Serving: Tallahassee, Florida area
Enrollment in this Plan is
limited; see page 6 for requirements.
Enrollment codes for this Plan:
EA1 Self Only
EA2 Self and Family
Authorized for distribution by the:
United States Office of
Personnel
Management
Retirement and Insurance Service
http:// www. opm. gov/
insure
2001
For changes
in benefits
see page 6.
RI 73-197
This Plan is Accredited
by NCQA. See the
2001 Guide
for more information on NCQA. 1
1 Page 2 3
2001 Capital Health
Plan 2
Table of Contents
Introduction
.........................................................................................................................................................................
4
Plain Language
......................................................................................................................................................................
4
Section 1. Facts about this HMO plan
.............................................................................................................................
5
How we pay providers
....................................................................................................................................
5
Who provides my health care?
........................................................................................................................
5
Patients' Bill of Rights
....................................................................................................................................
5
Service Area
....................................................................................................................................................
5
Section 2. How we change for 2001
................................................................................................................................
6
Program-wide changes
....................................................................................................................................
6
Changes to this Plan
........................................................................................................................................
6
Section 3. How you get care
............................................................................................................................................
7
Identification cards
..........................................................................................................................................
7
Where you get covered care
............................................................................................................................
7
° Plan providers
.....................................................................................................................................
7
° Plan facilities
......................................................................................................................................
7
What you must do to get covered care
............................................................................................................
7
° Primary care
.......................................................................................................................................
7
° Specialty care
.....................................................................................................................................
7
° Hospital care
.......................................................................................................................................
8
Circumstances beyond our control
..................................................................................................................
9
Services requiring our prior approval
.............................................................................................................
9
If you are referred to a specialist
.....................................................................................................................
9
Section 4. Your costs for covered services
.....................................................................................................................
10
° Copayments
......................................................................................................................................
10
° Deductible
........................................................................................................................................
10
° Coinsurance
......................................................................................................................................
10
Your out-of-pocket maximum
.......................................................................................................................
10
Section 5.
Benefits.................................................................
........................................................................................
11
Overview
.......................................................................................................................................................
11
(a) Medical services and supplies provided by physicians and other health
care professionals .............. 12
(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 ......................................... 25
(d) Emergency
services/ accidents
.............................................................................................................
28
(e) Mental health and substance abuse benefits
........................................................................................
30
(f) Prescription drug benefits
...................................................................................................................
33
(g) Special features
...................................................................................................................................
36
(h) Dental benefits
....................................................................................................................................
37
Section 6. General exclusions Ñ things we don't cover
................................................................................................
38
Table of Contents 2
2 Page 3 4
2001 Capital Health
Plan 3
Section 7. Filing a claim for covered services
...............................................................................................................
39
Section 8. The disputed claims process
.........................................................................................................................
40
Section 9. Coordinating benefits with other coverage
...................................................................................................
42
When you have...
° Other health coverage
.......................................................................................................................
42
° Original Medicare
............................................................................................................................
42
° Medicare managed care plan
............................................................................................................
44
TRICARE/ Workers' Compensation/ Medicaid
..............................................................................................
44
Other Government agencies
..........................................................................................................................
45
When others are responsible for
injuries.......................................................................................................
45
Section 10. Definitions of terms we use in this brochure
................................................................................................
45
Section 11. FEHB facts
....................................................................................................................................................
47
Coverage
information....................................................................................................................................
47
° No pre-existing condition limitation
...............................................................................................
47
° Where you get information about enrolling in the FEHB Program
............................................... 47
° Types of coverage
available for you and your family
..................................................................... 47
° When benefits and premiums start
..................................................................................................
48
° Your medical and claims records are confidential
........................................................................... 48
° When you retire
...............................................................................................................................
48
When you lose benefits
.................................................................................................................................
48
° When FEHB coverage ends
............................................................................................................
48
° Spouse equity coverage
...................................................................................................................
48
° Temporary Continuation of Coverage (TCC)
.................................................................................
48
° Converting to individual coverage
..................................................................................................
49
° Getting a Certificate of Group Health Plan Coverage
..................................................................... 49
Inspector General advisory:
..........................................................................................................................
49
Index
....................................................................................................................................................................................
50
Summary of benefits
............................................................................................................................................................
53
Rates
......................................................................................................................................................................
Back cover
Table of Contents 3
3 Page 4 5
2001 Capital Health
Plan 4
Introduction
Capital Health Plan, 2140 Centerville Place,
Tallahassee, Florida 32308
This brochure describes the benefits of
Capital Group Health Services of Florida, Inc., d. b. a. Capital Health Plan
under
our contract (CS 2034) 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 53. Rates are
shown at the end of this brochure.
Plain Language
The President and Vice President are making the
Government's communication more responsive, accessible, and under-standable
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 Capital Health Plan.
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
compari-sons
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.
Introduction/ Plain Language 4
4 Page 5 6
2001 Capital Health
Plan 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 employ physicians and 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 when you
follow Plan procedures for accessing care.
Who provides my health care?
Capital Health Plan, as a mixed model
prepaid direct service health plan, offers members a choice of primary care
physicians at many different locations in the greater Tallahassee area.
Members choose a primary care physician and
receive their basic care
(prevention and treatment) from this doctor. The Plan offers internal medicine
doctors, family
practice doctors and pediatricians as primary care
physicians. Laboratory tests and X-rays, as well as referrals to special-ists
and for hospital services, are authorized and coordinated by your primary
care physician.
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.
° We operate under a State of Florida Certificate of Authority and are
federally qualified under Title XIII, PHSA.
° 18 years in existence
° Not-for-Profit Corporation
If you want more information about us, call 850/ 383-3311, or write to
Capital Health Plan, 2140 Centerville Place,
Tallahassee, FL 32308. You may
also contact us by fax at 850/ 383-3590 or visit our website at www.
capitalhealth. com.
Service Area
To enroll with us, you must live or work in our
service area. This is where our providers practice. Our service area is
Tallahassee, Florida, including Gadsden, Jefferson, Leon and Wakulla
counties.
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 unless authorized by
the Plan.
