This Plan has an excellent accreditation
from the NCQA. See the 2001
Guide
for more information on NCQA.
Enrollment codes for this Plan:
G21 Self Only
G22 Self and Family
Arnett HMO Health Plan
2001
R1 73-288
For
changes in
benefits see
. page 6
http: / / www. arnettplans. com 1
1
Page 2 3
2001
Arnett HMO 2
Table of Contents
Introduction . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Plain language
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Section 1. Facts about this HMO plan . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
How we pay providers . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Patients
Bill of Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Service Area . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . 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
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 . 18
( c) Services
provided by a hospital or other facility, and ambulance services . . . . . . . .
. . . . . . . . 21
( d) Emergency services/ accidents . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
23(
e) Mental Health and Substance Abuse benefits . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . 25
( f) Prescription drug
benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . 27
( g) Dental benefits . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . 29
Table of Contents 2
2 Page 3 4
2001 Arnett HMO
3
Section 6. General Exclusions Things we don t cover . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Section
7. Filing a claim for covered services . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Section 8.
The disputed claims process . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Section 9.
Coordinating benefits with other coverage . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . 34
When you have
Other health coverage . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
What is Medicare?
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . 34
The Original Medicare Plan . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 36
Medicare Managed Care Plan . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
TRICARE/
Workers Compensation/ Medicaid . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . 36
Other Government Agencies . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
When others are responsible for injuries . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . 37
Section 10. Definitions of
terms we use in this brochure . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . 38
Section 11. FEHB facts . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . 39
Coverage information
No
pre-existing coverage limitation . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . 39
Where you get information about
enrolling in the FEHB Program . . . . . . . . . . . . . . . . . . . . 39
Types of coverage available to you and your family . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . 39
When benefits and premiums start . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 39
Your medical and claims records are confidential . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . 40
When you retire . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . 40
When you lose benefits
When FEHB coverage ends . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Spouse equity coverage . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Temporary
Continuation of Coverage ( TCC) . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . 40
Enrolling in TCC. . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 40
Converting to individual coverage . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Getting a
Certificate of Group Health Plan Coverage . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . 40
Inspector General Advisory Stop Healthcare Fraud! .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 42
Summary of benefits. . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Inside
back cover
Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. Back cover
Table of Contents 3
3 Page 4 5
2001 Arnett HMO
4 Introduction
Introduction
Arnett HMO
415 N. 26th
Street, Suite 101
Lafayette, IN 47903-6108
This brochure describes the benefits of Arnett HMO under our contract ( CS
2171) 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 11. Rates are
shown at the end of this brochure.
Plain Language
The President and V ce President are making the
Government s communication more responsive, accessible,
and understandable
to the public by requiring agencies to use plain language. In response, a team
of health plan
representatives and OPM staff worked cooperatively to make
this brochure clearer. Except for necessary technical
terms, we use common
words. You means the enrollee or family member. . We means Arnett HMO. .
The plain language team reorganized the brochure and the way we describe our
benefits. When you compare this plan
with other FEHB plans, you will find
that the brochures have the same format and similar information to make
comparisons easier.
If you have comments or suggestions about how to improve this brochure, let
us know. Visit OPM s Rate Us
feedback area at www. opm. gov/ insure or
e-mail us at fehbwebcomments@ opm. gov or write to OPM at Insurance
Planning
and Evaluation Division. P. O. Box 436, Washington, DC 20044-0436. 4
4 Page 5 6
2001 Arnett HMO 5
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
prescrib-
ing 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, coinsurance, and
deductibles described in this brochure. When you receive emergency services from
non-Plan providers, you may have to submit claim forms.
You should join an HMO because you prefer the plan s benefits, not because
a particular provider is available.
You cannot change plans because a
provider leaves our Plan. We cannot guarantee that any one physician,
hospital, or other provider will be available and/ or remain under contract
with us.
How we pay providers
We contract with individual physicians,
medical groups, and hospitals to provide the benefits in this brochure. These
Plan providers accept a negotiated payment from us, and you will only be
responsible for your copayments or
coinsurance.
Arnett HMO is a group model HMO. There are over 250 participating physicians.
Plan members may select their
primary care physicians among the
participating family practice physicians, internists, pediatricians, or
obstetrician/
gynecologists.
Patients Bill of Rights
OPM requires that all FEHB Plans comply
with the Patients Bill of Rights, recommended by the President s Advi-
sory
Commission on consumer protection and quality in the healthcare 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.
If you want more information about us, call 888-448-7440, or write to Arnett
HMO P. O. Box 6108, Lafayette, IN
47903-6108. You may also contact us by fax
at 765-448-7700, or visit our website at www. arnettplans. com.
Service Area
To enroll in this Plan, you must reside in, or within
30 miles of one of our counties, or within 30 miles of any Plan
Primary Care
Physician in our network. This is where our providers practice. Our services
area for this Plan are
available in the following area: The Greater
Lafayette, Indiana area; including the counties of Benton, Boone, Carroll,
Cass, Clinton, Fountain, Fulton, Howard, Jasper, Montgomery, Newton,
Pulaski, T ppecanoe, Warren, and White
counties.
Ordinarily you must get your care from our providers who contract with us. If
you receive care outside our service
area, we will pay only for emergency
care. We will not pay for any other health care services.
If you or a covered family member move outside of our service area, you can
enroll in another plan. If your depen-
dents 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. In this plan, the family member
would only be
covered for emergency care. For routine, maintenance, or illness they would need
to be seen in plan. 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.
Section 1 5
5 Page
6 7
2001 Arnett HMO 6
Section 2. How we change for 2001
ProgramÐ 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 deductibles, 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 Arnett HMO at 888-448-7440, or checking
our website, www. arnettplans. com.
You can find out more about patient
safety on the OPM website, www. opm. gov/ insure. To improve your
healthcare, take these five easy steps:
°° Speak up if you have questions or concerns
°° Keep a
list of all the medicines you take.
°° Make sure you get the results
of any test or procedure.
°° Talk with your doctor and health care
team about your options if you need hospital care.
°° Make sure you
understand what will happen if you need surgery.
° We clarified the language to show that anyone who needs a mastectomy
may choose to have the procedure
performed on an inpatient basis and remain
in the hospital up to 48 hours after the procedure. Previously, the
language
reference only women.
Changes to this Plan
° Your share of the non-Postal premium
will increase by 25.4% for Self Only or 18.4% for Self and Family.
° The
Plan has a limit of 90 days with no dollar limit for Extended Care or Skilled
Nursing Care.
