Serving: Most of Michigan
Enrollment in this Plan is limited; see
page 6 for requirements.
Enrollment codes for this Plan:
East Region KN1 Self Only
KN2 Self and Family K51 Self Only
K52 Self and Family Southeast Region
LX1 Self Only LX2 Self and Family
Mid Region LN1 Self Only
LN2 Self and Family West Region
KR1 Self Only KR2 Self and Family
KF1 Self Only KF2 Self and Family
G71 Self Only G72 Self and Family
RI 73-153
For changes in benefits
see page 8. 1
1
Page 2 3
2001
Blue Care Network of Michigan 2 Table of Contents
Table of
Contents
Introduction…………………………………………………………………................................................................
4
Plain
Language………………………………………………………………...............................................................
4
Section 1. Facts about this HMO plan
...........................................................................................................................
5
How we pay providers
.................................................................................................................................
5
Patients' Bill of Rights
.................................................................................................................................
5
Service
Area.................................................................................................................................................
6
Section 2. How we change for
2001………………………………………...................................................................
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.............................................................................................................
10
Services requiring our prior approval
........................................................................................................
11
Section 4. Your costs for covered services
.................................................................................................................
12
Copayments.............................................................................................................................................
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........ 21
(c)
Services provided by a hospital or other facility, and ambulance services
..................................... 24
(d) Emergency services/
accidents.........................................................................................................
26
(e) Mental health and substance abuse
benefits....................................................................................
28
(f) Prescription drug
benefits................................................................................................................
30
(g) Special features
...............................................................................................................................
32
(h) Dental benefits
................................................................................................................................
34
(i) Non-FEHB benefits available to Plan
members..............................................................................
35 2
2 Page 3 4
2001 Blue Care Network of Michigan 3 Table of
Contents
Section 6. General exclusions — things we don't cover
.............................................................................................
37
Section 7. Filing a claim for covered
services.............................................................................................................
38
Section 8. The disputed claims
process.......................................................................................................................
39
Section 9. Coordinating benefits with other
coverage.................................................................................................
41
When you have:
Other health coverage
.......................................................................................................................
41
Original Medicare
.............................................................................................................................
41
Medicare managed care
plan.............................................................................................................
43
TRICARE/ Workers' Compensation/ Medicaid
..........................................................................................
43
Other government
agencies.......................................................................................................................
44
When others are responsible for
injuries...................................................................................................
44
Section 10. Definitions of terms we use in this
brochure............................................................................................
45
Section 11. FEHB
facts...............................................................................................................................................
46
Coverage
information................................................................................................................................
46
No pre-existing condition limitation
.................................................................................................
46
Where you get information about enrolling in the FEHB Program
.................................................. 46
Types of coverage
available for you and your
family....................................................................... 46
When benefits and premiums start
....................................................................................................
46
Your medical and claims records are confidential
............................................................................ 47
When you
retire.................................................................................................................................
47
When you lose benefits
.............................................................................................................................
47
When FEHB coverage ends
..............................................................................................................
47
Spouse equity
coverage.....................................................................................................................
47
Temporary Continuation of Coverage (TCC)
...................................................................................
47
Converting to individual coverage
....................................................................................................
47
Getting a Certificate of Group Health Plan
Coverage.......................................................................
48
Inspector General advisory: Stop health care fraud!
.................................................................................
48
Index………………………………………………………………………………………………………….............
49
Summary of benefits
...................................................................................................................................................
50
Rates…………………………………………………………………………………………………………..
Back cover 3
3 Page
4 5
2001 Blue Care Network of Michigan
4 Introduction and Plain Language
Introduction
Blue
Care Network of Michigan 25925 Telegraph
Southfield, Michigan 48086-5043
This brochure describes the benefits of Blue Care Network of Michigan (BCN)
under our contract (CS 2011) 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, 2001, unless those
benefits are also shown in this brochure.
OPM negotiates benefits and rates
with each plan annually. Benefit changes are effective January 1, 2001, and are
summarized on page 8. Rates are shown on the back cover of this brochure.
Plain Language
The President and Vice President are making the
Government's communication more responsive, accessible, and understandable to
the public by requiring agencies to use plain language. In response, a team of
health plan
representatives and OPM staff worked cooperatively to make this
brochure clearer. Except for necessary technical terms, we use common words.
"You" means the enrollee or family member; "we" means Blue
Care Network of
Michigan.
The plain language team reorganized the
brochure and the way we describe our benefits. When you compare this Plan with
other FEHB plans, you will find that the brochures have the same format and
similar information to make
comparisons easier.
If you have comments or
suggestions about how to improve 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 or write to OPM at Insurance Planning and
Evaluation Division, P. O. Box 436, Washington, DC 20044-0436. 4
4 Page 5 6
2001 Blue Care Network of Michigan 5 Section 1
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.
More than 11,000
participating physicians provide health care services to enrollees in this Plan.
These doctors are located in private offices and medical centers throughout the
service area.
Patients' Bill of Rights
OPM requires that all FEHB Plans comply
with the Patients' Bill of Rights, recommended by the President's Advisory
Commission on Consumer protection and Quality in the Health Care Industry. 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 in BCN's Member Rights and
Responsibilities.
Member Rights
Blue Care Network believes that members are an essential part of the health
care team and have responsibility for their
own health.
All members have the right to: Receive information about
their health care in a manner that is understandable to them
Receive
medically necessary care as outlined in this brochure Receive considerate and
courteous care with respect for privacy and human dignity
Candidly discuss
appropriate medically necessary treatment options for their conditions,
regardless of cost of benefit coverage
Participate with practitioners in
decision making regarding their health care Expect confidentiality regarding
their care
Refuse treatment to the extent permitted by law and be informed
of the consequences of those actions Voice concerns about their health care by
submitting a formal written complaint or grievance through the BCN
Member
Grievance program Receive written information about BCN, its services,
practitioners and providers, and member rights and
responsibilities in a
clear and understandable manner Know BCN's financial relationships with its
health care facilities or primary care physician groups 5
5 Page 6 7
2001 Blue Care Network of Michigan 6 Section 1
Member Responsibilities BCN members also have responsibilities as
outlined in this brochure.
All members have the responsibility to:
Read
this brochure and all other materials for members, and call Customer Service
with any questions Coordinate all non-emergency care through their primary care
physician
Use the BCN provider network unless otherwise approved by BCN and
the primary care physician Comply with the treatment plans and instructions for
care as prescribed by their practitioners. Members, who choose
not to
comply, must advise their physician Provide, to the extent possible, information
that BCN and its physicians and providers need in order to provide care
Make
and keep appointments for non-emergency medical care, calling the doctor's
office to promptly cancel appointments when necessary
Participate in medical
decisions about their health Be considerate and courteous to providers, their
staff and other patients
Notify BCN of address changes and additions or
deletions of dependents covered by their contract Protect their identification
card against misuse and contact Customer Service immediately if a card is lost
or stolen
Report all other insurance programs that cover their health and
their family's health
Blue Care Network of Michigan is federally qualified
and licensed. BCN is a nonprofit HMO and an affiliate of Blue Cross Blue Shield
of Michigan. It formed in February 1998 when four affiliated Blue Care Network
organizations
(Blue Care Network of East Michigan, Blue Care Network-Great
Lakes, Blue Care Network Mid Michigan and Blue Care Network of Southeast
Michigan) merged into a single, new company. Of these former separate entities,
BCN of
East Michigan is the oldest. It became federally licensed as an HMO
in 1975. BCN Mid Michigan was established in 1977. BCN of Southeast Michigan was
licensed in 1981 and BCN-Great Lakes began operation in 1983.