If you or a covered family member move outside of 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. If you or a family member move, you do not
have
to wait until Open Season to change plans. Contact your employing or retirement
office. 5
5 Page 6
7
2001 Capital Health Plan 6 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 healthcare organizations have turned their attention this past
year to improving healthcare quality and patient
safety. OPM asked all FEHB
plans to join them in this effort. You can find specific information on our
patient safety
activities by calling Member Services at 850/ 383-3311, or
checking our website, www. capitalhealth. com. You can
find out more about
patient safety on the OPM website, www. opm. gov/ insure.
To improve your healthcare, 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 per-formed
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 10.5% for Self Only or 10.5% for Self and Family.
° The
copay for Inpatient Hospital services for all conditions (including Mental
Health and Substance Abuse) will increase from $0 to $100 per admission.
° The cost to you for obtaining Prescription Drugs will change as follows
in 2001:
Benefit Copayments in 2000 Copayments in 2001
Generic
Drugs $7 $7
Preferred Brand Drug $20 $20
Non-Preferred Brand $20 $35 6
6 Page 7 8
2001 Capital Health Plan 7 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 850/
383-
3311.
Where you get covered care You get care from "Plan
providers" and "Plan facilities." You will only pay copayments,
and/ or coinsurance, and you will not have to file claims.
° Plan providers Plan providers are physicians and other health
care professionals in our
service area that we contract with to provide
covered services to our
members. We credential Plan providers according to
national standards.
You must select a primary care physician to direct all
of your medical
care. Capital Health Plan offers you a choice of primary
care physicians
at many different locations in the greater Tallahassee area.
We list Plan providers in the provider directory, which we update
frequently. The list is also on our website, www. capitalhealth. com.
° Plan facilities Plan facilities also 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
frequently. The list is
also on our website, www. capitalhealth. com.
Primary care physicians
offices in our two health centers at Centerville
Road and Governors
Square Boulevard also offer the convenience of lab,
x-ray, vision care
and/ or pharmacy services.
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
impor-tant
since your primary care physician provides or arranges for most
of
your health care. Capital Health Plan's Directory of Physicians and
Service Providers lists the primary care physicians and their office
locations. You can make your selections from this list. This directory is
provided to all new members at the time of enrollment and upon request
by calling CHP's Member Services Department at 850/ 383-3311 or on
our
website at www. capitalhealth. com. This directory is subject to
change and
is updated on a regular basis. On occasion, some physicians
may not accept
new patients. CHP's Member Services staff will gladly
assist you with your
selection of a primary care physician.
° Primary care Your primary care physician can be a family
practitioner, internist or
pediatrician. Your primary care physician will
provide most of your
health care, or give you a referral to see a
specialist.
If you want to change primary care physicians or if your primary care
physician leaves the Plan, call us. We will help you select a new one.
° Specialty care Your primary care physician will refer you to a
specialist for needed care.
However, you may see a Plan optometrist,
chiropractor, or podiatrist for
to get covered care 7
7 Page 8 9
2001 Capital Health
Plan 8 Section 3
covered services without a referral. Female
members may also see a Plan
gynecologist for an annual routine exam only
without a referral. You may
see a Plan dermatologist for up to five visits
per year without a referral.
Here are other things you should know about specialty care:
° If you
need to see a specialist frequently because of a chronic,
complex, or
serious medical condition, your primary care physician
will develop a
treatment plan that allows you to see your specialist
for a certain number
of visits without additional referrals. Your
primary care physician will use
our criteria when creating your
treatment plan (the physician may have to
get an authorization or
approval beforehand).
° If you are seeing a specialist when you enroll in our Plan, talk to
your
primary care physician. Your primary care physician will decide
what treatment you need. If he or she decides to refer you to a
specialist, ask if you can see your current specialist. If your current
specialist does not participate with us, you must receive treatment
from
a specialist who does. Generally, we will not pay for you to see
a
specialist who does not participate with our Plan.
° If you are seeing a specialist and your specialist leaves the Plan,
call
your primary care physician, who will arrange for you to see another
specialist. You may receive services from your current specialist until
we can make arrangements for you to see someone else.
° If you have a chronic or disabling condition and lose access to your
specialist because we:
°° terminate our contract with your specialist for other than cause;
or
°° drop out of the Federal Employees Health Benefits (FEHB)
Program and you enroll in another FEHB Plan; or
°° reduce our service area and you enroll in another FEHB Plan,
you may be able to continue seeing your specialist for up to 90 days
after you receive notice of the change. Contact us.
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 850/ 383-3311. If you
are
new to the FEHB Program, we will arrange for you to receive care. 8
8 Page 9 10
2001 Capital Health Plan 9 Section 3
If you changed from another FEHB plan to us, your former plan will pay
for the hospital stay until:
° You are discharged, not merely moved to an alternative care center;
or
° The day your benefits from your former plan run out; or
° The
92 nd day after you become a member of this Plan, whichever
happens first.
These provisions apply only to the benefits of the hospitalized person.
Circumstances beyond our control Under certain extraordinary
circumstances, such as natural disasters, we
may have to delay your services
or we may be unable to provide them.
In that case, we will make all
reasonable efforts to provide you with the
necessary care.
Services requiring our
prior approval Your primary care physician
has authority to refer you for most services.
For certain services (such as
sending you to a hospital, referring you to a
specialist, or recommending
follow-up care), 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 practices.
We call this review and approval process utilization management. Your
physician must obtain authorization for services such as:
°
specialty care
° hospital care
° diagnostic services
°
all surgeries
° Mental Health/ Substance Abuse care
If you are referred to a specialist 1) We process routine visits to
specialists through an automated
system. You can confirm your referral and
obtain your referral
number within 3 to 5 working days by dialing 383-3530
and
following the instructions given.
2) Once you receive authorization, your primary care physician's
staff will schedule your appointment with the specialist. Many
times,
however, your physician will ask you to schedule the
appointment yourself.
If you schedule your own appointment,
please allow five (5) working days for
the necessary records to
arrive at the specialist's office. If your
appointment is scheduled
within five (5) working days from the date your
primary care
physician refers you, you will want to make arrangements to
hand-carry
any required records or x-rays.
3) Your referral to the specialist will be for a specific number of
visits
and is valid for sixty (60) days.
4) If the specialist recommends additional services, office visits,
diag-nostics
tests, surgery, hospitalization, or other specialty care, you
MUST call your primary care physician for authorization before
such
services are scheduled. 9
9 Page
10 11
2001 Capital Health Plan 10
Section 4
5) However, routine lab tests do not require
authorization from your
primary care physician. The physician ordering the
lab tests will
give you appropriate lab orders and directions.