° You pay a 20% copayment with up to $10,000 annual limit
for Durable Medical Equipment/ Prosthetic Devices.
° You pay a $75
copayment for In or Out of Service Area Emergency Care. The emergency copayment
is waived if
you are admitted.
° You pay a $25 copayment for Urgent Care visits.
° The Plan
covers Rehabilitative Therapy (physical/ occupational/ speech) up to 60
consecutive day limit.
° You pay a $50 copayment for outpatient MRI and
CAT scans.
Section 2 6
6 Page
7 8
2001 Arnett HMO 7
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 toll free at
888-448-7440 or 765-448-7440.
Where you get covered care You get care from Plan providers and Plan
facilities. You will only
pay copayments and you will not have to file
claims.
Plan Providers Plan providers are physicians and other health care
professionals in our
service area that we contract with to provide covered
services to our
members. We credential Plan providers according to national
standards.
We list Plan providers in the provider directory, which we update
periodically. The list is also on our website.
Plan Facilities Plan facilities are hospitals and other facilities in
our service area that we
contract with to provide covered services to our
members. We list these
in the provider directory, which we update
periodically. The list is also
on our website.
What you must do It depends on the type of care you need. First, you
and each family
member must choose a primary care physician. This decision
is impor-
tant since your primary care physician provides or arranges for
most of
your healthcare.
Primary Care Your primary care physician can be a family practitioner,
internist,
pediatrician, or obstetrician gynecologist. 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. When you receive a referral from your primary
care physician, you
must return to the primary care physician after the
consultation. All
follow-up care must be provided or arranged by the primary
care
physician. Do not go to the specialist unless your primary care
physician
has arranged for and the Plan has issued an authorization for the
referral
in advance.
Section 3 7
7 Page
8 9
2001 Arnett HMO 8
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.
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 Plan, or
reduce our service area and you enroll in another FEHB
Plan.
You may be able to continue seeing your specialist for up to 90 days
after you receive notice of the change. Contact us or, if we drop out
of
the program, contact your new Plan.
If you are in the second or third trimester of pregnancy and you lose
access to your specialist based on the above circumstances, you can
continue to see your specialist until the end of your postpartum care,
even if it is beyond the 90 days.
Hospital Care Your Plan primary care physician or specialist will make
necessary
hospital arrangements and supervise your care. This includes
admission
to a skilled nursing or other type of facility.
If you are in the hospital when your enrollment in our Plan begins,
call
our customer service department immediately at 765-448-7440 or
888-448-7440.
If you are new to the FEHB Program, we will arrange for
you to receive care.
If you changed from another FEHB plan to us, your former plan will pay
for the hospital stay until:
You are discharged, not merely moved to an alternate care center; or
The
day your benefits from your former plan run out; or
The 92nd day after you
become a member of this Plan, whichever
happens first.
Section 3 8
8 Page
9 10
2001 Arnett HMO 9
These
provisions apply only to the hospital benefit of the hospitalized
person; we
cover your other non-hospital care
Circumstances beyond our control Under certain extraordinary
circumstances, such as natural disasters, we
may have to delay your services
or we may be unable to provide them.
In that case, we will make all
reasonable efforts to provide you with the
necessary care.
Services requiring our
prior approval Your primary care physician
has authority to refer you for most services.
For certain services, however,
your physician must obtain approval from
us. Before giving approval, we
consider if the service is covered,
medically necessary, and follows
generally accepted medical practice.
Your physician must obtain prior approval by the Plan for the following
service, but not limited to:
All Inpatient Admissions
Same Day
Surgeries
Outpatient Mental Health and Substance Abuse visits
Home
Health Care
Skilled Nursing Facilities
Rehabilitation Therapies
Some
Durable Medical Equipment and Prosthetics
Out of Plan Network Referrals
Section 3 9
9 Page
10 11
2001 Arnett HMO 10
Section 4. Your Costs for Covered Services
You must share the
cost of some services. You are responsible for:
Copayments A
copayment is a fixed amount of money you pay to the provider
when you
receive services.
Example: When you see your primary care physician you pay
a copayment of
$ 10 per office visit.
Deductible We do not have a deductible with this Plan.
Coinsurance Coinsurance is the percentage of our negotiated fee that
you must pay
for your care. In our Plan, you pay 20% of our fees for durable
medical
equipment and prosthetics. You pay 50% of our allowance for
infertility
services by a non-primary care physician in our plan.
Your out-of-pocket maximum We do not have an out-of-pocket maximum for
coinsurance
and copayments.
Section 4 10
10 Page
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2001 Arnett HMO 11
Section 5. Benefits Ð OVERVIEW (See page 6 for how our
benefits changed this year and page 45 for a benefits summary.)
NOTE: This benefits section is divided into subsections.
Please read the important things you should keep in mind at
the beginning of
each subsection. Also, read the General Exclusions in Section 6; they apply to
the benefits in the
following subsections. To obtain claims filing advice,
or more information about our benefits, contact us at 765-448-
7440 or at our
website at www. arnettplans. com.
( a) Medical services and supplies provided by physicians and other health
care professionals . . . . . . . . . . . . 12-17
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
( b) Surgical and anesthesia services provided by physicians and other health
care professionals . . . . . . . . . . 18-20
Surgical procedures
Reconstructive surgery
Oral and maxillofacial surgery
( c) Services provided by a hospital or other facility, and ambulance
services . . . . . . . . . . . . . . . . . . . . . . . . . 21-22
Inpatient
hospital
Outpatient hospital or ambulatory surgical center
Extended care
benefits/ skilled
nursing facility benefits
( d) Emergency services/ accidents . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
23-24
Medical emergency
( e) Mental health and substance abuse benefits . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25-26
( f)
Prescription drug benefits . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27-28
( g) Dental benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 29
Summary of benefits. . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . 45
Section 5
Rehabilitative therapies
Hearing services ( testing, treatment, and
supplies)
Vision services ( testing, treatment, and supplies)
Foot care
Orthopedic and prosthetic devices
Durable medical equipment
Home
health services
Alternative treatments
Educational classes and programs
Ambulance
Hospice care
Ambulance
Organ/ tissue transplants
Anesthesia 11
11
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Nothing
( Copays may apply to associated
visits)
Preventative care, adult Ñ Continued on next page
Nothing
( Copays may apply to associated
visits)
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.