If you want more information about us, call 1-800-662-6667, or write to Blue
Care Network of Michigan, 25925 Telegraph, Southfield, MI 48086-5043. Our
website is www. bcbsm. com/ bcn/
Service Area
To enroll in this
Plan, you must live, or work, in our Service Area. This is where our providers
practice. Our Service Area is:
East Michigan Code K5 – serving Arenac, Bay, Gratiot, Isabella,
Midland, Saginaw and Tuscola counties
Code KN – serving
Genesee, Lapeer and Shiawassee (excluding the towns of Perry, Shaftsburg and
Morice) counties.
Mid-Michigan Code LN – serving Clinton,
Eaton, Ingham, Jackson, Livingston and parts of Shiawassee (the towns of Perry,
Shaftsburg and Morice), Ionia (the towns of Danby and Portland) and
Hillsdale (except for Somerset and Wright townships and Waldron Village)
counties.
Southeast Michigan Code LX – serving Macomb, Monroe, Oakland,
St. Clair, Washtenaw and Wayne counties.
West Michigan Code G7 –
serving Alcona, Alpena, Antrium, Benzie, Charlevoix, Cheboygan, Crawford,
Emmet, Grand Traverse,
Iosco, Kalkaska, Leelanau, Mackinac, Manistee
(portions of), Montmorency, Ogemaw, Oscoda, Otsego, Presque Isle and Roscommon
counties.
Code KF – serving Berrien, Calhoun, Cass, Kalamazoo,
St. Joseph, Van Buren and the portions of Allegan, Barry and Eaton (those areas
served by postal zip codes 49010, 49020, 49046, 49060, 49073, 49078 and 49080)
counties.
Code KR – serving Kent, Muskegon Oceana, Ottawa and
portions of Ionia, Mecosta, Montcalm, Newaygo and Wexford counties. And the
portion of Allegan County served by postal zip codes 49070, 49311, 49314, 49323,
49328,
49335, 49344, 49348, 49406, 49408, 49416, 49419, 49423, 49447, 49450
and 49543. 6
6 Page
7 8
2001 Blue Care Network of Michigan
7 Section 1
Ordinarily, you must get your care from providers who
contract with us. If you receive care outside our Service Area, we will pay only
for emergency care. We will not pay for any other health care services.
If
you or a covered family member move outside our Service Area, you can enroll in
another plan. If your dependents live out of the area (for example, if your
child goes to college in another state), you should consider enrolling in a
fee-for-
service plan or an HMO that has agreements with affiliates in other
areas. Almost anywhere within the state of Michgan, urgent care and in some
cases, routine services, can be arranged. Blue Care Network is also a part of a
national network of Blue Cross and Blue Shield HMOs, BluesConnect®.
Members can obtain urgent care in areas served by other Blue Cross and Blue
Shield HMOs affiliated with BluesConnect. If you would like more information
about receiving care away from home, please contact Customer Service. If you
or a family member move, you do not have to wait until open enrollment season to
change plans. Contact your employment or retirement office. 7
7 Page 8 9
2001 Blue Care Network of Michigan 8 Section 2
Section 2. How we change for 2001
Program-wide changes
The plain language team reorganized the brochure and the way we describe
our benefits. We hope this will make it easier for you to compare plans.
This year, the Federal Employees Health Benefits Program is implementing
network mental health and substance abuse parity. This means that your coverage
for mental health, substance abuse, medical, surgical, and hospital
services
from providers in our plan network will be the same with regard to coinsurance,
copays, and day and visit limitations when you follow a treatment plan that we
approve. Previously, we placed shorter day or visit limitations
on mental
health and substance abuse services than we did on services to treat physical
illness, injury, or disease.
Many health care organizations have turned
their attention this past year to improving health care quality and patient
safety. OPM asked all FEHB plans to join it in this effort. You can find
specific information on our patient safety
activities by calling Customer Service at 1-800-662-6667. You can find out
more about patient safety on the OPM website, www. opm. gov/ insure. To improve
your health care, take these five steps.
Speak up if you have questions or concerns. Keep a list of all the medicines
you take.
Make sure you get the results of any test or procedure. Talk with
your doctor and health care team about your options if you need hospital care.
Make sure you understand what will happen if you need surgery.
We
clarified the language to show that anyone who needs a mastectomy may choose to
have the procedure performed on an inpatient basis and remain in the hospital up
to 48 hours after the procedure. Previously, the language
referenced only
women.
Changes to this Plan
Your share of the non-postal premium
will increase by:
37.2% for Self Only or 31% for Self and Family for West
Michigan (code G7) 14% for Self Only or 20% for Self and Family for East
Michigan (code K5)
44.5% for Self Only or 120.5% for Self and Family for
West Michigan (code KF) 17.6% for Self Only or 29.8% for Self and Family for
East Michigan (code KN)
52.5% for Self Only or 87.1 for Self and Family for
West Michigan (code KR) 88.7% for Self Only or 75.4% for Self and Family for
Mid-Michigan (code LN)
19.7% for Self Only or 20% for Self and Family for
Southeast Michigan (code LX) 8
8 Page 9 10
2001 Blue Care
Network of Michigan 9 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when
you enroll. You should carry your ID card with you at all times. You must show
it whenever you
receive services from a Plan provider, or fill a
prescription at a Plan pharmacy. Until you receive your ID card, use your copy
of the Health
Benefits Election Form, SF-2809, your health benefits
enrollment confirmation (for annuitants), or your Employee Express confirmation
letter.
If you do not receive your ID card within 30 days after the
effective date of your enrollment, or if you need replacement cards, call us at
1-800-662-
6667.
Where you get covered care You get care from "Plan
providers" and "Plan facilities." You will only pay copayments,
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.
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.
What you must do It depends on the type of care you need. First, you
and each family member must choose a primary care physician. This decision is
important since
your primary care physician provides or arranges for most of
your health care. You can select any primary care physician who is accepting new
patients from our provider directory for your region.
Primary care
Your primary care physician can be a family practitioner, internist or, for
your children, a 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
may also change
primary care physicians through our website.
Specialty care Your
primary care physician will refer you to a specialist for needed care. However,
female members may self refer to a gynecologist or obstetrician
-gynecologist for their annual well-woman exams and routine services.
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 manage
your care, referring you
to a specialist when it is medically appropriate. Your primary care physician
will use our criteria when creating your
treatment plan (the physician may
have to get an authorization or approval beforehand). 9
9 Page 10 11
2001 Blue Care Network of Michigan 10
Section 3
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 1-800-662-6667. 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 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 hospital benefit of the hospitalized
person; we cover your other non-hospital care.
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. 10
10
Page 11 12
2001
Blue Care Network of Michigan 11 Section 3
Services requiring
our prior approval Your primary care physician has authority to refer you
for most services. For certain services, however, your physician must obtain
approval from us. Before giving approval, we consider if the service is
covered, medically necessary, and follows generally accepted medical
practice.
We call this review and approval process plan approval. Your
physician must obtain plan approval for services such as, but not limited to:
Inpatient hospitalization Reconstructive surgery
Transplants Certain
infertility treatments
Home Health Care Nursing Home Care
Physical/
Occupational/ Speech Therapy Cardiac/ Pulmonary Rehabilitation
Your primary care physician has been advised of the procedures that require
plan approval. The PCP must send a copy of the referral, along
with the
appropriate medical records to BCN so that BCN can review the request for
medical appropriateness. If the proper procedure is not
followed and BCN
does not assign an authorization for the procedure in question, the procedure
will not be covered and you may be financially
liable for all costs. Your
PCP must issue the referral and initiate this process. If your PCP will not
initiate the referral for you, you should
contact Customer Services at
1-800-662-6667 to determine how to proceed. BCN will make every effort to ensure
that appropriate care is
provided for you and your family in a timely
fashion.
