Serving: Central New York
You must live or work in the service
area to enroll in this Plan.
Enrollment in this Plan is limited; see page
5 for requirements.
This Plan has full accreditation from the NCQA. See the 2001 Guide for
More information on NCQA.
Enrollment codes for this Plan:
EB1 Self Only EB2 Self and Family
RI 73-461
For changes in benefits
see page 8 1
1
Page 2 3
2001
HMO-CNY 2 Table of Contents
Table of Contents
Introduction………………………………………………………………….
............................................................ 4
Plain
Language………………………………………………………………............................................................
4
Section 1. Facts about this HMO
plan.....................................................................................................................
5
How we pay
providers........................................................................................................................
5
Patients' Bill of Rights
...........................................................................................................................
5
Service
Area..........................................................................................................................................
7
Section 2. How we change for
2001………………………………………...............................................................
8
Program-wide
changes...........................................................................................................................
8
Changes to this Plan
..............................................................................................................................
8
Section 3. How you get care …………...
................................................................................................................
9
Identification cards
................................................................................................................................
9
Where you get covered care
...................................................................................................................
9
· Plan
providers..................................................................................................................................
9
· Plan
facilities...................................................................................................................................
9
What you must do to get covered care
..................................................................................................
10
· Primary care
..................................................................................................................................
10
· Specialty care
................................................................................................................................
10
· Hospital care
.................................................................................................................................
11
Circumstances beyond our
control........................................................................................................
11
Services requiring our prior approval
...................................................................................................
11
Section 4. Your costs for covered services
............................................................................................................
12
·
Copayments...................................................................................................................................
12
· Deductible
.....................................................................................................................................
12
Your out-of-pocket
maximum..............................................................................................................
12
Section 5.
Benefits…………………………………………………………............................................................
13
Overview.............................................................................................................................................
13
(a) Medical services and supplies provided by physicians and other health
care professionals .......... 14
(b) Surgical and anesthesia services
provided by physicians and other health care professionals ....... 22
(c)
Services provided by a hospital or other facility, and ambulance
services.................................... 25
(d) Emergency services/
accidents....................................................................................................
28
(e) Mental health and substance abuse benefits
................................................................................
30
(f) Prescription drug benefits
..........................................................................................................
32
(g) Special features
.........................................................................................................................
34
Section 6. General exclusions --things we don't cover
.........................................................................................
35
Section 7. Filing a claim for covered services
.......................................................................................................
36
Section 8. The disputed claims process
.................................................................................................................
37
Section 9. Coordinating benefits with other
coverage............................................................................................
39 2
2 Page 3 4
2001 HMO-CNY 3 Table of Contents
When you
have…
· Other health
coverage....................................................................................................................
39
· Original Medicare
.........................................................................................................................
39
· Medicare managed care plan
.........................................................................................................
41
TRICARE/ Workers' Compensation/
Medicaid......................................................................................
41
Other Government agencies
................................................................................................................
41
When others are responsible for injuries
..............................................................................................
41
Section 10. Definitions of terms we use in this brochure
.......................................................................................
42
Section 11. FEHB facts
........................................................................................................................................
44
· Coverage
information......................................................................................................................
44
· No pre-existing condition limitation
..........................................................................................
44
· Where you get information about enrolling in the FEHB
Program.............................................. 44
· Types of
coverage available for you and your family
................................................................. 44
· When benefits and premiums start
.............................................................................................
45
· Your medical and claims records are confidential
...................................................................... 45
· When you
retire........................................................................................................................
45
· When you lose
benefits..................................................................................................................
45
· When FEHB coverage
ends.......................................................................................................
45
· Spouse equity coverage
............................................................................................................
45
· Temporary Continuation of Coverage (TCC)
............................................................................ 45
· Converting to individual coverage
............................................................................................
46
· Getting a Certificate of Group Health Plan Coverage
................................................................ 46
Inspector General advisory:
...................................................................................................................................
46
Index
.........................................................................................................................................................
47
Summary of benefits
.............................................................................................................................................
49
Rates…………………………………………………………………………………………………………..