6) X-rays may be done at Capital Health Plan's x-ray departments
located at 2140 Centerville Place or 1491 Governors Square
Boulevard,
unless other arrangements have been made by your
primary care physician.
7) If you have any questions regarding the referral system, please
call
CHP's Member Services Department at 850/ 383-3311.
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 co-payment
of
$10 per office visit and when you go in the hospital, you pay
$100 per
admission.
° Deductible We do not have a deductible.
° Coinsurance We do
not have coinsurance.
Your out-of-pocket maximum Your out-of-pocket maximum for benefits
under this Plan is limited to $1,500/ Self Only or $3,000/ Self and Family per
year. You must pay the
copayment when you receive services. You are
responsible for keeping
records and submitting to the Plan when you reach
the maximums. 10
10 Page
11 12
2001 Capital Health Plan 11
Section 5. Benefits Ñ OVERVIEW
(See page 6 for how our
benefits changed this year and page 53 for a benefits summary.)
NOTE: This benefits section is divided into subsections. Please read
the important things you should keep in mind at the
beginning of each
subsection. Also read the General Exclusions in Section 6; they apply to the
benefits in the following
subsections. To obtain claim forms, claims filing
advice, or more information about our benefits, contact us at 850/ 383-
3311
or at our website at www. capitalhealth. com.
(a) Medical services and supplies provided by physicians and other health
care professionals ................................ 12-20
Section 5
° 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
° Alternative treatments
°
Educational classes and programs
(b) Surgical and anesthesia services provided by physicians and other health
care professionals ............................ 21-24
° Surgical
procedures
° Reconstructive surgery
° Oral and maxillofacial
surgery
° Organ/ tissue transplants
° Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services
........................................................... 25-27
°
Inpatient hospital
° Outpatient hospital or ambulatory surgical center
° Extended care benefits/ skilled nursing care facility benefits
° Hospice care
° Ambulance
(d) Emergency services/ accidents
..............................................................................................................................
28-29
° Medical emergency ° Ambulance
(e) Mental health and substance abuse benefits
.........................................................................................................
30-32
(f) Prescription drug benefits
.....................................................................................................................................
33-35
(g) Special features
..........................................................................................................................................................
36
° TDD Line: 1-800-332-8615
(h) Dental benefits
...........................................................................................................................................................
37
Summary of benefits
............................................................................................................................................................
53 11
11 Page 12
13
2001 Capital Health Plan 12
I
M
P
O
R
T
A
N
T
Section 5( a)
I
M
P
O
R
T
A
N
T
Section 5 (a) Medical services and supplies provided by physicians and
other
health care professionals
Here are some important things to keep in mind about these benefits:
° Please remember that all benefits are subject to the definitions,
limitations, and
exclusions in this brochure and are payable only when we
determine they are
medically necessary.
° Plan physicians must
provide or arrange your care.
° We have no calendar year deductible.
° Be sure to read Section 4, Your costs for covered services for
valuable information
about how cost sharing works. Also read Section 9 about
coordinating benefits
with other coverage, including with Medicare.
Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
° In physician's office $10
per visit
° Initial examination of a newborn child covered under a
family
enrollment
° Office medical consultations
° Second
surgical opinion
Professional services of physicians
° In an urgent care center $15
per visit
Professional services of physicians
° During a hospital stay Nothing
° In a skilled nursing facility
° At home
Diagnostic and treatment services Ñ Continued on next page 12
12 Page 13 14
2001 Capital Health Plan 13 Section 5( a)
Lab, X-ray and other diagnostic tests You pay
Tests, such as:
° Blood tests Nothing
° Urinalysis
° Non-routine pap
tests
° Pathology
° X-rays
° Non-routine Mammograms
° Cat Scans/ MRI
° Ultrasound
° Electrocardiogram and
EEG
Preventive care, adult You pay
Routine screenings, such as $10 per
office visit
° Blood pressure
° 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 $10 per office visit
Prostate Specific Antigen (PSA test) -one annually for men age 40 and
older $10 per office visit
Routine pap test $10 per office visit
Note: The office visit is covered
if pap test is received on the same day;
see Diagnosis and Treatment, above.
13
13 Page 14 15
2001 Capital Health Plan 14 Section 5( a)
Preventive care, adult (Continued) You pay
Routine mammogram -covered for women age 35 and older, as follows:
Nothing
° From age 35 through 39, one during this five year period
° From age 40 through 64, one every calendar year
° At age 65
and older, one every two consecutive calendar years
Not covered: Physical exams required for obtaining or continuing All
charges
employment or insurance, attending schools or camp, or travel.
Routine Immunizations, limited to: $10 per office visit
°
Tetanus-diphtheria (Td) booster -once every 10 years, ages19 and
over
(except as provided for under Childhood immunizations)
° Influenza/
Pneumococcal vaccines, annually, age 65 and over
Preventive care, children You pay
° Childhood immunizations
recommended by the American $10 per visit
Academy of Pediatrics
° Examinations, such as: $10 per visit
°° 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) 14
14 Page 15 16
2001 Capital
Health Plan 15 Section 5( a)
Maternity care You pay
Complete maternity (obstetrical) care, such as: Copayments waived
° 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 8 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 $100
per hospital admission
for illness and injury. See Hospital benefits
(Section 5c) and
Surgery benefits (Section 5b).
Not covered: Routine sonograms to determine fetal age, size or sex All
charges
Family planning You pay
° Voluntary sterilization $10 per visit
° Surgically implanted
contraceptives
° Injectable contraceptive drugs
° Intrauterine
devices (IUDs)
Not covered: reversal of voluntary surgical sterilization, genetic All
charges
counseling. 15
15 Page 16 17
2001 Capital
Health Plan 16 Section 5( a)
Infertility services You pay
Diagnosis and treatment of infertility, such as: $10 per visit
°
Artificial insemination:
°° intravaginal insemination (IVI)
Not covered: All charges
° Fertility drugs
° 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
Allergy care You pay
Testing and treatment $10 per visit
Allergy injection
Allergy serum Nothing
Not covered: provocative food testing and
sublingual allergy All charges
desensitization
Treatment therapies You pay
° Chemotherapy and radiation
therapy $10 per visit to a physician office
Note: High dose chemotherapy in
association with autologous bone You pay Nothing for the radiation
marrow
transplants are limited to those transplants listed under Organ/ therapy.