The contracted obstetrician-gynecologist practitioner must still
obtain prior authorization from the PCP for hospital admissions and outpatient
surgeries for eligible conditions.
To ensure continuity of care, the
member's PCP coordinates direct access to specialty care. When indicated,
authorization is given for an
adequate number of direct access visits under
an approved treatment plan.
The role of the specialist physician in part is to accept referrals of
members from PCP's and except in emergencies, provide only those
services
that were authorized by the member's PCP. The specialist physician should
consult with and seek further authorization from the
member's PCP if
additional treatment or tests are needed.
In instances where the member has
a complex or serious medical condition such as AIDS, end stage renal disease, or
advanced cancer a
case manager can work with a PCP to eliminate barriers
caused by the referral process. For example, a case manager will coordinate the
member's care between the PCP and specialty care physician( s) by
facilitating close communication among them via telephone and written
progress reports.
The PCP is fully apprised of the specialist's
treatment plan, thereby decreasing the frequency of member visits to the PCP. 11
11 Page 12 13
2001 Blue Care Network of Michigan 12
Section 4
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 when you
receive services.
Example: When you see your primary care physician you pay a copayment of $10
per office visit.
Coinsurance Coinsurance is the percentage of our
negotiated fee that you must pay for your care.
Example: In our Plan, you
pay 50 percent of our allowance for infertility services and durable medical
equipment.
Your out-of-pocket maximum for copayments and coinsurance We do not
have an out-of-pocket maximum. 12
12 Page 13 14
2001 Blue Care
Network of Michigan 13 Section 5
Section 5. Benefits
--OVERVIEW (See page 8 for how our benefits changed this year and page
50 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 1-800-662-6667 (1-800-257-9980, TTY for the hearing
impaired) or at our website at www. bcbsm. com/ bcn/.
(a) Medical services and supplies provided by physicians and other health
care professionals....................... 14 to 20 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
Rehabilitative therapies
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
Educational
classes and programs
(b) Surgical and anesthesia services provided by physicians and other health
care professionals ................... 21 to 23 Surgical procedures
Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue
transplants Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services
................................................. 24 to 25 Inpatient hospital
Outpatient hospital or ambulatory surgical center Extended care benefits/
skilled nursing care facility benefits Hospice care
Ambulance
(d)
Emergency services/
accidents.....................................................................................................................
26 to 27 Medical emergency Ambulance
(e) Mental health and substance abuse
benefits................................................................................................
28 to 29
(f) Prescription drug benefits
...........................................................................................................................
30 to 31
(g) Special features
...........................................................................................................................................
32 to 33 Flexible Benefit Option 24-Hour Nurse Line
Reciprocity Benefit
High-Risk Pregnancies Centers of Excellence for Transplants Travel Benefits/
Services Overseas
Educational Classes and Programs
(h) Dental benefits
.....................................................................................................................................................
34
(i) Non-FEHB benefits available to Plan members
.........................................................................................
35 to 36
Summary of benefits
...................................................................................................................................................
50 13
13 Page 14
15
2001 Blue Care Network of Michigan 14
Section 5( a)
Section 5 (a) Medical services and supplies provided
by physicians and other health care professionals
I M
P O
R T
A
N
T
Here are some important things 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.
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 You pay
Professional services of physicians
In physician's office
$10 per office visit
Professional services of physicians
In an urgent care center During a
hospital stay
In a skilled nursing facility Initial examination of a newborn child covered
under a family
enrollment Office medical consultations
Second surgical
opinion
$10 per office visit
At home 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 office visit 14
14 Page 15 16
2001 Blue Care
Network of Michigan 15 Section 5( a)
Preventive care, adult
You pay
Routine screenings, such as:
Blood lead level – one
annually Total blood cholesterol – once every three years, ages 19 through
64
Colorectal cancer screening, including Fecal occult blood test
Sigmoidoscopy, screening – every five years starting at age 50 Travel
immunizations
$10 per office visit
Prostate Specific Antigen (PSA test) – one annually for men age 40 and
older $10 per office visit
Routine pap test
Note: The office visit is
covered if pap test is received on the same day; see Diagnostic and Treatment
Services, above.
$10 per office visit
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
years
$10 per office visit
Not covered: physical exams required for obtaining or continuing
employment or insurance, attending schools or camp All charges
Routine
immunizations, limited to:
Tetanus-diphtheria (Td) booster – once
every 10 years, ages 19 and over (except as provided for under childhood
immunizations)
Influenza/ pneumococcal vaccines, annually, age 65 and over
$10 per office visit
Preventive care, children You pay
Childhood immunizations
recommended by the American Academy of Pediatrics $10 per office visit
Examinations, such as:
Eye exams through age 17 to determine the need for
vision correction. Ear exams through age 17 to determine the need for hearing
correction
Examinations done on the day of immunizations (through age 22) Well-child
care charges for routine examinations, immunizations and
care (through age
22)
$10 per office visit 15
15 Page 16 17
2001 Blue Care
Network of Michigan 16 Section 5( a)
Maternity care You pay
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 16 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 per office visit
Not covered: routine sonograms to determine fetal age, size or sex All
charges
Family planning You pay
Voluntary sterilization $10
per office visit
Surgically implanted contraceptives Injectable contraceptive drugs
Intrauterine devices (IUDs)
$5 copayment (paid under the pharmacy
benefit) and $10 per office
visit
Not covered: reversal of voluntary surgical sterilization, genetic
counseling All charges
Infertility services You pay
Diagnosis and treatment of
infertility, such as:
Artificial insemination: intravaginal insemination
(IVI)
intracervical insemination (ICI) intrauterine insemination (IUI)
Fertility drugs
Note: We cover injectable fertility drugs under medical
benefits and oral fertility drugs under the prescription drug benefit.
50 percent of charges
Not covered:
Assisted reproductive technology (ART) procedures,
such as: in vitro fertilization
embryo transfer and GIFT Services and supplies related to excluded
ART procedures
Cost of donor sperm
All charges 16
16 Page 17 18
2001 Blue Care
Network of Michigan 17 Section 5( a)
Allergy care You pay
Testing and treatment
Allergy injection
$10 per office visit
Allergy serum Nothing
Not covered: provocative food testing and
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 23. Respiratory and inhalation therapy
Dialysis – hemodialysis and peritoneal dialysis Intravenous (IV)/
Infusion Therapy – Home IV and antibiotic therapy
Growth hormone
therapy (GHT)
Note: We will only cover GHT when we preauthorize the
treatment. Call 1-800-662-6667 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.
$10 per office visit
Rehabilitative therapies You pay
Physical therapy, occupational
therapy and speech therapy --
60 visits per condition for the services of
each of the following: qualified physical therapists;
speech therapists; and occupational therapists
Note: We only cover therapy to restore bodily function or speech when there
has been a total or partial loss of bodily function or functional
speech due
to illness or injury.
Cardiac rehabilitation following a heart transplant,
bypass surgery or a myocardial infarction, limited to 60 consecutive days.
Phases three
and four of cardiac rehab are not covered.