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 You pay
Professional services of physicians $ 10 per office visit
In
physician s office
Professional services of physicians
In an urgent care center
During a
hospital stay
In a skilled nursing facility
Initial examination of a
newborn child covered
under a family enrollment
Office medical
consultations
Second surgical opinion
Lab, X-ray and other diagnostic tests
Tests, such as:
Blood
tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine mammograms
Ultrasound
Electrocardiogram and EEG
CAT scans and MRI $ 50 copay 12
12 Page 13 14
2001 Arnett HMO
13 Section 5( a)
Preventive care, adult You Pay
Nothing
( Copays may apply to
associated visits)
Nothing
( Copays may apply to
associated visits)
Nothing
( Copays may apply to
associated visits)
$ 10 for the initial office visit and
nothing therafter.
Routine screenings, such as:
Blood lead level One annually
Total
Blood Cholesterol once every three years, , ages 19 through 64
Colorectal
Cancer Screening, including
Fecal occult blood test
Sigmoidoscopy,
screening every five years starting at age 50
Prostate Specific Antigen (
PSA test) one annually for men
age 40 and older.
Routine pap test
Routine mammogram covered from age 35 and older as follows: :
From age
35 through 39, one during this five year period
From age 40 through 64, one
every calendar year
At age 65 and older, one every two consecutive calendar
years
Not covered: All charges
Physical exams required for obtaining or
continuing employment or
insurance, attending schools, camp, travel, or
sports are not covered.
Routine Immunizations
Preventive care, children
Childhood immunizations recommended by
the American Academy of Pediatrics
Well-child care charges for routine
examinations ( through age 17)
Examinations, such as:
Eye exams through age 17 to determine the need for
vision correction.
Ear exams through age 17 to determine hearing correction.
Examinations done on the day of immunizations ( through age 17)
Maternity care
Complete maternity ( obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:
You do not need to precertify
your normal delivery; see page 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 impatient
stay if medically necessary.
We cover routine
nursery care of the newborn child during the covered
portion of the mother s
maternity stay. We will cover other care of an
infant who requires
non-routine treatment only if we cover the infant
under a Self and Family
enrollment.
We pay hospitalization and surgeon services ( delivery) the same as for
illness or injury. See Hospital benefits ( Section 5c) and Surgery
benefits ( Section 5b) .
Routine sonograms to determine fetal age, size, or sex are not covered.
All charges
Nothing
( Copays may apply to
associated visits) 13
13 Page 14 15
2001 Arnett HMO 14 Section 5( a)
Family planning You Pay
Voluntary sterilization
Norplant
implantations
Injectable contraceptives drugs
Intrauterine devices ( IUD
s)
Not covered:
° Reversal of voluntary surgical sterilization
° Genetic counseling
° Voluntary abortion
Infertility services
Diagnosis and treatment of infertility, such
as:
Artificial insemination:
Intravaginal insemination ( IVI)
Intracervical insemination ( ICI)
Intrauterine insemination ( IUI)
Fertility drug Clomiohene citrate ( Clomid)
See Section 5( f)
Not covered:
° Assisted reproductive technology (ART) procedures,
such as:
°° In vitro fertilization
°° Embyo transfer and
GIFT
° Services and supplies related to excluded ART procedures
° Cost of donor sperm
Allergy care
Testing and treatment
Allergy injection
Allergy serum
Not covered: provocative food testing and sublingual All charges
allergy desensitization
Treatment therapies
Chemotherapy and radiation therapy
Note:
High dose chemotherapy in association with autologous bone
marrow
transplants are limited to those transplants listed under
Organ/ Tissue
Transplants on page 20.
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 from
your
physician s referral.
Nothing
( Copays may apply to
associated visits)
$ 10 per office visit with primary
care physician and 50%
coinsurance
for non primary
care physician and services.
Covered under the prescription
benefit.
Nothing
( Copays may apply to
associated visits)
Nothing
( Copays may apply to
associated visits)
All charges
All charges 14
14 Page 15 16
2001 Arnett HMO
15 Section 5( a)
Rehabilitative therapies You Pay
Physical therapy, occupational therapy, speech therapy, and
cardiac
rehabilitation
Note: 60 consecutive days of treatment
Not covered: All charges
° long-term rehabilitative therapy
° exercise programs
Hearing services ( testing, treatment, and supplies)
Hearing tests
are covered for diagnosis or treatment of disease or injury.
Hearing exams
are covered for diagnosis or treatment of disease
or injury.
Not covered: All charges
° All other hearing testing
°
Hearing aids, testing and examinations for them
Vision services ( testing, treatment, and supplies)
Annual eye
exam and refraction through age 17.
( See preventive care, children)
Diagnosis and treatment of disease or injury of the eyes.
Refractions
following cataract surgery.
Not covered: All charges
° Eyeglasses or contact lenses, and
examinations for them
° Eye exercises and orthoptics
° Radial
keratotomy and other refractive surgery
Foot care
Routine foot care when you are under active treatment
for a metabolic $ 10 per office visit
or peripheral vascular disease, such
as diabetes.
Podiatry care including bunions, spurs, ingrown toe nails, etc.
Not covered: All charges
° Shoe inserts and orthotics.
°
Cutting, trimming of toenails, and similar routine treatment of
conditions
of feet, except as stated above.
° Treatment of weak, strained or flat
feet and of instability, imbalance
or subluxation of the foot.
Nothing
( Copays may apply to
associated visits)
Nothing
( Copays may apply to
associated visits)
Nothing
( Copays may apply to
associated visits) 15
15 Page 16 17
2001 Arnett HMO 16 Section 5( a)
Orthopedic and prosthetic devices You Pay
Artificial limbs
and eyes, stump hose 20% coinsurance
Externally worn breast prostheses and
surgical bras, including
necessary replacements, following a mastectomy
Internal prosthetic devices, such as artificial joints, pacemakers,
cochlear implants, and surgically implanted breast implant following
mastectomy
Note: We pay internal prosthetic devices as hospital benefits;
see
Section 5( c) for payment information. See 5( b) for coverage
of surgery to
insert the device.
Orthopedic braces
Corrective orthopedic aplliance for non-dental
treatment of
temporomandibular joint ( TMJ) pain dysfunction syndrome
Not covered: All charges
° Orthopedic devices
° 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
Rental or purchase at our option,
including repair and adjustment, of 20% coinsurance
durable medical
equipment prescribed by your Plan physician, such as
oxygen and dialysis
equipment. Under this benefit, we also cover:
Hospital beds
Standard wheelchairs
Crutches
Walkers
Blood
glucose monitors
Insulin pumps
Nebulizers
Note: Our provider for our durable medical equipment is Lincare. They
can
be contacted directly once the physician has prescribed the equipment
through them. You can reach them at 800-487-0001 to make arrangements
for pick up or delivery. If you would like to know more about this service,
please call us at 888-448-7440.