Tissue Transplants on page 24.
° 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.
Your
primary care physician will request preauthorization. Ask us to
authorize
GHT before you begin treatment; otherwise, we will only
cover GHT services
from the date you submit the information. 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.
This is covered under our Prescription Drug
benefit. 16
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2001 Capital Health Plan 17 Section 5( a)
Rehabilitative therapies You pay
Physical therapy,
occupational therapy, and speech therapy Ñ $10 per visit
° Up to
two consecutive months per condition for the services of
each of the
following if significant improvement can be expected
within two months:
°° 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.
Speech therapy is limited to treatment of certain speech
impairments of
organic origin. Occupational therapy is limited to
services that assist the
member to achieve and maintain self-care
and improved functioning in other
activities of daily living.
Not covered: All Charges
° Cardiac rehabilitation following a
heart transplant, bypass surgery
or a myocardial infarction
° long-term rehabilitative therapy
° exercise programs
Hearing services (testing, treatment, and supplies) You pay
°
Hearing testing for children through age 17 (see Preventive $10 per visit
care, children)
Not covered: All charges
° all other hearing testing
°
hearing aids, testing and examinations for them 17
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2001 Capital Health Plan 18 Section 5( a)
Vision services (testing, treatment, and supplies) You pay
° One pair of eyeglasses or contact lenses to correct an impairment
$10 per visit
directly caused by accidental ocular injury or intraocular
surgery
(such as for cataracts) The initial pair of eyeglasses is limited to
the cost of the lens and up to $25 for the frame and obtained only
at
CHP's Eye Care Centers.
° Eye exam to determine the need for vision correction for $10 per visit
children through age 17 (see preventive care)
° Annual eye refractions to determine the need for eyeglasses
Not covered: All charges
° Eyeglasses, except initial pair
following cataract surgery or an
accidental injury which requires corrective
lenses
° An examination and fitting for contact lenses. CHP Eye Care
offers this service on a fee for service basis.
° Contact lenses
° Replacements for any lenses provided during the same calendar year
° Eye exercises
° Orthoptics
° Radial keratotomy and
other refractive surgery
Foot care You pay
Routine foot care when you are under active
treatment for a metabolic $10 per visit
or peripheral vascular disease, such
as diabetes.
See orthopedic and prosthetic devices for information on podiatric
shoe
inserts.
Not covered: All charges
° 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) 18
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Capital Health Plan 19 Section 5( a)
Orthopedic and prosthetic
devices You pay
° Artificial limbs and eyes to replace natural limbs
and eyes lost Nothing
° Braces and covered prosthetic devices (except
cardiac pacemaker)
are limited to the first such item prescribed for each
specific
medical condition.
° Oxygen for home use including equipment is covered.
° Cardiac pacemakers
° Breast prostheses and surgical bras
following 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.
Not covered: All charges
° All other prosthetic devices, including
braces used during athletic
activities, are excluded.
° 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
Durable medical equipment (DME) You pay
Durable medical equipment
and prosthetic appliances coverage is limited Nothing for up to $2500 maximum
per
to the following: member per contract year. Then you
pay full
charges.
° Crutches
° Canes
° Braces (only braces required to correct a medical
condition and
for the purposes of every day living are covered)
° Wheelchairs
CHP reserves the right to rent or purchase durable medical equipment
and
members are entitled to use but not own such equipment.
Note: Call us at 850/ 383-3300 as soon as your Plan physician
prescribes
this equipment. We 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
Not covered: All charges
° Motorized wheel chairs 19
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2001 Capital Health Plan 20 Section 5( a)
Home health services You pay
° Home health care ordered
by a Plan physician and provided by a Nothing
registered nurse (R. N.),
licensed practical nurse (L. P. N.), licensed
vocational nurse (L. V. N.),
or home health aide. The Plan physician
will periodically review the program
for continuing appropriateness
and need.
° Services include oxygen therapy, intravenous therapy and
medications.
Not covered: All charges
° 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.
Educational classes and programs You pay
Coverage is limited to: Nothing
° Smoking Cessation
°
Diabetes self-management
° Newborn care
° Childhood Safety and
CPR
° CPR and Basic Life Support Training
° Adult Asthma
Management
° Pediatric Asthma Management 20
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Capital Health Plan 21 Section 5( b)
You pay nothing for
physician
services at a hospital or outpatient
surgery center.
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Section 5 (b). Surgical and anesthesia services provided by physicians and
other
health care professionals
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 changes associ-ated
with the facility (i. e., hospital, surgical
center, etc.).
° YOU MUST GET PRECERTIFICATION OF SOME SURGICAL PROCE-DURES.
Please
refer to the precertification information shown in Section 3 to be
sure
which services require precertification and identify which surgeries require
precertification.
Benefit Description You pay
Surgical procedures
° Treatment of fractures, including
casting $10 per office visit
° 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 Ñ a condition in which an
individual weighs 100 pounds or 100% over his or her normal
weight
according to current underwriting standards; when
determined to be medically
necessary. Surgery for morbid obesity
will be authorized only as a last
resort, only when the member's
health is endangered and more conservative
medical measures
have not been successful.
° Insertion of internal prosthetic devices. The internal prosthetic
device must be medically necessary to restore bodily function and
require a surgical incision. See 5( a) -Orthopedic braces and
prosthetic
devices for device coverage information.
Surgical procedures continued on next page. 21
21 Page 22 23
2001 Capital Health Plan 22 Section 5( b)
Surgical procedures (Continued) You pay
° Voluntary
sterilization
° Norplant (a surgically implanted contraceptive) and
intrauterine
devices (IUDs) Note: Devices are covered under 5( a)
° Treatment of burns $10 per office visit
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.
Not covered: All charges
° Reversal of voluntary sterilization
° Routine treatment of conditions of the foot; see Foot care.
Reconstructive surgery
° Surgery to correct a functional
defect $10 per office visit
° 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.
° All stages of breast reconstruction surgery following a mastectomy,
such as:
°° surgery to produce a symmetrical appearance on the other breast;
°° treatment of any physical complications, such as lymphedemas;
°° breast prostheses and surgical bras and replacements (see
Prosthetic devices)
Note: If you need a mastectomy, you may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to 48
hours after the procedure.
Not covered: All charges
° 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
You pay nothing for physician
services at a hospital or outpatient
surgery center.