$10 per office visit
Not covered: long-term rehabilitative therapy
exercise
programs
All charges 17
17 Page 18 19
2001 Blue Care
Network of Michigan 18 Section 5( a)
Hearing services
(testing, treatment and supplies) You pay
First hearing aid and testing
only when necessitated by accidental injury
Hearing testing for children
through age 17 (see Preventive care, children)
$10 per office visit
Not covered:
all other hearing testing hearing aids,
testing and examinations for them
All charges
Vision services (testing, treatment and supplies) You pay
Annual
eye refraction from Plan optometrists to provide a written lens prescription for
eyeglasses $5 per office visit
One pair every 12 months of: colorless glass lenses, medically necessary
tinted #1 and #2 lenses, bifocal and trifocal lenses, or
contact lenses when
provided by an optician or physician.
$7.50
One pair of frames All charges above $42.50
Non-Plan providers of vision
services are paid at 75% of reasonable charges less the $5 copay. $5 plus all
charges above Plan allowance
Not covered:
Eye exercises Photo-sensitive lenses
Non-medically necessary tinted lenses Safety glasses
Repair or replacement of lost or broken lenses or frames
All charges
Foot care You pay
Routine foot care 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.
$10 per office visit
Not covered:
Cutting, trimming or removal of corns, calluses,
or the free edge of toenails, and similar routine treatment of conditions of the
foot,
except as stated above Treatment of weak, strained or flat feet or
bunions or spurs; and of
any instability, imbalance or subluxation of the
foot (unless the treatment is by open cutting surgery)
All charges 18
18 Page 19 20
2001 Blue Care
Network of Michigan 19 Section 5( a)
Orthopedic and prosthetic
devices You pay
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.
50 percent of charges
Not covered:
orthopedic and corrective shoes arch
supports
foot orthotics heel pads and heel cups
lumbosacral
supports corsets, trusses, elastic stockings, support hose, and other
supportive
devices prosthetic replacements provided less than three
years after the last
one we covered bite splints
All charges
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; wheelchairs;
motorized wheelchairs, if medical criteria are met; crutches;
walkers;
blood glucose monitors;
insulin pumps; and oxygen therapy.
Note: Call our DME provider, Northwood, at 1-800-677-8496 as soon as your
Plan physician prescribes this equipment. It will arrange with a
health care
provider to rent or sell you durable medical equipment at discounted rates and
will tell you more about this service when you call.
50 percent of charges
Not included: deluxe equipment and convenience items 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.
$10 per visit 19
19 Page
20 21
2001 Blue Care Network of
Michigan 20 Section 5( a)
Home health services (continued)
Not covered: nursing care requested by, or for the convenience
of, the patient or
the patient's family; nursing care primarily for hygiene, feeding,
exercising, moving the
patient, homemaking, companionship or giving oral
medication.
All charges
Educational classes and programs You pay
Blue Care Network's
Health Education department provides a number of special events each year.
Although topics change from time to time,
recent examples include programs on general health, healthy cooking, men's
health, women's heath and menopause. BCN sends members a
catalog of classes
and invitations to special events.
The Disease Management Department
provides support and educational opportunities for members with asthma, diabetes
and congestive heart
failure and for expectant mothers.
No charge 20
20 Page
21 22
2001 Blue Care Network of
Michigan 21 Section 5( b)
Section 5 (b). Surgical and
anesthesia services provided by physicians and other health care professionals
I M
P O
R T
A N
T
Here are some important things 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.
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 facility (i. e. hospital, surgical center, etc.)
YOU 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 You pay
Treatment of fractures, including casting Normal pre-and post-operative
care by the surgeon
Correction of amblyopia and strabismus Endoscopy procedure
Biopsy
procedure Removal of tumors and cysts
Correction of congenital anomalies
(see reconstructive surgery) Surgical treatment of morbid obesity — a
condition in which an
individual weighs 100 pounds or 100 percent 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 braces and
prosthetic devices for device
coverage information. Voluntary sterilization
Norplant (a surgically
implanted contraceptive) and intrauterine devices (IUDs) Note: Devices are
covered under 5( a).
Treatment of burns
Note: Generally, we pay for
internal prostheses (devices) according to where the procedure is done. For
example, we pay hospital benefits for a
pacemaker and surgery benefits for
insertion of the pacemaker.
$10 per office visit
Not covered:
Reversal of voluntary sterilization Routine
treatment of conditions of the foot; see Foot care.
All charges 21
21 Page 22 23
2001 Blue Care Network of Michigan 22
Section 5( b)
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; birth marks;
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.
Nothing
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 You pay
Oral surgical procedures,
limited to:
Reduction of fractures of the jaws or facial bones; Surgical
correction of cleft lip, cleft palate or severe functional
malocclusion; Removal of stones from salivary ducts;
Excision of
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
Not covered:
Oral implants and transplants Procedures
that involve the teeth or their supporting structures (such as
the periodontal membrane, gingiva, and alveolar bone) Bite splints
All charges 22
22 Page 23 24
2001 Blue Care
Network of Michigan 23 Section 5( b)
Organ/ tissue transplants
You pay
Limited to:
Cornea Heart
Heart/ lung Kidney
Kidney/ pancreas Liver
Lung: single – double
Pancreas
Allogenic (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
National
Transplant Program (NTP)
Limited benefits -Treatment for breast cancer,
multiple myeloma, and epithelial ovarian cancer may be provided in an NCI-or
NIH-approved
clinical trial at a Plan-designated center of excellence and if approved by
the Plan's medical director in accordance with the
Plan's protocols.
Note: We cover related medical and hospital expenses 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
Anesthesia You pay
Professional services provided in –
Hospital (inpatient)
Nothing
Professional services provided in –
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Nothing
Office $10 per office visit 23
23 Page 24 25
2001 Blue Care
Network of Michigan 24 Section 5( c)
Section 5 (c). Services
provided by a hospital or other facility, and ambulance services
I M
P O
R T
A N
T
Here are some important things 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.
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 Section 5( a) or (b).
YOU MUST GET PRECERTIFICATION OF 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.
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
Take-home
items Medical supplies, appliances, medical equipment, and any covered
items
billed by a hospital for use at home (Note: calendar year deductible applies.)
Nothing 24
24 Page
25 26
2001 Blue Care Network of
Michigan 25 Section 5( c)
Inpatient hospital (continued)
Not covered:
Custodial care Non-covered facilities,
such as nursing homes, extended care
facilities, schools Personal comfort items, such as telephone,
television, barber
services, guest meals and beds Private nursing
care
All charges.
Outpatient hospital or ambulatory surgical center You pay
Operating, recovery, and other treatment rooms Prescribed drugs and
medicines
Diagnostic laboratory tests, X-rays, and pathology services Administration of
blood, blood plasma, and other biologicals
Blood and blood plasma, if not
donated or replaced Pre-surgical testing
Dressings, casts, and sterile tray
services Medical supplies, including oxygen
Anesthetics and anesthesia
service
Note: We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment. We
do not
cover the dental procedures.
Nothing
Not covered: blood and blood derivatives not replaced by the member All
charges
Extended care benefits/ skilled nursing care facility
benefits You pay
Extended care Nothing
Skilled nursing facility (SNF): 730 days if the patient meets criteria.
Nothing
Not covered: custodial care All charges
Hospice care You pay
If hospice care is provided in the home, the
home health care benefit applies. If hospice care is provided in a skilled
nursing facility, the
skilled nursing facility benefit applies.
Nothing
Not covered: independent nursing, homemaker services All charges
Ambulance You pay
Local professional ambulance service when
medically appropriate Air ambulance service when medically appropriate Nothing
25
25 Page 26 27
2001 Blue Care Network of Michigan 26
Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits: Please
remember that all benefits are subject to the definitions, limitations, and
exclusions in this brochure. 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,
gun shot 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:
Emergencies within our service area:
If you are in an emergency situation, please call your primary care doctor.
