page 44 45
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 …
OriginalMedicare This Plan
1) Areanactiveemployee
withtheFederalgovernment (includingwhenyouor afamilymemberare
eligibleforMedicaresolely becauseofadisability),
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, or
d) Are a former spouse of an
active employee
Claims process --You probably will never have to file a claim form
when you have both our Plan and Medicare.
. When we are the primary payer,
we process the claim first.
2002 The Health Plan HMO 44 Section 9
. 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 44
44 Page 45 46
about filing your claims, call us at (800) 624-6961; or email us at info@
healthplan. org.
. Medicare managed care plan If you are eligible for
Medicare, you may choose to enroll in and get your Medicare benefits from 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 benfits 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 our Medicare managed care plan: You may enroll in our
Medicare managed care plan and also remain enrolled in our FEHB
plan. In
this case, we do not waive any of our copayments, or coinsurance for your FEHB
coverage.
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 (if you use our Plan providers), but we will not waive any of our
copayments or coinsurance. 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 service area.
. If you do not enroll Note: If you do not have one or both Parts of
Medicare, you can
Medicare Part A or Part B still be covered under
the 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 members, eligible
dependents, 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.
2002 The Health Plan HMO 45 Section 9 45
45 Page 46 47
Once OWCP or similar agency pays its maximum benefits
for your treatment, we will cover your eligible care. You must use our
providers.
Medicaid When you have this Plan and Medicaid, we pay
first.
When other Government agencies We do not cover services and
supplies when a local, State, are responsible for your care or Federal
Government agency directly or indirectly pays for them.
When others are responsible for injuries When you receive money to
compensate you for medical or hospital care
for injuries or illness caused
by another person, you must reimburse us for any expenses we paid. However, we
will cover the cost of treatment
that exceeds the amount you received in the
settlement.
If you do not seek damages, you must agree to let us try. This
is called subrogation. If you need more information, contact us for our
subrogation procedures.
2002 The Health Plan HMO 46 Section 9 46
46 Page 47 48
Section 10. Definitions of terms we use in this
brochure
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.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services. See page 12.
Coinsurance Coinsurance is the
percentage of our allowance that you must pay for your care. See page 12.
Covered services Care we provide benefits for, as described in this
brochure.
Custodial care Treatment or services that are designed
mainly to help the patient with daily living activities.
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 12.
Experimental or Services, devices or drugs that we determine are not
nationally accepted investigational services in conjunction with
accredited specialty consultants, government
agencies, and other regulatory
agencies.
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.
Medical necessity A service, device, or drug that meets its
standardized medical criteria, derived from recognized accredited national
sources. It is important to
know that your physician may recommend a
service, device, or drug that may sometimes not qualify as being medically
necessary. Medical
necessity is determined by our Medical staff, in
coordination with local or regional members of the medical community or academic
faculties.
Plan allowance Plan allowance is the amount we use to determine our
payment and your coinsurance for covered services. Plans determine their
allowances in
different ways. We determine our allowance based on our
contracted amounts with our providers.
Us/ We Us and we refer to The Health Plan HMO
You You
refers to the enrollee and each covered family member.
2002 The Health Plan HMO 47 Section 10 47
47 Page 48 49
Section 11. FEHB facts
No pre-existing
condition We will not refuse to cover the treatment of a condition that you
had limitation before you enrolled 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 about enrolling in the can answer your
questions, and give you a Guide to Federal Employees
FEHB Program
Health Benefits Plans, brochures 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 for you and your family you, your spouse, 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 or turns 22.
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.
2002 The Health Plan HMO 48 Section 11 48
48 Page 49 50
When benefits and Premiums Start The benefits
in this brochure are effective on January 1. If you joined this Plan during
Open Season, your coverage begins 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.
The benefits in this brochure are effective on January 1. If you joined this
Plan during Open Season, your coverage begins 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.
Your medical and claims We will keep your medical and claims
information confidential. Only records are confidential the following
will 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; or
. OPM, when reviewing a disputed claim or defending litigation about a claim.
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
coverage continue to get 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.
. TCC If you leave Federal service, or if you lose coverage because
you no longer qualify as a
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 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.
2002 The Health Plan HMO 49 Section 11 49
49 Page 50 51
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.
. Converting to You may convert to an 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 or 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. If you
become eligible for other group health coverage, you will not be offered
an individual policy.
Getting a Certificate of Group Health Plan Coverage You may be
entitled to continued coverage through the Health Insurance Portability and
Accountibility Act of 1996 (HIPPA). This Federal law 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.