You pay 22
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2001 Capital Health Plan 23
Section 5( b)
Oral and maxillofacial surgery You pay
Oral
surgical procedures, limited to: $10 per visit
° 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.
Not covered: All charges
° Oral implants and transplants
°
Procedures that involve the teeth or their supporting structures
(such as
the periodontal membrane, gingiva, and alveolar bone) 23
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2001 Capital Health Plan 24 Section 5( b)
Nothing for physician services
at a hospital
Anesthesia You pay
Professional services provided in -Nothing
° Hospital (inpatient)
Professional services provided in -Nothing
° Hospital outpatient
department
° Skilled nursing facility
° Ambulatory surgical
center
Professional services provided in -$10 per visit
° Office
Organ/ tissue transplants You pay
Limited to: $10 per office visit
° Cornea
° Heart
° Heart/ lung
° Kidney
° Kidney/ Pancreas
° Liver
° Lung: Single -Double
° Pancreas
° Allogeneic (donor) bone marrow transplants
° Autologous bone marrow transplants (autologous stem cell and
peripheral stem cell support) for the following conditions: acute
lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's
lymphoma;
advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer;
multiple myeloma; epithelial
ovarian cancer; and testicular, mediastinal,
retroperitoneal and
ovarian germ cell tumors
Limited Benefits -Treatment for breast cancer, multiple myeloma, and
epithelial ovarian cancer must be 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.
Not covered: All charges
° Implants of artificial organs
°
Transplants not listed as covered 24
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2001 Capital
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Section 5 (c). Services provided by a hospital or other facility, and
ambulance
services
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
associ-ated
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 the
precertification information shown in Section 3 to be sure which services
require precertification.
Benefit Description You pay
Inpatient hospital
Room and board,
such as $100 per admission
° 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.
Inpatient hospital continued on next page. 25
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2001 Capital Health Plan 26
Inpatient
hospital (Continued) You pay
Other hospital services and supplies, such
as: See above.
1. 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.)
Not covered: All charges
° 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
Outpatient hospital or ambulatory surgical center You pay
° Operating, recovery, and other treatment rooms Nothing
°
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.
Section 5( c) 26
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2001 Capital
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Extended care benefits/ skilled
nursing care facility benefits You pay
Extended care/ Skilled nursing
facility (SNF): The Plan provides a comprehen-Nothing
sive range of benefits
for up to 60 days per admission with subsequent
admission available 180 days
from discharge date of previous admission when
full-time skilled nursing
care is necessary and confinement in a skilled nursing
facility is medically
appropriate as determined by a Plan doctor and approved
by the Plan.
All necessary services are covered, including:
° Bed, board and general nursing care
° Drugs, biologicals,
supplies, and equipment ordinarily
provided or arranged by the skilled
nursing facility when
prescribed by a Plan doctor.
Not covered: custodial care All charges
Hospice care You pay
Supportive and palliative care for a
terminally ill members is Nothing
covered in the home or hospice facility.
Services include inpatient
and outpatient care, and family counseling; these
services are
provided under the direction of a Plan doctor who certifies
that the
patient is in the terminal stages of illness, with a life
expectancy of
approximately six months or less.
Not covered: Independent nursing, homemaker services All charges
Ambulance You pay
° Local professional ambulance service when
medically Nothing
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Section 5 (d). Emergency services/ accidents
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.
What is a medical emergency?
A medical emergency is the sudden and
unexpected onset of a condition or an injury that you believe endangers your
life
or could result in serious injury or disability, and requires immediate
medical or surgical care. Some problems are
emergencies because, if not
treated promptly, they might become more serious; examples include deep cuts and
broken
bones. Others are emergencies because they are potentially
life-threatening, such as heart attacks, strokes, poisonings,
gunshot
wounds, or sudden inability to breathe. There are many other acute conditions
that we may determine are
medical emergencies -what they all have in common
is the need for quick action.
What to do in case of emergency:
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 Plan member so they
can notify the Plan.
You or a family member should notify the Plan within 48
hours unless it was not reasonably possible to do so. It is your
responsibility to ensure that the Plan has been timely notified.
If you need to be hospitalized, the Plan must be notified within 48 hours or
on the first working day following your
admission, unless it was not
reasonably possible to notify the Plan within that time. If you are hospitalized
in non-Plan
facilities and Plan doctors believe 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 the Plan or
provided by Plan providers.
Section 5( d) 28
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2001 Capital
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Benefit Description You pay
Emergency within our service area
° Emergency care at a doctor's
office $15 per visit
° Emergency care at an urgent care center $15 per
visit
° Emergency care as an outpatient or inpatient at a hospital, $50 per
visit
including doctors' services
Not covered: Elective care or non-emergency care All charges
Emergency outside our service area
° Emergency care at a
doctor's office $15 per visit
° Emergency care at an urgent care center
$15 per visit
° Emergency care as an outpatient or inpatient at a hospital, $50 per
visit
including doctors' services
Not covered: All charges
° 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
Ambulance
Professional ambulance service when medically appropriate. Nothing
See 5(
c) for non-emergency service.
Not covered: air ambulanceÑ unless medically necessary and All
charges
approved by the Plan's Medical Director. 29
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Section 5 (e). Mental health and substance abuse benefits
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 bro-chure.
° 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.
Benefit Description You pay
Mental health and substance abuse benefits
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.
° Professional services, including individual or group therapy by $10 per
visit
providers such as psychiatrists, psychologists, or clinical
social
workers
° Medication management
Mental health and substance abuse benefits -Continued on next page
Your cost sharing responsibilities
are no greater than for other
illness or conditions.
Section 5( e) 30
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2001 Capital
Health Plan 31 Section 5( e)
Mental health and substance abuse
benefits (Continued) You pay
° Diagnostic tests $10 per (visit or
test)
° Services provided by a hospital or other facility $100 per admission
° Services in approved alternative care settings such as partial
hospitalization, full-day hospitalization, facility based intensive
outpatient treatment
Not covered: Services we have not approved. All charges
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.
Preauthorization To be eligible to receive these benefits you must
follow your treatment plan and the following authorization processes. These
include:
If you are referred to a specialist 1) We process routine
visits to specialists through an automated system. You can confirm your referral
and obtain your referral
number within 3 to 5 working days by dialing
383-3530 and
following the instructions given.