In extreme emergencies, if you are unable to contact your doctor, contact the
local emergency system (e. g., the 911 telephone
system) or go to the
nearest hospital emergency room. Be sure to tell the emergency room personnel
that you are a member of this Plan so they can notify this Plan. You or a family
member should notify this Plan within 24 hours unless it was not
reasonably
possible to do so. It is your responsibility to ensure that this Plan has been
notified in a timely manner.
If you need to be hospitalized, this Plan
should be notified within 24 hours unless it was not reasonably possible to do
so. If you are hospitalized in a non-Plan facility and a Plan 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.
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.
To be covered by this Plan, any follow-up care recommended by non-Plan
providers must be approved by this Plan or provided by Plan providers.
Plan
pays: Reasonable charges for emergency care services to the extent the services
would have been covered if received from Plan providers.
You pay: $25 per
visit in a hospital emergency room, or $10 per visit in an urgent care facility,
and $10 per visit in a physician's office for emergency care services that are
covered benefits of this Plan. If the emergency results in
admission to a
hospital, the emergency care copay is waived.
Emergencies outside our
service area: Benefits are available for any medically necessary health
service that is immediately required because of injury or unforeseen illness.
If you need to be hospitalized, this Plan must be notified within 24 hours
unless it was not reasonably possible to do so. If a Plan physician believes
care can be better provided in a Plan hospital, you would be transferred when
medically feasible
with any ambulance charges covered in full.
To be
covered by this Plan, any follow-up care recommended by non-Plan providers must
be approved by this Plan or provided by Plan providers. 26
26 Page 27 28
2001 Blue Care Network of Michigan 27
Section 5( d)
Plan pays: Reasonable charges for emergency care
services to the extent the services would have been covered if received from
Plan providers.
You pay: $25 per visit in a hospital emergency room, or $10
per visit in an urgent care facility, and $10 per visit in a physician's office
for emergency care services that are covered benefits of this Plan. If the
emergency results in admission
to a hospital, the emergency care copay is
waived.
Benefit Description You pay
Emergency within our service area You pay
Emergency care at a doctor's office Emergency care at an urgent care
center $10 per office visit
Emergency care as an outpatient or inpatient at a hospital, including
doctors' services $25 per visit (waived if admitted)
Not covered:
elective care or non-emergency care All charges
Emergency outside our
service area You pay
Emergency care at a doctor's office Emergency care
at an urgent care center $10 per visit
Emergency care as an outpatient or inpatient at a hospital, including
doctors' services $25 per visit (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 area
All charges.
Ambulance You pay
Professional ambulance service when medically
appropriate.
Air ambulance when medically appropriate.
See 5( c) for
non-emergency service.
Nothing 27
27 Page
28 29
2001 Blue Care Network of
Michigan 28 Section 5( e)
Section 5 (e). Mental health and
substance abuse benefits
I M
P O
R T
A N
T
Parity
Beginning in 2001, all FEHB plans' mental health and
substance abuse benefits will achieve "parity" with other benefits.
This means that we will provide mental health and substance abuse
benefits differently than in the past.
When you get our approval for
services and follow a treatment plan we approve, cost-sharing and limitations
for Plan mental health and substance abuse benefits will be no greater than for
similar benefits for other illnesses and conditions.
Here are some
important things to keep in mind about these benefits:
All benefits are
subject to the definitions, limitations, and exclusions in this brochure.
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 After the calendar year
deductible…
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 office visit
Diagnostic tests $10 per office visit
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
Nothing
Not covered: services we have not approvd..
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. 28
28 Page 29 30
2001 Blue Care
Network of Michigan 29 Section 5( e)
Preauthorization To
be eligible to receive these benefits you must follow your treatment plan and
all the following authorization processes:
Members call ValueOptions at
1-800-482-5982 to arrange behavioral health services. Call this number for
information on referral procedures, providers
and inpatient and outpatient
services.
Special transitionalbenefit If a mental health or substance abuse
professional provider is treating you under our plan as of January 1, 2001, you
will be eligible for continued
coverage with your provider for up to 90 days
under the following condition:
If your mental health or substance abuse professional provider with
whom
you are currently in treatment leaves the plan at our request for other than
cause.
If this condition applies to you, we will allow you reasonable time to
transfer your care to a Plan mental health or substance abuse professional
provider. During the transitional period, you may continue to see your
treating provider and will not pay any more out-of-pocket than you did in
the year 2000 for services. This transitional period will begin with our
notice to you of the change in coverage and will end 90 days after you
receive our notice. If we write to you before October 1, 2000, the 90-day
period ends before January 1 and this transitional benefit does not apply.
Limitation We may limit your benefits if you do not follow your
treatment plan. 29
29 Page
30 31
2001 Blue Care Network of
Michigan 30 Section 5( f)
Section 5 (f). Prescription drug
benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
We cover prescription drugs, brand name and generic, which are listed in the
Clinical Formulary, 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 your doctor and health plan feel they are
medically necessary.
A single copayment of $5 will be applied to each
prescription. 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 Plan physician or referral physician must write the prescription. Coverage
is also provided for any prescription( s) prescribed by a licensed dentist or
podiatrist.
Where you can obtain them. You may have your
prescription filled at: 2, 200 participating retail pharmacies in the state,
60,000 MedCare pharmacies out-of-state, Merck-Medco Managed Care, LLC , our
mail order pharmacy
Your doctor can order up to a 90-day supply of a mail order prescription for
a $5 copayment.
We use a modified, open formulary. Blue Care Network
has a modified, open formulary that is maintained by the BCN Pharmacy and
Therapeutics Committee. Generic substitution is mandatory
where appropriate. Generic substitution is not mandatory for critical drugs.
Critical drugs are products where clinical judgment recommends using the
brand-name drug because the generic drug
cannot be safely substituted. These
drugs are Lanoxin, Dilantin, Coumadin, Premarin, Theodur, Slophyllin, and
Tegretol. A few select drugs on the formulary are part of the BCN Quality
Interchange Program and may require prior authorization. Coverage is
provided for a nonformulary drug when the Plan and doctor agree that it's
medically necessary.
These are the dispensing limitations. A 34-day supply is the limit for
most prescription drugs filled at a participating retail pharmacy. The pharmacy
may dispense up to a 100-day supply for certain
maintenance drugs. Copies of
the maintenance drug list can be requested from Customer Service.
Note: The
Plan will approve a prescription for the same medication when it is filled at
least one week in advance of the next fill date. The pharmacy will charge you a
separate copay for each prescription when
a vacation supply is requested, e.
g., if you request a two-month supply, you will be charged two copays or $10.
You may be required to pay the difference in costs between a brand name drug and
the price of
its generic equivalent if a dispense-as-written (DAW)
prescription is not preauthorized by the Plan.
When you have to file a claim. Prescriptions filled at non-network
pharmacies will be reimbursed in full, less your $5 copayment, in urgent or
emergency situations. Non-emergency prescriptions will be
reimbursed at the
Plan's cost, less the $5 copayment. You must submit proof of payment for
prescription services to Customer Services.