Get OPM pamphlet RI 79-27, Temporary
Continuation of Coverage (TCC) under the FEHB Program. It highlights 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 HIPPA, and it has information about Federal and State
agencies you can
contact for more information.
2002 The Health Plan HMO 50 Section 11 50
50 Page 51 52
Long Term Care Insurance Is Coming Later in 2002!
. Many FEHB
enrollees think that their health plan and/ or Medicare will cover their
long-term care needs. Unfortunately, they are WRONG!
. How are YOU
planning to pay for the future custodial or chronic care you may need? .
You
should consider buying long-term care insurance.
The Office of Personnel Management (OPM) will sponsor a high-quality long
term care insurance program effective in October 2002. As part of its
educational effort, OPM asks you to consider these questions:
. It's
insurance to help pay for long term care services you may need if you can't take
care of yourself because of an extended illness or injury, or an age-related
disease such as Alzheimer's. What is long term care (LTC) insurance?
. LTC insurance can provide broad, flexible benefits for nursing home care,
care in an
assisted living facility, care in your home, adult day care,
hospice care, and more. It can supplement care provided by family members,
reducing the burden you place on
them.
I'm healthy. I won't need long term care. Or, will I? .
Welcome to the club! .
76% of Americans believe they will never need long
term care, but the facts are that about half them will. And it's not just the
old folks. About 40% of people needing
long term care are under age 65. They may need chronic care due to a serious
accident, a stroke, or developing multiple sclerosis, etc.
. We hope you
will never need long term care, but everyone should have a plan just in
case. Many people now consider long term care insurance to be vital to their
financial and retirement planing.
. Yes, it can be very expensive. A year in a nursing home can exceed $50,000.
Home
care for only three 8-hour shifts a week can exceed $20,000 a year. And
that's before inflation! Is long term care expensive?
. Long term care can easily exhaust your savings. Long term care insurance
can
protect your savings.
. Not FEHB. Look at the "Not covered" blocks in sections 5( a) and 5(
c) of your
FEHB brochure. Health plans don't cover custodial care or a stay
in an assisted living facility or a continuing need for a home health aide to
help you get in and out
of bed and with other activities of daily living. Limited stays in skilled
nursing facilities can be covered in some circumstances.
But won't my FEHB plan, Medicare or Medicaid cover
my long term care?
. Medicare only covers skilled nursing home care (the highest level of
nursing care)
after a hospitalization for those who are blind, age 65 or
older or fully disabled. It also has a 100 day limit.
. Medicaid covers long term care for those who meet their state's poverty
guidelines,
but has restrictions on covered services and where they can be
received. Long term care insurance can provide choices of care and preserve
your independence. {RV:
7-26}
When will I get more information on how to apply for this
new
insurance coverage?
. Employees will get more information from
their agencies during the LTC open
enrollment period in the late summer/
early fall of 2002. . Retirees will receive information at home.
. Our toll-free teleservice center will begin in mid-2002. In the meantime, you can
learn more about the program on our web site at www. opm. gov/ insure/ ltc.
How can I find out more about the program NOW?
2002 The Health Plan HMO 51 Long Term Care Insurance 51
51 Page 52 53
Index
Do not rely on this page; it is for
your convenience and may not show all pages where the terms appear.