2) Once you receive authorization, your primary care physician's staff
will schedule your appointment with the specialist. Many
times, however, your physician will ask you to schedule the
appointment
yourself. If you schedule your own appointment,
please allow five (5)
working days for the necessary records to
arrive at the specialist's office.
If your appointment is scheduled
within five (5) working days from the date
your primary care
physician refers you, you will want to make arrangement to
hand-carry
any required records or x-rays.
3) Your referral to the specialist will be for a specific number of
visits and is valid for sixty (60) days.
4) If the specialist recommends additional services, office visits,
diag-nostics tests, surgery, hospitalization, or other specialty care, you
MUST call your primary care physician for authorization before
such
services are scheduled.
5) However, routine lab tests do not require authorization from your
primary care physician. The physician ordering the lab tests will
give you appropriate lab orders and directions.
6) X-rays may be
done at Capital Health Plan's x-ray departments located at 2140 Centerville
Place or 1491 Governors Square
Boulevard, unless other arrangements have been made by your
primary care
physician.
7) If you have any questions regarding the referral system, please
call CHP's Member Services Department at 850/ 383-3311. 31
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2001 Capital Health Plan 32
Special
transitional benefit 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.
Section 5( e) 32
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Section 5 (f). Prescription drug benefits
Here are some important
things to keep in mind about these benefits:
° We cover prescribed
drugs and medications, as described in the chart beginning on the next page.
° All benefits are subject to the definitions, limitations and exclusions
in this brochure and are payable only when we determine they are medically
necessary.
° 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.
There are important features you should be aware of. These include:
° Who can write your prescription. A Plan physician or
licensed dentist must write the prescription.
° Where you can obtain
them. You must fill the prescription at a Plan pharmacy.
° These
are the dispensing limitations. Prescription drugs prescribed by a Plan or
referral doctor and obtained at a Plan pharmacy will be dispensed for up to a
30-day supply or one commercially
prepared unit (i. e. one inhaler, one vial ophthalmic medication or insulin)
you pay a $20 copay per
prescription unit or refill for any brand drug which
appears on the plan's Preferred Medication List
when generic substitution is
not available and a $7 copay per prescription unit or refill for generic
drugs. For brand drugs not on the plan's Preferred Medication List you pay
$35. If a generic drug is
available and at the request of the member or the
prescribing physician a brand name prescription is
dispensed, you pay the
price difference between the generic and name brand drug as well as the
copay for the preferred or non-preferred brand name drug per prescription
unit or refill. Prescription
refills will not be covered until at least 75
percent of the previous prescription has been used by the
member (based on
the dosage schedule prescribed by the physician).
Prescription drug benefits begin on the next page. 33
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2001 Capital Health Plan 34
Benefit
Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a $7 per
prescription for generic drugs
Plan physician and obtained from a Plan
Pharmacy:
° Drugs for which a prescription is required by law
° Oral and
injectable contraceptive drugs
° Insulin with a $7 copay charge applied
to each vial
° Disposable needles and syringes needed to inject covered
prescribed
medication
° Allergy serum, you pay nothing
° Diabetic supplies including test strips and glucometers at the CHP
Pharmacy only
° Drugs for sexual dysfunction
° Vitamins
After the calendar year deductible...
$20 per prescription for
preferred
brand name drugs
$35 per prescription for non-preferred
brand prescription drugs
Note: If there is no generic
equivalent available, you will still
have to pay the brand name copay.
Section 5( f) 34
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2001 Capital
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Covered medications and supplies (continued) You pay
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 requests a name brand. If you receive
a name brand drug when a Federally-approved generic drug is
available,
you have to pay the difference in cost between the name
brand drug and the
generic.
° You pay a $20 copay per prescription unit or refill for any brand
drug which appears on the plan's Preferred Medication List when
generic
substitution is not available and a $7 copay per prescription
unit or refill
for generic drugs. For brand drugs not on the plan's
Preferred Medication
List you pay $35. If a generic drug is available
and at the request of the
member or the prescribing physician a
brand name prescription is dispensed,
you pay the price difference
between the generic and name brand drug as well
as the copay for
the preferred or non-preferred brand name drug per
prescription
unit or refill.
° We administer an open formulary. If your physician believes a name
brand product is necessary or there is no generic available, your
physician may prescribe a name brand drug from a formulary list.
This
list of name brand drugs is a preferred list of drugs that we
selected to
meet patient needs at a lower cost. Brand name drugs
not on the preferred
list are dispensed at a higher copay. To order a
prescription drug brochure,
call 850/ 383-3311.
Not covered: All Charges
° Nonprescription medicines
° Drugs obtained at a non-Plan pharmacy except for out-of-area
emergencies
° Medical supplies such as dressing and antiseptics
° Drugs and supplies for cosmetic purposes including appetite
suppressants
° Drugs to enhance athletic performance
° Injectable and oral medications to treat infertility
°
Smoking cessation drugs and medications, including nicotine patches
Section 5( f) 35
35 Page 36 37
2001 Capital
Health Plan 36
Section 5 (g). Special Features
Feature
Description
Flexible benefits 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
with draw 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.
Services for deaf and TDD Line: 1-800-332-8615
hearing impaired
Section 5( g)
option 36
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2001 Capital Health Plan 37
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Section 5( h)
Section 5 (h). Dental benefits
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.
Accidental injury benefit You pay
We cover restorative services
and supplies necessary to promptly Nothing
repair (but not replace) sound
natural teeth. The need for these
services must result from an accidental
injury.
Dental benefits
We have no other dental benefits. 37
37 Page 38 39
2001 Capital Health Plan 38 Section 6
Section 6. General exclusions Ñ 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. 38
38 Page 39 40
2001 Capital
Health Plan 39 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.
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 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 assis-tance,
call us at 850/ 383-3311.
When you must file a claim Ñ such as for out-of-area care Ñ
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
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 Ñsuch as the Medicare Summary Notice (MSN);
and
° Receipts, if you paid for your services.