Prescription drug benefits begin on the next page. 30
30 Page 31 32
2001 Blue Care Network of Michigan 31
Section 5( f)
Benefit Description You pay
Covered medications
and supplies
We cover the following medications and supplies when
prescribed by a Plan physician and obtained from a Plan pharmacy or through our
mail
order program: Generic and brand-name formulary drugs for which a
prescription is
required by law; Insulin;
Insulin syringes and needles;
Disposable needles and syringes for the administration of covered
medications; Intravenous fluids and medications for home use;
Contraceptive devices, including diaphragms, IUDs, and implants; Injectable
contraceptive drugs;
Fertility drugs are covered under this Plan's
infertility benefit with 50 percent coinsurance (see page 16);
Smoking
cessation drugs and medications or gum; Drugs to treat sexual dysfunction are
limited. Contact this Plan for
dose limits. Oral contraceptive drugs –
up to a three-cycle supply
$5 per prescription
Note: If there is no generic equivalent available,
you will still
have to pay the brand name copay.
$5 up to the dose limits — all charges thereafter
Appetite
suppressants are covered when preauthorized $5 up to dose limits
Here are
some things to keep in mind about our prescription drug program:
A generic
equivalent will be dispensed if it is available, unless your physician
specifically requires a name brand. If you receive a name brand
drug when a
Federally approved generic drug is available, and your physician has not
specified Dispense as Written (DAW) for the name
brand drug, you have to pay
the difference in cost between the name brand drug and the generic.
We have an open formulary. If your physician believes a name brand product is
medically necessary or there is no generic available, your
physician may
prescribe a name brand drug from the formulary list. The formulary is a
preferred list of brand name and generic drugs covered by
the Plan. To
request a copy of the formulary call Customer Service at 1-800-662-6667.
Not covered:
Medical supplies such as dressings and antiseptics
Drugs and supplies for cosmetic purposes
Vitamins and nutritional substances that can be purchased without a
prescription
Nonprescription medicines Drugs to enhance
athletic performance
All charges 31
31 Page 32 33
2001 Blue Care
Network of Michigan 32 Section 5( g)
Section 5 (g). Special
Features
Feature Description
Flexible benefits option Under the
flexible benefits option, we determine the most effective way to provide
services. We may identify medically appropriate alternatives to traditional
care and coordinate other benefits as a less costly alternative benefit.
Alternative benefits are subject to our ongoing review.
By approving an
alternative benefit, we cannot guarantee you will get it in the future.
The
decision to offer an alternative benefit is solely ours, and we may withdraw it
at any time and resume regular contract benefits.
Our decision to offer or
withdraw alternative benefits is not subject to OPM review under the disputed
claims process.
24-hour nurse line For any of your health concerns, 24 hours a day,
seven days a week, you may call 1-800-622-6252 and talk with a registered nurse
who will discuss treatment options and answer your health questions.
Reciprocity benefit Blue Care Network works with Blue plans across
the United States to provide care for members who are travelling or who are
temporarily living away from home.
Away from Home Care: Urgent care is
available throughout Michigan. Contact the Away from Home Care coordinator at
1-877-465-5122
during regular business hours. The coordinator will direct
you to the most convenient BCN locations.
BluesConnect: BCN participates in a nationwide network of Blue Cross and Blue
Shield Association HMOs to provide urgent care for
members travelling
outside Michigan. Contact BluesConnect at 1-800-446-6872 to make arrangements
for care. The coordinator is available
24-hours a day, seven days a week.
Guest membership program: You can prearrange for routine care for members
who are seasonal residents or for families living apart, such
as for covered dependents attending college or a family member living in a
different BCN service region. Guest memberships are only
available when a
member is going to be out of the service region for more than 90 consecutive
days. Guest memberships are limited to a
six-month maximum for subscribers.
Guest memberships must be renewed annually. Contact the Away from Home
coordinator at 1-877-
465-5122 to arrange guest membership.
High-risk pregnancies Our pregnancy program identifies high-risk
pregnancies and refers expectant mothers to our case management program for
personalized intervention and follow-up. Studies have proven that early
intervention
in high-risk pregnancies significantly increases positive
outcomes.
The same program provides education and support to not only
pregnant women but to those who are thinking of becoming pregnant.
Though our health education program, we encourage expectant parents to attend
prenatal education classes offered by BCN network hospitals. 32
32 Page 33 34
2001 Blue Care Network of Michigan 33
Section 5( g)
Centers of excellence for transplants Blue Care
Network uses the Blue Cross Blue Shield of Michigan Centers of Excellence for
Transplants.
Travel benefit/ services overseas Immunizations to meet
foreign travel requirements are a covered benefit. Emergency treatment is also
covered. Members must submit
bills and documentation.
Educational classes and programs Blue Care Network's Health Education
Department provides a number of special events each year. Although topics change
from time to time,
recent examples include programs on general health,
healthy cooking, men's health, women's health and menopause. BCN sends members a
catalog of classes and invitations to special events.
The Disease
Management Department provides support and educational opportunities for members
with asthma diabetes and
congestive heart failure and for expectant mothers.
33
33 Page 34 35
2001 Blue Care Network of Michigan 34
Section 5( h))
Section 5 (h). Dental benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are
medically necessary.
Plan dentists must provide or arrange your care.
We cover hospitalization for dental procedures only when a nondental
physical impairment exists which makes hospitalization necessary to safeguard
the health of
the patient; we do not cover the dental procedure unless it is described
below.
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 34
34
Page 35 36
2001
Blue Care Network of Michigan 35 Section 5( i)
Section 5 (i).
Non-FEHB benefits available to Plan members
The benefits on this page
are not part of the FEHB contract or premium, and you cannot file an FEHB
disputed claim about them. Fees you pay for these services do not count
toward FEHB deductibles or out-of-pocket maximums.
BlueSafe sm BlueSafe offers discounts on safety equipment such as
child car seats, bicycle helmets, smoke and carbon monoxide detectors, baby
gates, fire escape ladders, home medical equipment and athletic gear. Call
toll free 1-877-BLUESAFE for discount coupons and more information on
participating retailers.
Disease management Members with asthma, congestive heart failure and
diabetes are supported through BCN's Disease Management program. Participants
receive educational materials through the mail and are invited to
special
programs that help them learn more about their conditions and how to maximize
their health.
Publications Each household receives Good Health twice a year, a
newsletter from BCN that includes health information, notices of coming events
and updates on benefits. Blue Cross Blue Shield of Michigan sends
members a
magazine twice a year. Living Healthy is a lively publication that features
wellness articles, features about Blue
members and other timely information.
Medicare prepaid plan enrollment BCN offers Medicare recipients the
opportunity to enroll in this Plan through Medicare. Annuitants and former
spouses with FEHB coverage and Medicare Part B may elect to drop their FEHB
coverage
and enroll in a Medicare prepaid plan when one is available in
their area. They may then later reenroll in the FEHB program. Most Federal
annuitants have Medicare Part A. Those without Medicare Part A may join the
Medicare prepaid Plan but will probably have to pay for
hospital coverage in
addition to the Part B premium. Before you join this Plan, ask whether this Plan
covers hospital benefits and, if so, what
you will have to pay. Contact your
retirement system for information on dropping you FEHB enrollment and changing
to a Medicare
prepaid plan. Contact us at 1-800-529-8360 for information on
the Medicare prepaid Plan and the cost of that enrollment.
If you are Medicare eligible and are interested in enrolling in a Medicare
HMO sponsored by this Plan without dropping your
enrollment in this Plan's
FEHB plan, call 1-800-529-8360 for information on the benefits available under
the Medicare HMO.
Community education
programs
The Health Education Department arranges discounts for community and
hospital-based educational programs and fitness activities. It sends
members
a catalog of classes and programs annually. 35
35
Page 36 37
2001
Blue Care Network of Michigan 36 Section 5( i)
Non-FEHB
benefits available to Plan members (continued)
Dental benefits from Dental
Care
Network
Dental Care Network, an affiliate of Blue Cross Blue Shield of Michigan,
provides a complete package of individual dental benefits. Your dental care is
provided, arranged and coordinated by a qualified participating dentist who
practices from his or her own private office. All DCN participating dentists are
licensed and carefully chosen by DCN's credentialling staff. Each dentist is
reviewed periodically to ensure compliance with DCN's quality assurance
guidelines, and they must also uphold DCN's managed care standards.