Not covered: All charges
° Personal comfort or convenience items.
° Single patient use, self-administered dressings and
other
disposable supplies 16
16 Page 17 18
2001 Arnett HMO
17 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 aid.
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.
Alternative treatments
Not covered: All charges
°
Acupuncture;
° Chiropractic services;
° Naturopathic services;
° Hypnotherapy;
° Biofeedback
Educational Classes and programs
Smoking Cessation The
reimbursement is based upon completion
of an approved stop smoking class and
includes prescription,
class fees, etc. Call us at 888-448-7440 for more
information.
100% reimbursement up to $ 200
per member per lifetime. 17
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2001 Arnett HMO 18
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 medi-cally
necessary.
° Plan physicians must
provide or arrange your care.
° Be sure to read Section 4. Your costs
for covered services for valuable information
about how cost sharing works.
Also read Section 9 about coordinating benefits with
other coverage,
including with Medicare.
° The amounts listed below are for the charges
billed by a physician or other health
care professional for your surgical
care. Look in Section 5( c) for charges associated
with the facility (i. e.,
hospital, surgical center, etc.).
° YOU MUST GET PRECERTIFICATION ON ALL
SURGICAL PROCEDURES.
Please refer to the precertification information shown
in Section 3.
Benefit Description You pay
Surgical procedures You pay
Treatment of fractures, including casting Nothing
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 constructive surgery)
Surgical
treatment of morbid obesity which is defined in our Plan as
A weight of at
least two ( 2) times the ideal weight for frame, age,
height, and gender as
specified in the 1983 Metropolitan Life
Insurance tables;
A body mass
index of at least thirty-five ( 35 kilograms per meter
squared with
comorbidity or coexisting medical conditions such as
hypertension,
cardiopulmonary conditions, sleep apnea, or diabetes;
A body mass index of
at least forty ( 40) kilograms per meter
squared without comorbidity
Morbid obesity that has persisted for at least five ( 5) years;
For
which non-surgical treatment that is supervised by a physician
has been
unsuccessful for at least eighteen ( 18) consecutive months.
Note: For purposes of this section, body mass index equals weight in
kilograms divided by height in meters squared.
Insertion of internal prosthetic devices. See 5( a) Orthopedic braces
and
prosthetic device coverage information.
Voluntary sterilization
Norplant
( a surgically implanted contraceptive) and intrauterine devices
( IUDs)
Note: Devices are covered under 5( a) .
Treatment of burns
Section 5( b)
Surgical procedures Ñ Continued on next page
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2001
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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
Nothing
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 for the common form or norm. Examples of
congenital anomalies are: protruding ear deformities, cleft lip, cleft
palate, birth marks, webbed fingers, 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
prosthesis and surgical bras and replacements
( see Prosthetic devices)
Note: If you need a mastectomy, you may choose to have this
procedure on
an inpatient basis and remain in the hospital up to
48 hours after the
procedure.
Oral and maxillofacial surgery
Oral surgical procedures, limited
to:
Reduction of fractures of the jaws or facial bones;
Surgical
correction of cleft lip, cleft palate or severe
functional malocclusion;
Removal of stones from salivary ducts;
Excision of leukoplakia or
malignancies;
Excision of cysts and incision of abscesses when done as
independent
procedures; and
Other surgical procedures that do not
involve teeth or their
supporting structures.
Section 5( b)
Surgical procedures (Continued) You pay
Nothing
Oral and maxillofacial surgery Ñ Continued on next
page 19
19 Page
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2001 Arnett HMO 20
Oral and maxillofacial surgery (Continued) You pay
Not covered: All charges
° Oral implants and transplants
° Procedures that involve the teeth or their supporting structures (such
as
periodontal membrane, gingiva, and alveolar bone.
° Any dental
care involved in treatment of temporomandibular
joint (TMJ) pain dysfunction
syndrome.
Organ/ tissue transplants
Limited to: Nothing
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 leukemia;
advanced Hodgkin s lymphoma; advanced
non-Hodgkin s lymphoma; advanced
neurpblastoma; breast cancer;
multiple myeloma; epithelial ovarian cancer;
and testicular, mediastinal,
retroperitoneal and ovarian germ cell tumors
National Transplant Program ( NTP)
Limited Benefits Treatment of breast cancer, multiple myeloma, and
epithelial ovarian cancer may be provided in an NCI-or NIH-approved
clinical trial at a Plan-designated center of excellence and if approved
by the Plan s medical director in accordance with the Plan s protocols.
Note: We cover related medical and hospital expenses of the donor as
long
as the recipient is enrolled into our Plan.
Not covered: All charges
° Donor screening tests and donor search
expenses, except those
performed for the actual donor.
° Implants of
artificial organs
° Transplants not listed as covered
Anesthesia
Professional services provided in: Nothing
Hospital
inpatient
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office
Section 5( b) 20
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2001 Arnett HMO
21 Section 5( c)
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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 associated
with the professional charge ( i. e.,
physicians, etc. ) are covered in Section 5( a) or 5( b) .
YOU MUST
GET PRECERTIFICATION ON ALL SURGICAL PROCEDURES.
Please refer to the
precertification information shown in Section 3.
Benefit Description You pay
Inpatient hospital You pay
Room
and board, such as Nothing
Ward, semiprivate, or intensive care
accommodations;
General nursing care; and
Meals and special diets
Note: If you want a private room and it is not medically necessary,
you
pay the additional charge above the semiprivate room rate.
Other hospital services and supplies, such as:
Operating, recovery,
maternity, and other treatment rooms
Prescribed drugs and medicines given
while admitted.
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 supplies
Medical supplies, appliances, medical
equipment, and any covered
items billed by a hospital for use at home.
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
°
Take-home drugs. 21
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2001 Arnett HMO 22
Section 5( c)
Outpatient hospital or ambulatory surgical center
You Pay
Operating, recovery, and other treatment rooms Nothing
Drugs
and medications given at the facility
Diagnostic laboratory tests, X-rays,
and pathology services
Administration of blood, blood plasma, and other
biologicals
Blood or 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.