Submit your claims to: Capital Health Plan
Post Office Box 15349
Tallahassee, FL 32317-5349
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. 39
39 Page
40 41
2001 Capital Health Plan 40
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: Capital Health Plan, ATTN: Grievance Coordinator, P. O. Box
15349,
Tallahassee, FL 32317-5349; 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, if applicable arrange for the health care provider to give you
the care); or
(b) Write to you and maintain our denial Ñ 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 Ñ 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. 40
40 Page
41 42
2001 Capital Health Plan 41
Section 8
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 repre-sentative,
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
adminis-trative
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 850/
383-3311 and we will
expedite our review; or
(b) We denied your initial request for care or preauthorization/ prior
approval, then:
°° If we expedite our review and maintain our denial, we will inform
OPM so that they can give your claim expedited treatment too, or
°° You can call OPM's Health Benefits Contracts Division III at 202/
606-0755 between 8 a. m. and 5 p. m. eastern time. 41
41 Page 42 43
2001 Capital Health Plan 42 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
medical expenses without regard to fault. This is called
"double cover-age."
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 Commission-ers'
guidelines.
When we are the primary payer, we will pay the benefits described in this
brochure.
When we are the secondary payer, we will determine our allowance.
After
the primary plan pays, we will pay what is left of our allowance, up
to our
regular benefit. We will not pay more than our allowance.
° What is Medicare? Medicare is a Health Insurance Program for:
°° People 65 years of age and older.
°° Some people with
disabilities, under 65 years of age.
°° People with End-Stage Renal
Disease (permanent kidney failure requiring dialysis or a transplant).
Medicare has two parts:
°° Part A (Hospital Insurance). Most
people do not have to pay for Part A.
°° Part B (Medical Insurance). Most people pay monthly for Part B.
If you are eligible for Medicare, you may have choices in how you get
your health care. Medicare + Choice is the term used to describe the
various health plan choices available to Medicare beneficiaries. The
information in the next few pages shows how we coordinate benefits with
Medicare, depending on the type of Medicare managed care plan you
have.
° The Original Medicare Plan The Original Medicare Plan is
available everywhere in the United States. It is the way 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 primary care physician.
We will not waive any of our copayments.
(Primary payer chart
begins on next page.) 42
42 Page 43 44
2001 Capital
Health Plan 43 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
1) Are an active employee with the Federal government (including when you
or a family member are eligible for Medicare solely because of a
disability),
2) Are an annuitant,
3) Are a reemployed annuitant with the Federal
government when...
a) The position is excluded from FEHB,
or.....................
b) The position is not excluded from
FEHB..................
Ask your employing office which of these applies to
you.
4) Are a Federal judge who retired under title 28, U. S. C., or a Tax
Court
judge who retired under Section 7447 of title 26, U. S. C. (or if your
covered spouse is this type of judge),
5) Are enrolled in Part B only, regardless of your employment status,
(for Part B services) (for other services)
6) Are a former Federal employee receiving Workers' Compensation
and the
Office of Workers' Compensation Programs has determined (except for claims
that you are unable to return to duty, related to Workers'
Compensation.)
B. When you Ñ or a covered family member Ñ 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........................................................................
A. When either you Ñ or your covered spouse Ñ are age 65 or
over
and ...
Then the primary payer is...
Original Medicare This Plan
4
4
4
4
4
4 4
4
4
4
4
4
4 43
43 Page
44 45
2001 Capital Health Plan 44
Section 9
Claims process Ñ 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 some
thing about filing your claims, call us
at our Coordination of
Benefits Office 850/ 383-3377.
° 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 Medi-care
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 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, coinsurance,
or deductibles 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, coinsurance, or deductibles.
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 enroll-ment,
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
covered under the FEHB Program. We cannot require you to
enroll in
Medicare.
TRICARE TRICARE is the health care program for members, 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.
Medicare Part B 44
44 Page 45 46
2001 Capital
Health Plan 45 Section 10
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 We do not cover services and supplies
when a local, State,
are responsible for your care or Federal
Government agency directly or indirectly pays for them.
When others are responsible When you receive money to compensate you
for for injuries 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 subroga-tion
procedures.
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 10.
Covered services Care we provide benefits for, as described in this
brochure.
Custodial care Custodial care means care that serves to
assist an individual in the activities of daily living, such as assistance in
walking, getting in and out
of bed, bathing, dressing, feeding, and using
the toilet, preparation of
special diets, and supervision of medication that
usually can be self-administered.
Custodial care essentially is personal
care that does not
require the continuing attention of trained medical or
paramedical
personnel. In determining whether a person is receiving
custodial care,
consideration is given to the level of care and medical
supervision
required and furnished. A determination that care received is
custodial is
not based on the patient's diagnosis, type of Condition, degree
of
functional limitation, or rehabilitation potential.
for injuries 45
45 Page 46 47
2001 Capital
Health Plan 46 Section 10
Experimental or When CHP
determines that an evaluation, treatment, therapy or device is experimental/
investigational, it will not be covered by the Plan. CHP
makes such
determinations based in part on information obtained from
the United States
Food and Drug Administration, The Florida Depart-ment
of Health and most
recently published medical literature in the
United States, Canada or Great
Britain. A consensus of opinion among
experts is sought showing that the
evaluation, treatment, therapy or
device is considered safe and effective as
compared with the standard
means for treatment or diagnosis of the condition
in question.
Medical necessity Medical necessity means, for coverage and payment
purposes, that a medical service or supply is required for the identification,
treatment, or
management of a condition, and is, in the opinion of CHP: 1)
consistent
with the symptom, diagnosis, and treatment of the Members'
condition;
2) widely accepted by the practitioners' peer group as
efficacious and
reasonably safe based upon scientific evidence; 3)
universally accepted in
clinical use such that omission of the service or
supply in these circum-stances
raises questions regarding the accuracy of
diagnosis or the
appropriateness of the treatment; 4) not experimental or
investigational;
5) not for cosmetic purposes; 6) not primarily for the
convenience of the
Member, the Member's family, the physician or other
provider; and, 7)
the most appropriate level of service, care or supply
which can safely be
provided to the Member. When applied to inpatient care,
medically
necessary further means that the services cannot be safely
provided to the
Member in an alternative setting.
Us/ We Us and we refer to Capital Health Plan.
You You
refers to the enrollee and each covered family member.
Investigational services 46
46 Page 47 48
2001 Capital
Health Plan 47 Section 11
Section 11. FEHB facts
No
pre-existing condition We will not refuse to cover the treatment of a
condition that you had before you enrolled in this Plan solely because you had
the condition
before you enrolled.