Enrollment is offered twice a year. The first enrollment period is May 1 to
31 for a July 1 effective date. The second enrollment period is Nov. 1 to Dec.
15
for a Jan. 1 effective date.
To receive an enrollment package with
rates, benefit description., provider directory and application, call a DCN
Customer Service representative at 1-
800-321-8077. Be sure to identify
yourself as a Federal employee when calling during the November-December open
season.
These dental benefits are not a part of the FEHB contract. 36
36 Page 37 38
2001 Blue Care Network of Michigan 37
Section 6
Section 6. General exclusions --things we don't cover
The exclusions in this section apply to all benefits. Although we may
list a specific service as a benefit, we will not cover it unless your Plan
doctor determines it is medically necessary to prevent, diagnose, or
treat
your illness, disease, injury or condition.
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 or when the
pregnancy is the result of an act of rape or
incest;
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. 37
37 Page 38 39
2001 Blue Care
Network of Michigan 38 Section 7
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 1-800-662-6667.
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: Member Claims
Blue Care Network
of Michigan P. O. Box 68767
Grand Rapids, MI 49516-8767
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. 38
38 Page 39 40
2001 Blue Care Network of Michigan 39
Section 8
Section 8. The disputed claims process
Follow
this Federal Employees Health Benefits Program disputed claims process if you
disagree with our decision on your claim or request for services, drugs, or
supplies — including a request for preauthorization:
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: Appeals and Grievances — mail code B845
Blue Care Network
P. O. Box 284 25925 Telegraph Road
Southfield, MI
48037-0284 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 III, P. O. Box 436, Washington, D. C. 20044-0436.
39
39 Page 40 41
2001 Blue Care Network of Michigan 40
Section 8
Disputed Claims Process (continued)
Send OPM the
following information:
A statement about why you believe our decision was
wrong, based on specific benefit provisions in this brochure;
Copies of documents that support your claim, such as physicians' letters,
operative reports, bills, medical records, and explanation of benefits (EOB)
forms;
Copies of all letters you sent to us about the claim; Copies of all
letters we sent to you about the claim; and
Your daytime phone number and
the best time to call.
Note: If you want OPM to review different claims, you
must clearly identify which documents apply to which claim.
Note: You are the only person who has a right to file a disputed claim with
OPM. Parties acting as your representative, such as medical providers, must
provide 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. This is the only deadline that may not be
extended.
OPM may disclose the information it collects during the review process to
support their disputed claim decision. This information will become part of the
court record.
You may not sue until you have completed the disputed claims process.
Further, Federal law governs your lawsuit, benefits, and payment of benefits.
The Federal court will base its review on the record that was
before OPM
when OPM decided to uphold or overturn our decision. You may recover only the
amount of benefits in dispute.
NOTE: If you have a serious or life threatening condition (one that
may cause permanent loss of bodily functions or death if not treated as soon as
possible), and
(a) We haven't responded yet to your initial request for care
or preauthorization/ prior approval, then call us at 1-800-662-6667 and we will
expedite our review; or
(b) We denied your initial request for care or
preauthorization/ prior approval, then:
(c) 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 III at (202) 606-0737
between 8 a. m. and 5 p. m. eastern time. 40
40
Page 41 42
9001
Blue Care Network of Michigan 41 Section 9
Section 9.
Coordinating benefits with other coverage
When you have other health
coverage You must tell us if you are covered or a family member is covered
under another group health plan or have automobile insurance that pays health
care expenses without regard to fault. This is called "double
coverage."
When you have double coverage, one plan normally pays its
benefits in full as the primary payer and the other plan pays a reduced benefit
as the
secondary payer. We, like other insurers, determine which coverage is
primary according to the National Association of Insurance
Commissioners'
guidelines.
When we are the primary payer, we will pay the benefits
described in this brochure.
When we are the secondary payer, we will determine our allowance. After the
primary plan pays, we will pay what is left of our allowance, up
to our
regular benefit. We will not pay more than our allowance.
What is Medicare? Medicare is the 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 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 managed care plan is the term used to
describe the various health
plan choices available to Medicare beneficiaries. The information on 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 most people get their
Medicare Part A and Part B benefits. You may go to any doctor, specialist, or
hospital that accepts Medicare.
Medicare pays its share and you pay your
share. Some things are not covered under Original Medicare, like prescription
drugs.
When you are enrolled in this Plan and Original Medicare, 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, or precertified as required.
(Primary payer chart begins on next page.) 41
41 Page 42 43
9001 Blue Care Network of Michigan 42
Section 9
The following chart illustrates whether Original Medicare
or this Plan should be the primary payer for you according to your employment
status and other factors determined by Medicare. It is critical that you tell us
if you or a covered
family member has Medicare coverage so we can administer
these requirements correctly.
Primary Payer Chart
Then the primary
payer is… A. When either you — or your covered spouse — are
age 65 or over and …
Original Medicare This Plan
1. Are an active employee with the
Federal government (including when you or a family member are eligible for
Medicare solely because of a disability),
2. Are an annuitant,
3. Are an employed 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 42
42 Page 43 44
9001 Blue Care Network of Michigan 43
Section 9
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.
When Original Medicare is the
primary payer, Medicare processes
your claim first. In most cases, your
claims will be coordinated automatically and we will pay the balance of covered
charges. You
will not need to do anything. To find out if you need to do something about
filing your claims, call us at 1-800-662-6667.
When Medicare is the primary payer, we do not waive any out-of-pocket costs.
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 cover all Medicare Part A and Part B benefits. 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.
Suspended FEHB coverage and 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.
Enrollment in Note: If
you choose not to enroll in Medicare Part B, you can still be Medicare Part B
covered under the FEHB Program. We cannot require you to enroll in
Medicare.
TRICARE TRICARE is the health care program for eligible dependents of
military persons and retirees of the military. TRICARE includes the CHAMPUS
program. If both TRICARE and this Plan cover you, we pay first. See your
TRICARE Health Benefits Advisor if you have questions about
TRICARE
coverage. 43
43 Page
44 45
9001 Blue Care Network of
Michigan 44 Section 9
Workers' Compensation We do not
cover services that:
You need because of a workplace-related disease or
injury that the Office of Workers' Compensation Programs (OWCP) or a similar
Federal or State agency determines they must provide; or
OWCP or a
similar agency pays for through a third party injury settlement or other similar
proceeding that is based on a claim you
filed under OWCP or similar laws.
Once OWCP or similar agency pays its maximum benefits for your treatment, we
will cover your benefits. You must use our providers.
Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies are responsible for your care We do not
cover services and supplies when a local, State, 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. 44
44 Page
45 46
9001 Blue Care Network of
Michigan 45 Section 10
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.
Experimental or
investigational services A product or procedure is considered not
experimental or investigational if it meets all of the following conditions:
It has final approval from the appropriate government regulatory bodies;
The scientific evidence permits conclusions concerning the effect of the
technology on health outcomes;
The technology improves the net health
outcome; and The technology is as beneficial as any established alternatives.
The investigational setting may be eliminated if the research and
experimental stage of development is completed, and the improvement in
net
health outcome is attainable outside the investigational settings.