CAT Scans and MRIs $ 50 copay
Not covered: All charges
° Take
home drugs
Extended care benefits/ skilled nursing facility benefits
Extended
care/ skilled nursing benefit Nothing
( 90 day annual limit)
Not covered: All charges
° Custodial care
Hospice Care
Care for a terminally ill member is covered in the
home or skilled facility Nothing
as long as there are skilled components
medically necessary. 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.
Ambulance
Local professional ambulance service when medically
appropriate Nothing 22
22 Page
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2001 Arnett HMO 23
Section 5( d)
Section 5( d). Emergency services/ accidents
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.
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 if 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, poisoning, 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: Benefits are provided for urgent and
emergency medical services whether rendered inside or outside of the
Plan s
Service Area.
Urgent Care: Medical direction and advice is
available through your primary care physician, seven ( 7) days a
week,
twenty four ( 24) hours a day. All urgent care services whether inside or
outside of the service area must
be referred in advance by
your primary care physician.
Emergency Care: Benefits are not provided for the use of an
emergency room except for emergency care. In
the event of an Emergency, you
should go to a participating practitioner, unless the condition requires you to
go to the nearest emergency room. If you are admitted, the applicable copay
would be waived. If admitted in
an out of area facility, please notify the
Plan within 48 hours of admitting, unless it is not reasonably possible
to
do so. If this is the case, notify the Plan as soon as possible.
Benefit Description You pay
Emergency within our service area You pay
Emergency care at doctor s office $ 10 copay
Emergency care at an approved urgent care center $ 25 copay
Emergency
care at a hospital, and not admitted. $ 75 copay
Emergency care at a
hospital, and admitted. Nothing
Not covered: All charges
°
Elective care or non-emergency care
I M
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2001
Arnett HMO 24 Section 5( d)
Emergency outside our service area
You pay
Emergency care at an urgent care center $ 25 copay
Emergency care at a hospital, and not admitted. $ 75 copay
Emergency care
at a hospital, and admitted. Nothing
Not covered: All charges
°
Elective care or non-emergency care
° Emergency care provided outside
the service area is 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. 24
24 Page 25 26
2001 Arnett HMO 25
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 remember 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.
YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the
instructions after the benefits description below.
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Section 5( e)
Benefit Description You pay
Network mental
health and substance abuse benefits
All diagnostic and treatment
services recommended by a Plan provider and
contained in a treatment plan
that we approve. The treatment plan may
include services, drugs, and
supplies described elsewhere in this brochure.
Note: Plan benefits are payable only when we determine the care isclinically
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 providers
such as psychiatrists, psychologists, or clinical social workers
Medication management
Diagnostic tests Nothing
Services provided by a hospital or other
facility Nothing
Services in approved alternative care settings such as
partial hospitalization,
full-day hospitalization, facility based intensive
outpatient treatment
Not covered: All charges
° Services we have not approved
Note: OPM s review of disputes about the network treatment plans will be
based on the treatment plan s clinical appropriateness. OPM will generally
not order one clinically appropriate treatment plan in favor of another.
Network mental health and substance abuse benefits Ñ Continued on
next page
Your cost sharing responsi-
bilities are no greater than for
other
illness or conditions
$ 10 copay per office visit 25
25 Page 26 27
2001 Arnett HMO
26
Preauthorization To be eligible to receive these enhanced
mental health and substance abuse benefits you must follow your treatment plan
and all of our
network authorization processes.
Note: You primary care
physician will make the referral for the treatment
plan for you. Please
contact your physician if you have questions, or call
us at 765-448-7440 or
toll free at 888-448-7440.
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 conditions:
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 network mental health or substance abuse
professional provider. During the transitional period, you may continue
to see your treating provider. This transitional period will last for up to
90 days from the date you receive notice of the change. You may receive
this notice prior to January 1, 2001, and the 90-day period begins with
receipt of the notice.
Network limitation We may limit your benefits if you do not follow
your treatment plan.
How to submit network claims Our network
providers should bill us directly, but if by chance you
receive a bill of
charges, you may contact us at 765-448-7440 or mail
them to us:
Arnett Health Plans, Attn HMO Claims Department, P. O. Box 6108,
Lafayette, IN 47903
Section 5( e)
Mental health and substance abuse benefits (Continued) 26
26 Page 27 28
2001 Arnett HMO 27
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 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 must write the
prescription.
Where can you obtain them. Prescriptions must be
dispensed by a participating pharmacy, In order
to receive this benefit you
must present your Arnett HMO membership card at the time the prescrip-
tion
is filled. The participating pharmacy will then charge you the applicable
copayment amount.
There are some specific drugs that require prior
authorization by Arnett HMO. Your ordering
physician or the participating
pharmacy will then charge you the applicable copayment amount.
Take-home
prescriptions dispensed from a hospital facility will not be covered.
We use a formulary. The Arnett Prescription Drug Formulary is based on
the recommendations of
our Pharmacy and Therapeutics ( P& T) Committee
and from the input we receive from our physi-
cians. The P& T Committee
is made up of pharmacists and physicians who make decisions regarding
the
formulary. They review medications on an ongoing basis to decide which are the
safest and most
effective. The Committee meets every four months to develop
and update the formulary. Many
medications have the same chemical structure
but are packaged differently. The formulary limits the
number of similar
drugs from which providers may choose. This allows us to purchase drugs in
volume at greater discounts. This cost savings is passed on to our members
in the form of reduced
premiums and increased benefits.
These are the dispensing limitations. All prescriptions are filled for
up to a one month supply.
We offer three levels of copayments for this
prescription:
Generic Drugs . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . $ 5 copay ( up to a one month supply)
Formulary Brand Name
Drugs . . . . . . . . . . . . . . . . . . $ 15 copay ( up to a one month supply)
Non-Formulary Brand Name Drugs . . . . . . . . . . . . . . $ 30 copay ( up
to a one month supply)
Note: If a generic drug is available and the prescription is filled with a
brand name drug, ( formulary or
non-formulary) member pays the difference in
cost between the generic and brand name drug in
addition to the copayment.
Drugs that require prior authorization must be authorized prior to the
prescription being filled in order to be considered for payment.
When you have to file a claim. Our network providers should bill us
directly, but if by chance you
receive a bill of charges, you may contact us
at 765-448-7440 or mail them to us:
Arnett Health Plans, Attn HMO Claims Department, P. O. Box 6108, Lafayette,
IN 47903
I M
P O
R T
A N
T
I M
P O
R T
A N
T
Section 5( f)
Prescription drug benefits begin on next page 27
27 Page 28 29
2001 Arnett HMO 28 Section 5( f)
Benefit Description You Pay
Covered medications and supplies
We cover the following medications and supplies
prescribed by a Plan
physician and obtained from
a Plan pharmacy:
Drugs for which a prescription is required by
Federal law
Insulin,
with a copay charge applied to each visit.