Accidental injury 37 Allergy tests 18
Alternative treatment 22
Allogenic (donor) bone marrow
transplants 25 Ambulance 29, 31
Anesthesia
26 Autologous bone marrow
transplant 25 Biofeedback Therapy
(incontinence only) 22 Biopsies 23
Blood and blood plasma 28 Breast
cancer screening 15
Casts 23 Catastrophic protection 12
Changes
for 2002 8 Chemotherapy 18
Childbirth 16 Chiropractic 22
Cholesterol tests 15 Claims 40
Coinsurance 12 Colorectal cancer screening
15
Congenital anomalies 23 Contraceptive devices and drugs 17
Coordination of benefits 43, 44 Covered providers 9, 10
Crutches 21
Deductible 12
Definitions 47 Dental care 37
Diagnostic services
14 Disputed claims review 41, 42
Donor expenses (transplants) 25 Dressings
28
Durable medical equipment (DME) 21
Educational classes and
programs 22 Effective date of enrollment 49
Emergency 30, 31 Experimental or
investigational
39, 47
Eyeglasses 19 Family planning 17
General Exclusions 39
Hearing services 19
Home health services 21 Hospice care 29
Home
nursing care 21 Hospital 27, 28
Immunizations 16 Infertility 17
In hospital physician care 15 Inpatient Hospital Benefits 27,
28 Insulin
35
Laboratory and pathological services 28
Magnetic
Resonance Imagings (MRIs) 14
Mammograms 14, 15 Maternity Benefits 16
Medicaid 46 Medically necessary 47
Medicare 43, 44 Mental Conditions/
Substance
Abuse Benefits 32, 33 Newborn care 16
Non-FEHB Benefits
38 Nurse
Licensed Practical Nurse 21 Nurse Anesthetist 28
Registered
Nurse 21 Nursery charges 16
Obstetrical care 16 Occupational therapy
18
Ocular injury 19 Office visits 14
Oral and maxillofacial surgery 24,
25 Orthopedic devices 20
Ostomy and catheter supplies 21 Out-of-pocket
maximum 12
Outpatient facility care 28 Oxygen 21, 28
Pap test 15
Physical therapy 18 Physician 14
Pre-surgical testing 28 Precertification
11, 23, 28,
32, 33 Preventive care, adult 15
Preventive care, children
16 Prescription drugs 34, 35, 36
Preventive services 15, 16 Prior approval
11, 23, 28, 32,
33 Prostate cancer screening 15
Prosthetic devices 20
Psychologist 32, 33
Radiation therapy 18 Renal dialysis 18
Room
and board 27 Second surgical opinion 14
Skilled nursing facility care
28 Smoking cessation 22
Speech therapy 19 Splints 28
Sterilization
procedures 17 Subrogation 47
Substance abuse 32, 33 Surgery 23
.
Anesthesia 26 . Oral 23, 28
. Outpatient 23, 28 . Reconstructive 24
Syringes 35 Temporary continuation of
coverage 49, 50 Transplants
25
Vision services 19 Well child care 16
Wheelchairs 21
Workers' compensation 45,
46 X-rays 28
2002 The Health Plan HMO 52 Index 52
52 Page 53 54
NOTES:
2002 The Health Plan HMO 53
Notes 53
53 Page
54 55
NOTES:
2002 The
Health Plan HMO 54 Notes 54
54 Page 55 56
Summary of
benefits for The Health Plan HMO -2002
. Do not rely on this chart
alone. All benefits are provided in full unless indicated and 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.
. We only cover services provided or arranged by Plan physicians, except in
emergencies.
Benefits You Pay Page
Medical services provided by physicians:
. Diagnostic and treatment services provided in the office.................
Office visit copay: $10 primary care; $10 specialist 14
Services provided by a hospital:
. Inpatient
...........................................................................................
.
Outpatient.........................................................................................
Nothing
Nothing
27, 28
28
Emergency benefits:
. In-area
.............................................................................................
. Out-of-area
......................................................................................
$50 per visit
$50 per visit
31
31
Mental health and substance abuse treatment
..................................... Regular cost sharing 32, 33
Prescription
drugs.................................................................................
$10 copay generic
$20 copay formulary brand
$35 non-formulary brand
34, 35, 36
Dental
Care.......................................................................................
No benefit. 37
Vision
Care.......................................................................................
$10 per visit. 19
Protection against catastrophic costs (your out-of-pocket
maximum) ........................................................ Nothing
after $1,500/ Self Only or $3,000/ Family
enrollment per year
Some costs
do not count toward this protection
11
2002 The Health Plan HMO 55 Summary 55
55 Page 56
2002
Rate Information for The Health Plan of the Upper Ohio Valley
Non-Postal
rates apply to most non-Postal enrollees. If you are in a special enrollment
category, refer to the FEHB Guide for that category or contact the agency that
maintains your health benefits
enrollment.
Postal rates apply to
career Postal Service employees. Most employees should refer to the FEHB Guide
for United States Postal Service Employees, RI 70-2. Different postal rates
apply and
special FEHB guides are published for Postal Service Nurses, RI
70-2B; and for Postal Service Inspectors and Office of Inspector General (OIG)
employees (see RI 70-2IN).
Postal rates do not apply to non-career postal employees, postal retirees, or
associate members of any postal employee organization who are not career postal
employees. Refer to the applicable
FEHB Guide.
Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type
of Enrollment Code Gov't Share Your Share Gov't Share Your Share USPS Share Your
Share
Self Only U41 $88.00 $29.33 $190.67 $63.55 $104.13 $13.20
Self and
Family U42 $223.41 $99.25 $484.06 $215.04 $263.75 $58.91
2002 The Health Plan HMO 56 Rates 56