Back cover 3
3 Page
4 5
2001 HMO CNY 4 Introduction/ Plain
Language
Introduction
HMO-CNY P. O. Box 4712, 344 South Warren
Street
Syracuse, N. Y. 13221-4712
This brochure describes the benefits
of HMO-CNY under our contract (CS 2318) with the Office of Personnel Management
(OPM), as authorized by the Federal Employees Health Benefits law. This brochure
is the official
statement of benefits. No oral statement can modify or
otherwise affect the benefits, limitations, and exclusions of this brochure.
If you are enrolled in this Plan, you are entitled to the benefits described
in this brochure. If you are enrolled for Self and Family coverage, each
eligible family member is also entitled to these benefits. You do not have a
right to
benefits that were available before January 1, 2001, unless those
benefits are also shown in this brochure.
OPM negotiates benefits and rates
with each plan annually. Benefit changes are effective January 1, 2001, and are
summarized on page 8. Rates are shown at the end of this brochure.
Plain Language
The President and Vice President are making the
Government's communication more responsive, accessible, and understandable to
the public by requiring agencies to use plain language. In response, a team of
health plan
representatives and OPM staff worked cooperatively to make this
brochure clearer. Except for necessary technical terms, we use common words.
"You" means the enrollee or family member; "we" means
HMO-CNY.
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 HMO-CNY 5 Section
1
Section 1. Facts about this HMO plan
This Plan is a health
maintenance organization (HMO). We require you to see specific physicians,
hospitals, and other providers that contract with us. These Plan providers
coordinate your health care services.
HMOs emphasize preventive care such as routine office visits, physical exams,
well-baby care, and immunizations, in addition to treatment for illness and
injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan
providers, you will not have to submit claim forms or pay bills. You only pay
the copayments, 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.
HMO-CNY is
an independent corporation organized under the Public Health Law and Insurance
Law of New York State. HMO-CNY operates under licenses with the Blue Cross and
Blue Shield Association, an association of
independent Blue Cross and Blue
Shield Plans which permits HMO-CNY to use the Blue Cross and Blue Shield service
marks in a portion of New York State. HMO-CNY is solely responsible for honoring
its agreements to
provide or administer benefits for health care. HMO-CNY is
an independent practice association health plan founded in 1984.
A primary care physician you choose from the Provider Directory will provide
or arrange your health care services. In addition, participating specialists
cover a wide range of professional specialty care.
If you have a question
about choosing a personal physician from the Directory or have a question
regarding the Plan, a marketing representative will gladly assist you. Please
note that during physician vacations, urgent visits, etc.,
appropriate
coverage will be available.
HMO-USA guest membership benefits are available
to subscribers and their dependents when out of this Plan's service area for an
extended period of time. This benefit includes access to primary care doctors in
the out-of-area
location (i. e. an eligible student dependent attending
college outside this Plan's service area). HMO-USA is a network of Blue Cross
and Blue Shield HMOs that can coordinate your medical care. If you need more
information,
the Plan can tell you more about its reciprocity benefits.
Patients' Bill of Rights
OPM requires that all FEHB Plans comply
with the Patients' Bill of Rights, recommended by the President's Advisory
Commission on Consumer Protection and Quality in the Health Care Industry. You
may get information
about us, our networks, providers, and facilities. OPM's
FEHB website (www. opm. gov/ insure) lists the specific types of information
that we must make available to you. Some of the required information is listed
below.
· HMO-CNY is compliant with State licensing effective May 16, 1988
through the New York State Department of Health (NYSDOH).
· HMO-CNY
has received a three year accreditation by the National Committee for Quality
Assurance (NCQA). · HMO-CNY has been granted a Health Maintenance
Organization certificate of Authority to operate pursuant to
Article 44 of
the New York State Public Health Law effective May 16, 1988. · HMO-CNY is
a privately owned for profit corporation. 5
5
Page 6 7
2001
HMO-CNY 6 Section 1
· HMO-CNY meets State, Federal, and accreditation
requirements for fiscal solvency, confidentiality and transfer of medical
records.
If you want more information about us, call 800/ 447-6269, or write
to HMO-CNY, P. O. Box 4712, 344 South Warren Street, Syracuse, N. Y. 13221-4712.