Diabetic supplies, including
insulin syringes, needles,
glucose test tablets and test tape, Benedict s
solution
or equivalent, and acetone
test tablets
Disposable needles
and syringes needed for injecting
covered prescribed medication
Oral
contraceptive drugs; contraceptive devices
Not covered: All charges.
° Drugs available without a prescription
or for which
there is a nonprescription equivalent available
° Drugs
obtained at a non-Plan pharmacy except for
out-of-area emergencies where the
network does
not extend.
° Vitamins, nutrients, and food supplements
even if
a physician prescribes or administers them
° Medical
supplies such as dressings and antiseptics
° Drugs and supplies for
cosmetic purposes
° Drugs to enhance athlete performance
°
Smoking cessation drugs and medications, including
nicotine patches
° Fertility drugs except for Chomiphene (Clomid)
$ 5 copay Generic Drugs
$ 15 copay Formulary Brand Name Drugs
$ 30
copay Non--Formulary Brand Name Drugs
Note: Copays cover for up to a
one-month supply.
If there is no generic available, you will still
have
to pay the brand name copay. 28
28 Page 29 30
2001 Arnett HMO
29
I M
P O
R T
A N
T
I M
P O
R T
A N
T
Section 5( g)
Section 5( g). Dental benefits
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
providers must arrange your care.
We cover hospitalization for dental
procedures only when a non-dental physical
impairment exists which makes
hospitalization necessary to safeguard the health
of the patient; we do not
cover the dental procedure.
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
We cover restorative services and
supplies necessary to promptly repair ( but not replace) sound natural teeth.
The need for these services must result from an accidental injury. Services
must be received within 72 hours
of the injury.
Service You Pay
In physician s or referral special st s off ce $
10 copay
In an urgent care center $ 25 copay
In a hospital emergency room $ 75
copay
We have no other dental benefits. 29
29
Page 30 31
2001
Arnett HMO 30 Section 6
Section 6. General exclusions Ð
things we don't cover
The exclusions in this section apply to all
benefits. Although we 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. 30
30 Page 31 32
2001 Arnett HMO
31 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, such as emergency
care services. 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 765-448-7440 or toll free at 888-448-7440.
When you must file a claim such as an out of area emergency care
submit
it on the HCFA-1500 or a claim form that includes the informa-
tion shown
below. Bills and receipts should be itemized and show:
Covered member s name
and ID number;
Name and address of the physician or facility that provided
the
service or supply;
Dates you received the services or supplies;
Diagnosis;
Type of each service or supply ;
The charge for
each service or supply;
A copy of the explanation of benefits, payments, or
denial from any
primary payer such as the Medicare Summary Notice ( MSN) ;
and
Receipts, if you paid for your services.
Submit your claims to: Arnett Health Plans
Attn: HMO Claims
Department
P. O. Box 6108
Lafayette, IN 47903
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 administra-
tive 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. 31
31 Page
32 33
2001 Arnett HMO 32
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
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: Arnett HMO, Member Services
Department, P. O. Box 6108,
Lafayette, IN 47903
(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.
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 Ñ go to step 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.
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, P. O.
Box 436, Washington, D. C. 20044-0436.
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. You are the only person who has a
right to file a disputed claim with OPM. Parties acting as
your
representative, such as medical providers, must provider a copy of your specific
written consent with
the review request.
1
2
3
4 32
32 Page
33 34
2001 Arnett HMO 33
Section 8
Note: The above deadlines may be extended if you show that
you were unable to meet the deadline because of
reasons beyond your control.
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 admin-istrative
appeals.
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 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 765-448-7440 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 they can give your claim
expedited treatment too, or
You can call OPM s Health Benefits Contracts Division at 202-606-0737 between
8 a. m. and 5 p. m.
eastern time.
5
6
The disputed claims process (Continued) 33
33 Page 34 35
2001 Arnett HMO 34 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 coverage.
When you have double coverage, one plan normally pays its benefits in
full as the primary payer and the other plan pays a reduced benefit as the
secondary payer. We, like other insurers, determine which coverage is
primary according to the National Association of Insurance
Commissioners
guidelines.
When we are the primary payer, we will pay the benefits described in
this
brochure.
When we are the secondary payer, we will determine our allowance.
After
the primary plan pays, we will pay what is left if 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 managed care plan 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.
(Primary payer chart begins on next page) 34
34 Page 35 36
2001 Arnett HMO 35 Section 9
(
except for claims
related to Workers
Compensation)
The following chart illustrates whether Original Medicare or this Plan should
be the primary payer for you according to
our enrollment 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
A. When either you or a covered spouse are age 65
or over and Then the primary Payer is
Original Medicare This Plan
1)
Are an active employee with the Federal government ( including when
you or
a family member are eligible for Medicare solely because of
a disability) .
2) Are an annuitant
3) Are a re-employed annuitant with the Federal
government when
a) The position is excluded from FEHB, or . . . . . . . . .
. . . . . . . . . . . .
b) The position is not excluded from FEHB . . . .
. . . . . . . . . . . . . . . . .
Ask your employing office which of these
applies to you.
4) Are a Federal judge who retired under title 28. U. S. C. , or a Tax Court
Judge who retired under Section 7447 of title 26, U. S. C. ( or if your
covered spouse is this type of judge) .
5) Are enrolled in Part B only, regardless of your employment status.
( for Part B ( for other
services) services)
6) Are a former Federal employee receiving Workers Compensation and
the
Office of Workers Compensation Programs has determined that you
are unable
to return to duty.
B. When you or a covered family member have Medicare based
on end
stage renal disease ( ESRD) and
1) Are within the first 30 months of eligibility to receive Part A benefits
solely because of ESRD.
2) Have completed the 30-month ESRD coordination period and are still
eligible for Medicare due to ESRD.
3) Become eligible for Medicare due to ESRD after Medicare became
primary for you under another provision.
C. When you or a covered family member have FEHB and
1) Are
eligible for Medicare based on disability, and
a) Are an annuitant . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b) Are an active employee . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . 35
35 Page
36 37
2001 Arnett HMO 36
Claims process You probably will never have to file a claim form
when you have both our Plan and Medicare.
When we are the primary payer, we process the claim first.