Where you can get information See www. opm. gov/ insure. Also, your
employing or retirement office can answer your 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 Self Only coverage is for you alone. Self
and Family coverage is for for you, your spouse, and your unmarried dependent
children under age 22,
including any foster children or stepchildren your
employing or retire-ment
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.
limitation
about enrolling in the
FEHB Program
you and your family 47
47 Page 48 49
2001 Capital
Health Plan 48 Section 11
When benefits and 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.
Your medical and claims 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 Continua-tion
of
Coverage.
° Spouse equity If you are divorced from a Federal employee or
annuitant, you may not coverage continue to get benefits under your
former spouse's enrollment. But, you
may be eligible for your own FEHB coverage under the spouse equity
law.
If you are recently divorced or are anticipating a divorce, contact
your
ex-spouse's employing or retirement office to get RI 70-5, the
Guide to
Federal Employees Health Benefits Plans for Temporary
Continuation of
Coverage and Former Spouse Enrollees, or other
information about your
coverage choices.
° TCC If you leave Federal service, or if you lose coverage
because you no
longer qualify as a family member, you may be eligible for
Temporary
Continuation of Coverage (TCC). For example, you can receive TCC
if
you are not able to continue your FEHB enrollment after you retire.
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.
premiums start
records are confidential 48
48 Page 49 50
2001 Capital Health Plan 49 Section 11
° Converting to You may convert to a non-FEHB individual
policy if:
°° Your coverage under TCC or the spouse equity law ends.
If you canceled your coverage or did not pay your premium, you cannot
convert;
°° You decided not to receive coverage under TCC or the
spouse equity law; or
°° You are not eligible for coverage under TCC or the spouse equity
law.
If you leave Federal 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 If you leave the FEHB Program, we will give
you a Certificate of 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 850/ 383-3311
and explain the situation.
° If we do not resolve the issue, call THE
HEALTH CARE FRAUD HOTLINEÑ 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, Washing-ton,
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 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.
Group Health Plan Coverage
individual coverage 49
49 Page 50 51
2001 Capital Health Plan 50 Index
Index
Do not rely on this page; it is for your convenience
and does not explain your benefit coverage.
Accidental injury 37
Allergy tests 16
Ambulance 27, 29
Anesthesia 24
Autologous bone marrow
transplant 24
Biopsies
21
Blood and blood plasma 13, 26
Breast cancer screening 24
Casts 26
Catastrophic protection 10
Changes for 2001 6
Chemotherapy 16
Cholesterol tests 13
Claims 39
Coinsurance 10
Colorectal cancer screening 13
Congenital anomalies 21-22
Contraceptive devices and drugs 34
Coordination of benefits 42-45
Covered charges 12-37
Covered providers 7
Crutches 19
Deductible 10
Definitions 45-46
Dental care 37
Diagnostic
services 12
Disputed claims review 40-41
Donor expenses (transplants) 24
Dressings 26
Durable medical equipment
(DME) 19
Educational
classes and programs 20
Effective date of enrollment 45
Emergency
28-29
Experimental or investigational 46
Eyeglasses 18
Family
planning 15
Fecal occult blood test 13
General Exclusions 38
Hearing
services 17, 36
Home health services 20
Hospice care 27
Home
nursing care 20
Hospital 8-9
Immunizations 5, 14
Infertility
16
Inpatient Hospital Benefits 6, 25-26
Insulin 34
Laboratory
and pathological
services 5,13
Magnetic Resonance Imagings
(MRIs) 13
Mammograms 13-14
Maternity Benefits 15
Medicaid 45
Medically necessary 46
Medicare 42-45
Members 7
Mental
Conditions/ Substance
Abuse Benefits 30-32
Newborn care 15
Nurse
Licensed Practical Nurse 20
Registered Nurse 20
Nursery
charges 15
Obstetrical care 15
Occupational therapy 17
Ocular
injury 18
Office visits 5
Oral and maxillofacial surgery 23
Orthopedic devices 19
Out-of-pocket expenses 10
Outpatient facility
care 26
Oxygen 26
Pap test 13
Physical examination 5, 14
Physical therapy 17
Physician 7
Precertification 15, 21, 25, 30
Preventive care, adult 13-14
Preventive care, children 14
Prescription drugs 33
Prior approval 9
Prostate cancer screening 13
Prosthetic devices 19
Psychologist 30
Radiation therapy 16
Rehabilitation therapies 17
Renal
dialysis 16
Room and board 25
Second surgical opinion 12
Skilled nursing facility care 27
Smoking cessation 20
Speech therapy
17
Splints 26
Sterilization procedures 22
Subrogation 45
Substance abuse 30-32
Surgery 21-22
° Anesthesia 24
° Oral 23
° Reconstructive 22 Syringes 34
Temporary continuation of
coverage 48
Transplants 24
Treatment therapies 16
Vision services 18
Well child
care 5, 14
Wheelchairs 19
Workers' compensation 45
X-rays 5,
13 50
50 Page 51
52
2001 Capital Health Plan 51
Notes
51
51 Page 52
53
2001 Capital Health Plan 52
Notes
52
52 Page 53
54
2001 Capital Health Plan 53 Summary
Summary of benefits for Capital Health Plan -2001
° Do
not rely on this chart alone. All benefits are provided in full unless indicated
and are subject to the defini-tions,
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 12
Services provided by a hospital:
° Inpatient $100 per admission copay
25-26
° Outpatient Nothing 26
Emergency benefits:
° In-area $50 per emergency room visit 29
° Out-of-area $50 per emergency room visit 29
Mental health and substance abuse treatment Regular cost sharing 30-32
Prescription drugs $7 generic
$20 preferred brand
$35 non-preferred
brand 33-35
Dental Care No benefit 37
Vision Care No benefit 18
Special features:
Services for deaf and hearing impaired 36
Protection against catastrophic
costs 10
(your out-of-pocket maximum)
Office visit copay: $10
primary care; $10 specialist
Your out-of-pocket expenses
for benefits under this Plan are
limited
to the stated
copayments required for a few
benefits. 53
53 Page 54
2001
Capital Health Plan 54 Rate Information
2001 Rate Information
for
Capital Health Plan
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 Inspec-tors
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
Tallahassee, Florida area
Type of Gov't Your Gov't Your USPS Your
Enrollment Code Share Share Share Share Share Share
Self Only EA1 $70.39 $23.46 $152.51 $50.83 $83.29 $10.56
Self and
Family EA2 $187.91 $62.64 $407.15 $135.71 $222.36 $28.19 54