You may also contact us by fax at 315/ 448-4922 or visit our website at
www.
bcbscny. org. 6
6 Page
7 8
2001 HMO-CNY 7 Section 1
Service Area
To enroll in this Plan, you must live in or work in
our Service Area. The service area for this Plan includes the following areas:
The New York counties of Broome, Cayuga, Chemung, Cortland, Onondaga, Oswego,
Schuyler, Steuben, Tioga, and Tompkins and the zip codes listed in the following
counties: Madison County (NY), 13030, 13032, 13035, 13037,
13038, 13043,
13043, 13051, 13052. Chenango County (NY), 13730, 13733, 13830, 13778. Delaware
County (NY), 13742, 13755, 13756, 13783, 13804, 13838, 13804, 13838, 13839.
Benefits for care outside the service area are limited to emergency services
as described on page 28.
If you or a covered family member move outside the
service area, you may enroll in another approved plan. It is not necessary to
wait until you move or for the open season to make such a change; contact your
employing office or
retirement system for information if you are
anticipating a move. 7
7 Page
8 9
2001 HMO-CNY 8 Section 2
Section 2. How we change for 2001
Program-wide changes
· The plain language team reorganized the brochure and the way we
describe our benefits. We hope this will make it easier for you to compare
plans.
· This year, the Federal Employees Health Benefits Program is
implementing network mental health and substance abuse parity. This means that
your coverage for mental health, substance abuse, medical, surgical, and
hospital
services from providers in our HMO's "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
visit limitations on mental health and substance abuse services that
we did not place 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 800/ 447-6269, or checking our
website www. bcbscny. org. You can find out more about patient safety on the OPM
website, www. opm. gov/ insure. To improve your healthcare, take these
five
steps:
·· Speak up if you have questions or concerns.
·· Keep a list of all the medicines you take.
·· Make sure you get the results of any test or procedure.
··
Talk with your doctor and health care team about your
options if you need hospital care. ·· Make sure you understand
what will happen if you need surgery.
· We clarified the language to show that anyone who needs a mastectomy
may choose to have the procedure performed on an inpatient basis and remain in
the hospital up to 48 hours after the procedure. Previously, the
language
referenced only women.
Changes to this Plan
· Your share of the non-Postal premium will increase by 22.5% for Self
Only or 53.1xx% for Self and Family. · The inpatient and outpatient
mental health and substance abuse visit limitation was removed.
· The
outpatient alcohol and substance abuse copay was increased from $5 to $10. 8
8 Page 9 10
2001 HMO-CNY 9 Section 3
Section 3. How you get
care
Identification cards We will send you an identification (ID) card
when you enroll. You should carry your ID card with you at all times. You must
show it
whenever you receive services from a Plan provider, or fill a
prescription at a Plan pharmacy. Until you receive your ID card, use your copy
of the
Health Benefits Election Form, SF-2809, your health benefits
enrollment confirmation (for annuitants), or your Employee Express confirmation
letter.
If you do not receive your ID card within 30 days after the
effective date of your enrollment, or if you need replacement cards, call us at
800/ 447-
6269.
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 providers include primary care, specialists, ancillary, laboratories,
and DME suppliers.
· 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.
HMO-CNY contracts with all hospitals in our servicing area. The hospitals
are:
· Our Lady of Lourdes Memorial Hospital, Binghamton ·
United Health Services Hospitals, Binghamton
· Auburn Memorial
Hospital, Auburn · Arnot Ogden Medical Center, Elmira
· St
Joseph's Hospital, Elmira · Cortland Memorial Hospital, Cortland
· The Hospital, Sidney · Community Memorial Hospital, Hamilton
· Community General Hospital, Syracuse · Crouse Hospital,
Syracuse
· St Joseph's Hospital Health Center, Syracuse ·
University Hospital Health Science Center, Syracuse
· A. L. Lee
Memorial Hospital, Fulton · Oswego Hospital, Oswego
· Schuyler
Hospital, Montour Falls · Corning Hospital, Corning
· IRA
Davenport Hospital, Bath · St. James Mercy Hospital, Hornell
·
Barnes Kasson Hospital, Susquehanna, PA · Endless Mountains Health
System, Montrose, PA 9
9 Page
10 11
2001 HMO-CNY 10 Section 3
· Cayuga Medical Center at Ithaca, Ithaca
What you must do
It depends on the type of care you need. First, you and each family member
must choose a primary care physician. This decision is
important since your
primary care physician provides or arranges for most of your health care.