When Original
medicare is the primary payer, Medicare processes
your claim first. In most
cases, your claims will be coordinated
automatically, and we will pay the
balance of covered charges.
You will not need to do anything. To find out if
you need to do
something about filing your claims, call us at 765-448-7440
or
toll free at 888-448-7440.
We do not waive any out-of-pocket cost when you have Medicare.
Managed Care Plan If you are eligible for Medicare, you may choose to
enroll in and get
your Medicare benefits form a Medicare managed care plan.
These are
health care choices ( like HMOs) in some areas of the country. In
most
Medicare managed care plans, you can only go to doctors, specialists,
or
hospitals that are part of the plan. Medicare managed care plans cover
all
Medicare Part A and PartB 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 another Plan's Medicare managed care plan: You
may
enroll in another plan s Medicare managed care plan and also
remain in our
FEHB plan. We will still provide benefits when your
Medicare managed care
plan is primary, even out of the manged care
plan s network and/ or service
area ( if you use our Plan providers) , but
we will not waive any of our
copayments or coinsurance and you must
remain in our network.
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 premiums. ) For
information on suspending your FEHB
enrollment, contact your retirement
office. If you later want to re-enroll
in the FEHB program, generally you
may do so only at the next open
season unless you involuntarily lose
coverage or move out of the
Medicare managed care plan service area.
Enrollment in Medicare
Part B 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 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.
Section 9 36
36 Page
37 38
2001 Arnett HMO 37
Workers' Compensation We do not cover services that:
You need
because of a workplace-related disease or injury that the
Office of Workers
Compensation Programs ( OWCP) or a similar
Federal or State agency
determines they must provide; or
OWCP or a similar agency pays for through a third party injury
settlement
or other similar proceeding that is based on a claim you
filed under OWCP or
similar laws.
Once OWCP or similar agency pays its maximum benefits for your
treatment,
we will cover your benefits. You must use our providers.
Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies
are responsible for your care We do
not cover services and supplies when a local, State, or Federal Government
agency directly or indirectly pays for them.
When others are responsible
for injuries When you receive money to
compensate you for medical or hospital care for injuries and illness caused by
another person, you must reimburse us
for any expenses we paid. However, we will cover the cost of treatment
that exceeds the amount you received in the settlement.
If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our
subrogation procedures.
Section 9 37
37 Page
38 39
2001 Arnett HMO 38
Section 10. Definitions of terms we use in this brochure
Calendar
year January 1 through December 31 of the same year. For enrollees, the
calendar year begins on the effective date of their enrollment and ends in
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.
Coinsurance Coinsurance is the percentage of our allowance that you
must pay for your care. See page 10.
Covered Services Care we provide
benefits for, as described in this brochure.
Deductible A deductible
is a fixed amount of covered expenses you must incur for certain covered
services and supplies before we start paying benefits for
those services.
See page 10.
Experimental or
Investigational services Drugs, devices, services,
supplies, medical treatments or procedures which are experimental or
investigational in nature. The Plan will apply
the following criteria in determining whether services or supplies are
experimental or investigational:
a. Any medical device, drug or biological product must have received
final approval to market by the United States Food and Drug
Administra-
tion ( FDA) for the particular diagnosis or condition.
b. Conclusive evidence from the published peer-review medical litera-
ture
must exist that over time the technology has a definite positive
effect on
health outcomes; such evidence must include well-designed
investigations
that have been reproduced by nonaffiliated authoritative
sources, with
measurable results, backed up by the positive endorse-
ments of national
medical bodies or panels regarding the efficacy and
rationale.
c. Demonstrated evidence as reflected in the published peer-review
literature must exist that over time the technology leads to improvements
in health outcomes, i. e., the beneficial effects outweigh the
harmful
effects.
d. Proof as reflected in the published peer-reviewed literature must exist
that the technology is at least as effective in improving health outcomes
as established technology, or is usable in appropriate clinical contexts in
which established technology is not employable.
e. Proof as reflected in the published peer-reviewed medical literature
must exist that improvements in health outcomes, as defined in
para-
graph c, is possible in standard conditions of medical practice,
outside
clinical investigatory settings.
Us/ We Us and we refer to Arnett HMO.
You You refers to the
enrollee and each covered family member.
Section 10 38
38 Page
39 40
2001 Arnett HMO 39
Section 11
Section 11. FEHB facts
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.
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.
Self Only Coverage is for you alone. Self and Family coverage is for
you,
your spouse, and your unmarried dependent children under age 22,
including
any foster children or stepchildren your employing or 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 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.
The benefits in this brochure are effective 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.
No pre-existing condition
limitation
Where you can get information
about enrolling in the FEHB
Program
Types of coverage available
for you and your family
When benefits and
premiums start 39
39
Page 40 41
2001
Arnett HMO 40
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
Coverage ( TCC) .
When you lose benefits
When FEHB coverage ends You will
receive an additional 31 days of coverage, for no additional
premium, when:
Your enrollment ends, unless you cancel your enrollment, or
You are a
family member no longer eligible for coverage.
You may be eligible for spouse equity coverage or Temporary
Continuation
of Coverage.
Spouse Equity coverage If you are divorced from a Federal employee or
annuitant, you may not
continue to get benefits under your former spouse s
enrollment. But, you
may be eligible for your own FEHB coverage under the
spouse equity
law. If you are recently divorced or are anticipating a
divorce, contact
your ex-spouse s employing or retirement office to get RI
70-5, the
Guide to Federal Employees Health Benefits Plans for Temporary
Continuation of Coverage and Former Spouse Enrollees, or other
information about your coverage choices.
TCC If you leave Federal service, or if you lose coverage because you
no
longer qualify as a family member, you may be eligible for Temporary
Continuation of Coverage ( TCC) . For example, you can receive TCC if
you are not able to continue your FEHB enrollment after you retire.
You may not elect TCC if you are fired from your Federal job due to
gross
misconduct.
Get the RI 79-27, which describes TCC, and the RI 70-5, the Guide to
Federal Employees Health Benefits Plans for Temporary Continuation
of
Coverage and Former Spouse Enrollees, from your employing, or
retirement
office or from www. opm. gov/ insure.
Section 11
Your medical and claims
records are confidential 40
40 Page 41 42
2001 Arnett HMO 41
You may convert to a
non-FEHB 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 office will not notify you. You must
apply in writing to us within 31 days after you are no longer eligible
for coverage.
Your benefits and rates will differ from those under the FEHB Program;
however, you will not have to answer questions about your health,
and we
will not impose a waiting period or limit your coverage due to
pre-existing
conditions.