Plan
providers will follow generally accepted medical practice in prescribing any
course of treatment. Before you enroll in this Plan, you
should determine
whether you would be able to accept treatment or procedures that may be
recommended by this Plan's providers.
Us/ We Us and we refer to Blue Care Network of Michigan
You
You refers to the enrollee and each covered family member. 45
45 Page 46 47
9001 Blue Care Network of Michigan 46
Section 11
Section 11. FEHB facts
No pre-existing condition
limitation We will not refuse to cover the treatment of a condition that you
had before you enrolled in this Plan solely because you had the condition
before you enrolled.
Where you can get information about enrolling in
the FEHB
Program
See www. opm. gov/ insure. Also, your employing or retirement office can
answer your questions, and give you a Guide to Federal Employees
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 for you and your family
Self Only coverage is for you alone. Self and Family coverage is for 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.
When benefits and premiums start The benefits in this brochure are
effective on January 1. If you are new to this Plan, your coverage and premiums
begin on the first day of your
first pay period that starts on or after
January 1. Annuitants' premiums begin on January 1. 46
46 Page 47 48
9001 Blue Care Network of Michigan 47
Section 11
Your medical and claims records are confidential We
will keep your medical and claims information confidential. Only 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 coverage If you are divorced from a Federal
employee or annuitant, you may not 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.
You may not elect TCC if you are fired from your Federal job due to gross
misconduct.
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.
Converting to individual coverage You may convert to an individual
policy if:
Your coverage under TCC or the spouse equity law ends. If you
canceled your coverage or did not pay your premium, you cannot
convert; 47
47 Page
48 49
9001 Blue Care Network of
Michigan 48 Section 11
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.
Getting a Certificate of Group Health Plan 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.
Inspector General advisory Stop health care fraud! Fraud increases the
cost of health care for everyone. If you suspect that a physician, pharmacy, or
hospital has
charged you for services you did not receive, billed you twice
for the same service, or misrepresented any information, do the following:
Call the provider and ask for an explanation. There may be an error. If the
provider does not resolve the matter, call us at 1-800-662-6667
and explain
the situation.
If we do not resolve the issue, call THE HEALTH CARE FRAUD HOTLINE —
202/ 418-3300 or write to: The United States Office of
Personnel Management,
Office of the Inspector General Fraud Hotline, 1900 E Street, NW, Room 6400,
Washington, DC 20415.
Penalties for fraud Anyone who falsifies a claim to obtain FEHB
Program benefits can be prosecuted for fraud. Also, the Inspector General may
investigate
anyone who uses an ID card if the person tries to obtain
services for someone who is not an eligible family member, or is no longer
enrolled
in the Plan and tries to obtain benefits. Your agency may also take
administrative action against you. 48
48 Page 49 50
9001 Blue Care
Network of Michigan 49 Index
Index Do not rely on this
page. It is for your convenience and does not explain your benefit coverage.
24-hour nurse line, 32
Allergy care, 17 Ambulance, 25, 27
Ambulatory
surgical center, 25 Anesthesia, 23
Anesthesia services, 21
Benefits, 13
Bill of Rights, 5
Blue Care Network of Michigan, 6
BlueSafe sm , 35
Calendar year, 45 Centers of excellence for
transplants, 33 Coinsurance,
12, 45
Coordinating benefits, 41 Copayment, 12, 45
Coverage, 46 Covered
services, 12, 45
Definitions, 45 Dental benefits, 34
Diagnostic and treatment services, 14
Disease management, 35 Disputed claims, 39
Durable medical equipment, 19
East Michigan, 6 Educational classes, 20
Emergency services, 26
Enrolling, 45
Experimental, 45 Extended care benefits, 25
Facilities, 9 Family planning, 16
Filing a claim, 38 Flexible benefits
option, 32
Foot care, 18 Fraud, 48
General exclusions, 37
Health maintenance
organization, 5
Hearing services, 18 High-risk pregnancies, 32
Home
health services, 19 Hospice care, 25
Hospital care, 10
Identification
cards, 9 Infertility services, 16
Inpatient hospital, 24 Investigational
services, 45
Lab, 14
Maternity care, 16 Medicaid, 44
Medical services, 14
Medicare, 41
Medicare prepaid plan enrollment, 35
Mental health, 28
Mid-Michigan, 6
Oral and maxillofacial surgery, 22
Organ/ tissue transplants, 23
Orthopedic, 19
Out-of-pocket maximum, 12 Outpatient hospital, 25
Parity, 28 Patient safety, 8
Plain language, 4 Pre-existing condition, 45
Premiums, 46, 51 Prescription drug benefits, 30
Preventive care, adult,
15
Preventive care, children, 15 Primary care, 9
Prior approval, 11
Professional services of
physicians, 14 Providers, 5, 9
Publications, 35
Reciprocity benefit, 32 Reconstructive surgery, 22
Rehabilitative
therapies, 17
Service Area, 6 Skilled nursing care facility benefits,
25
Southeast Michigan, 6
Specialty care, 9 Substance abuse, 28
Surgical
procedures, 21
Transitional benefit, 29 Travel benefit, 33
Treatment
therapies, 17 TRICARE, 43
ValueOptions, 29 Vision services, 18
West Michigan, 6 Workers'
Compensation, 44
X-ray, 14 49
49 Page 50 51
9001 Blue Care
Network of Michigan 50 Summary
Summary of benefits for Blue
Care Network of Michigan — 2001
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 .................
$10 per office visit 14
Services provided by a hospital:
Inpatient............................................................................................
Outpatient
.........................................................................................
Nothing
Nothing
24
25
Emergency benefits:
In-area..............................................................................................
Out-of-area
......................................................................................
$25 per visit, waived if admitted
$25 per visit, waived if admitted
27
27
Mental health and substance abuse
treatment...................................... Regular cost sharing. 28
Prescription drugs
.................................................................................
$5 per prescription filled 30
Dental Care
Accidental injury
benefit...................................................................
Nothing 34
Vision Care:
Annual eye exams.,
.................................................................... Lenses and
contact lenses ..........................................................
Frames
.......................................................................................
$5 copayment per office visit $7.50
All charges above $42.50
18 18
18
Special features:
Flexible benefits option 24-hour nurse line
Reciprocity benefit High-risk pregnancies
Centers of excellence for
transplants Travel benefit/ services overseas
Educational classes and
programs
32 32
32 32
33 33
33 50
50 Page 51 52
2001 Blue Care
Network of Michigan 51 Rate information
2001 Rate Information
for Blue Care Network of Michigan
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 and Tool & Die employees
(see 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. Refer to the applicable FEHB Guide.
Non-Postal Premium Postal Premium Biweekly Monthly Biweekly
Type
of Enrollment Code Govt share Your share Govt share Your share USPS share
Your share
East Michigan Region Self Only K51 $82.17 $27.39 $178.04 $59.34 $97.23
$12.33
Self and Family K52 $195.82 $110.14 $424.28 $238.63 $231.17 $74.79
Serving these counties: Arenac, Bay, Gratiot, Isabella, Midland, Saginaw
and Tuscola
East Michigan Region Self Only KN1 $86.09 $28.69 $186.52 $62.17
$101.87 $12.91
Self and Family KN2 $195.82 $124.75 $424.28 $270.29 $231.17
$89.40 Serving these counties: Genessee, Lapeer and Shiawassee (excluding
the towns of Perry,
Shaftsburg and Morice)
Mid Michigan Region
Self Only LN1 $86.59 $49.15 $187.61 $106.49 $102.22 $33.52
Self and
Family LN2 $195.82 $130.90 $424.28 $283.61 $231.17 $95.55 Serving these
counties: Clinto