Primary care physicians are listed in our provider directory, with their
locations, phone numbers, and whether or not the doctor is accepting new
patients. You can choose a primary care physician from the provider
directory, or call our Member Services Department at 315/ 448-6820.
· Primary care Your primary care physician can be a general or
family practitioner, pediatrician, or internist. Your primary care physician
will provide most
of your health care, or give you a referral to see a
specialist.
If you want to change primary care physicians or if your primary
care physician leaves the Plan, call us. We will help you select a new one.
· Specialty care Your primary care physician will refer you to
a specialist for needed care. However, you may see a plan ophthalmologist or
optometrist for a
routine eye exam without a referral. Also, a woman may see
her plan gynecologist directly without a referral from her primary care
physician.
Here are other things you should know about specialty care:
· If
you need to see a specialist frequently because of a chronic, complex, or
serious medical condition, your primary care physician
will develop a
treatment plan with you and your health plan that allows you to see your
specialist for a certain number of visits without
additional referrals. Your
primary care physician will use our criteria when creating your treatment plan
(the physician may have to get an
authorization or approval beforehand).
· If you are seeing a specialist when you enroll in our Plan, talk to
your primary care physician. Your primary care physician will decide
what
treatment you need. If he or she decides to refer you to a specialist, ask if
you can see your current specialist. If your current
specialist does not
participate with us, you must receive treatment from a specialist who does.
Generally, we will not pay for you to see
a specialist who does not
participate with our Plan.
· If you are seeing a specialist and your
specialist leaves the Plan, call your primary care physician, who will arrange
for you to see another
specialist. You may receive services from your
current specialist until we can make arrangements for you to see someone else.
· If you have a chronic or disabling condition and lose access to your
specialist because we:
··terminate our contract with your
specialist for other than cause; or
··drop out of the Federal
Employees Health Benefits (FEHB) Program and you enroll in another FEHB Plan; or
··reduce our service area and you enroll in another FEHB Plan,
10
10 Page 11 12
2001 HMO-CNY 11 Section 3
you may be able to
continue seeing your specialist for up to 90 days after you receive notice of
the change. Contact us or, if we drop out of
the Program, contact your new
plan.
If you are in the second or third trimester of pregnancy and you lose
access to your specialist based on the above circumstances, you can
continue
to see your specialist until the end of your postpartum care, even if it is
beyond the 90 days.
· Hospital care Your Plan primary care physician or specialist
will make necessary hospital arrangements and supervise your care. This includes
admission
to a skilled nursing or other type of facility.
If you are in
the hospital when your enrollment in our Plan begins, call our customer service
department immediately at 800/ 447-6269. If you
are new to the FEHB Program,
we will arrange for you to receive care.
If you changed from another FEHB
plan to us, your former plan will pay for the hospital stay until:
· You are discharged, not merely moved to an alternative care center;
or
· The day your benefits from your former plan run out; or
· The 92 nd day after you become a member of this Plan, whichever
happens first.
These provisions apply only to the benefits of the hospitalized person.
Circumstances beyond our control Under certain extraordinary
circumstances, such as natural disasters, we may have to delay your services or
we may be unable to provide them.
In that case, we will make all reasonable
efforts to provide you with the necessary care.
Services requiring our prior approval Your primary care physician has
authority to refer you for most services.
For certain services, however,
your physician must obtain approval from us. Before giving approval, we consider
if the service is covered,
medically necessary, and follows generally
accepted medical practice.
We call this review and approval process prior
approval. Your physician must obtain prior approval for the following services,
such as:
· Home Healthcare · Treatment of mental health conditions
· Treatment of alcoholism · Treatment of substance abuse
· Physical therapy, Speech therapy, Occupational therapy ·
Prosthetics
· Durable medical equipment (rental or purchase) ·
All out-of-plan referrals
The provider who initially treats a member must submit a treatme nt plan to
HMO-CNY for continued treatment. If a treatment plan is not
submitted, or if
we do not approve the treatment plan, we will not pay for any health service
after the initial prior approved service. 11
11
Page 12 13
2001
HMO-CNY 12 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
· Copayments A copayment is a fixed amount of money you pay to
the provider when you receive services.
Example: When you see your primary care physician you pay a copayment of $10
per office visit.
· Deductible We do not have a deductible.