If you leave the FEHB program, we will give you a Certificate of Group
Health Plan Coverage that indicates how long you have been enrolled
with
us. You can use this certificate when getting health insurance or
other
health care coverage. Your new plan must reduce or eliminate
waiting
periods, limitations, or exclusions for health related conditions
based on
the information in the certificate, as long as you enroll within
63 days of
losing coverage under this Plan.
If you have been enrolled with us for less than 12 months, but were
previously enrolled in other FEHB plans, you may also request a
certificate from those plans.
Inspector General Advisory Stop health care fraud! Fraud increases the
cost of health care for everyone. If you suspect that a physician, pharmacy, or
hospital has
charged you for services you did not receive, billed you twice
for the
same service, or misrepresented any information, do the following:
Call the provider and ask for an explanation. There may be an error.
If
the provider does not resolve the matter, call us at 765-448-7440
and
explain the situation.
If we do not resolve the issue, call THE HEALTH CARE
FRAUD
HOTLINE 202--418-3300 or write to: The United States Office of
Personnel Management, Office of the Inspector General Fraud
Hotline,
1900 E Street NW, Room 6400, Washington, DC 20415
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB
Program benefits can be prosecuted for fraud. Also, the Inspector General may
investigate
anyone who uses an ID card if the person tries to obtain
services for
someone who is not an eligible family member, or are no longer
enrolled
in the Plan and tries to obtain benefits. Your agency may also take
administrative action against you.
Section 11
° Converting to
individual coverage
Getting a Certificate of
Group Health Plan Coverage 41
41 Page 42 43
2001 Arnett HMO 42
A ccidental njury
29
Allergy tests 14
Alternative treatment 17
Ambulance 24
Anesthesia 20
Autologous bone marrow
transplant 20
B iopsies 18
Blood and blood plasma 21
Breast cancer screening
13
C asts 18
Catastrophic protection 11
Changes for 2001 6
Chemotherapy 14
Childbirth 13Cholesterol
tests 12
Circumcision
13Claims
5
Coinsurance 10
Colorectal cancer screening 12
Congenital anomalies 19
Contraceptive devices and drugs 27
Coordination of benefits 34
Covered charges 10
Covered providers 7
Crutches 16
D eductible 10
Definitions 38
Dental care 29
Diagnostic
services 12
Disputed claims review 32
Donor expenses ( transplants) 20
Dressings 16
Durable medical
equipment ( DME) 16
E ffective date of enrollment 39
Emergency 23Experimental
or
investigational 38
Eyeglasses 15
F amily planning 14
Fecal occult blood test 12
G eneral Exclusions 30
earing services 15
Home health services
17
Hospice care 22
Home nursing care 17
Hospital 21
I mmunizations 13Infertility
14
In-hospital physician care 18
Inpatient Hospital benefits 21
Insulin 28
L aboratory and
pathological services 12
M achine diagnostic tests 12
Magnetic Resonance
Imaging (
MRIs) 22
Mammograms 13Maternity
benefits 13Medicaid
36
Medicare 34
Members 38
Mental conditions/ Substance abuse
benefits 25
N ewborn care 12
O bstetrical care 13Occupational
therapy 15
Ocular injury 15
Office visits 12
Oral and
maxillofacial surgery 19
Orhopedic devices 16
Out-of-pocket expenses 10
Outpatient facility care 22
Oxygen 16
P ap test 12
Physicial examination 12-13Physical
therapy 12
Physician 12
Precertification 9
Preventive care, adult 12
Preventive care, children 13Prescription
drugs 27
Preventive
services 12
Prior approval 9
Prostate cancer screening 12
Prosthetic
devices 16
Psychologist 25
Psychotherapy 25
R adiation therapy 14
Rehabilitation therapies 15
Renal
dialysis 14
Room and board 21
S econd surgical opinion 12
Skilled nursing facility care 22
Smoking cessation 17
Speech therapy 15
Splints 16
Subrogation 37
Surgery 18
° Anesthesia 20
° Oral 19
° Outpatient 22
° Reconstructive 19
Syringes 16
T emporary Continuation
of Coverage 40
Transplants 20
Treatment therapies 14
V ision services 15
W ell child care 13Wheelchairs
16
X -rays 12
Index
Index
Do not rely on this page; it is for your convenience and
does not explain benefit coverage. 42
42 Page 43 44
2001 Arnett HMO
43 Summary
° 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 . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nothing 21
Outpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . Nothing 22
CAT scans and MRI tests ( Outpatient) . . . . . . . . . . . . . . . . . . . .
. . . . . $ 50 copay 12
Emergency benefits:
In-and Out-of-area
Urgent Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . $ 25 copay23
Hospital . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . $ 75 copay23, 24
Mental health and substance abuse treatment . . . . . . . . . . . . . . . . .
. . Regular cost sharing 25
Prescription drugs:
Generic drugs . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 5
copay27
Formulary brand name drugs . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . $ 15 copay 27
Non-formulary brand name drugs . . . . . . .
. . . . . . . . . . . . . . . . . . . $ 30 copay 27
Dental care: Accidental injury only . . . . . . . . . . . . . . . . . . . . .
. . . . . . Nothing 29
Vision care . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . Nothing 15
Summary of Benefits for Arnett HMO Health Plan Ð 2001
Office
visit copay: $ 10 primary
care; $ 10 specialist 43
43 Page 44
2001
Arnett HMO 44 28
2001 Rate Information for
Arnett HMO 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 most career U. S. Postal Service employees. Most
employees should refer to
the FEHB Guide for United States Postal Service
Employees, RI 70-2. Different postal rates apply
and special FEHB guides are
published for Postal Service Nurses and Tool & Die employees (see
RI
70-2B), and for Postal Service Inspectors and Office of Inspector General (OIG)
employees (see
RI 70-21N).
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
Monthly Biweekly
Type of Gov't Your Gov't Your
USPS Your Enrollment Code Share Share Share Share Share Share
Self Only G21 $86.59 $34.61 $187.61 $74.99 $102.22 $18.98
Self and
Family G22 $195.82 $119.32 $424.28 $258.52 $231.17 $83.97
Postal Premium A
Our services for this Plan are available in the
following area: The Greater Lafayette, Indiana area;
including the counties
of Benton, Boone, Carroll, Cass, Clinton, Fountain, Fulton, Howard, Jasper,
Montgomery, Newton, Pulaski, Tippecanoe, Warren, and White counties.
Biweekly 44