Your out-of-pocket maximum We do not have an out-of-pocket maximum.
12
12 Page 13 14
2001 HMO-CNY Section 5 13
Section 5. Benefits
--OVERVIEW (See page 8 for how our benefits changed this year and page
49 for a benefits summary.)
NOTE: This benefits section is
divided into subsections. Please read the important things you should keep in
mind at the beginning of each subsection. Also read the General Exclusions in
Section 6: they apply to the benefits in the
following subsections. To
obtain claims forms, claims filing advice, or more information about our
benefits, contact us at 315/ 448-6820 or 1/ 800-447-6269 or at our website at
www. bcbscny. org.
(a) Medical services and supplies provided by physicians and other health
care professionals………………….
13-20
· Diagnostic and treatment services · Lab, X-ray, and
other diagnostic tests
· Preventive care, adult · Preventive
care, children
· Maternity care · Family planning
·
Infertility services · Allergy care
· Treatment therapies
· Rehabilitative therapies
· Hearing services (testing, treatment, and supplies)
·
Vision services (testing, treatment, and supplies)
· Foot care
· Orthopedic and prosthetic devices
· Durable medical
equipment (DME) · Home health services
· Alternative
treatments · Educational classes and programs
(b) Surgical and anesthesia services provided by physicians and other health
care professionals ...................... 21-24
· Surgical procedures
· Reconstructive surgery · Oral and maxillofacial surgery ·
Organ/ tissue transplants
· Anesthesia
(c) Services provided by a
hospital or other facility, and ambulance services
.................................................. 25-27
· Inpatient hospital · Outpatient hospital or ambulatory
surgical
center
· Extended care benefits/ skilled nursing care
facility benefits
· Hospice care · Ambulance
(d) Emergency services/
accidents...................................................................................................................
28-29 · Medical emergency · Ambulance
(e) Mental health and
substance abuse
benefits...............................................................................................
30-31
(f) Prescription drug benefits
.........................................................................................................................
32-33
(g) Special features
..............................................................................................................................................
34 · Services for deaf and hearing impaired · Reciprocity benefit
· Travel benefit/ services overseas · Centers of Excellence
Summary of benefits
.............................................................................................................................................
48 13
13 Page 14
15
2001 HMO-CNY Section 5a 14
Section 5 (a)
Medical services and supplies provided by physicians and other health care
professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
· Please remember that all benefits are subject to the
definitions, limitations, and exclusions in this brochure and are payable only
when we determine they are medically necessary.
· Plan physicians must provide or arrange your care.
· We
have no calendar year deductible.
· Be sure to read Section 4,
Your costs for covered services for valuable information about how cost
sharing works. Also read Section 9 about coordinating benefits with other
coverage, including with Medicare.
I M
P O
R T
A N
T
Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
· In physician's office
$10 per office visit
Professional services of physicians
· In an urgent care center
· During a hospital stay
· In a skilled nursing facility
{plan specific}
· Initial examination of a newborn child
covered under a family enrollment
Nothing
· Office medical consultations
· Second surgical opinion
$10 per office visit
Lab, X-ray and other diagnostic tests
Laboratory tests, such as:
· Blood tests
· Urinalysis
· Non-routine pap
tests
· Pathology
· X-rays
· Non-routine
Mammograms
· Cat Scans/ MRI
· Ultrasound
·
Electrocardiogram and EEG
Nothing if you receive these services during your office visit;
otherwise, $10 per office visit 14
14 Page 15 16
2001 HMO-CNY
Section 5a 15
Preventive care, adult
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
$10 per office visit
·· Sigmoidoscopy, screening – every five years starting
at age 50 $10 per office visit
Prostate Specific Antigen (PSA test) –
one annually for men age 40 and older $10 per office visit
Routine pap test
Note: The office visit is covered if pap test is received on the same day;
see Diagnosis and Treatment, above.
Nothing
Routine mammogram –covered for women age 35 and older, as follows:
· From age 35 through 39, one during this five year period
· From age 40 through 64, one every calendar year
· At age
65 and older, one every two consecutive calendar years
Nothing
Not covered: Physical exams required for obtaining or continuing employment
or insurance, attending schools or camp, or travel. All charges.
Routine Immunizations, limited to:
· Tetanus-diphtheria (Td)
booster – once every 10 years, ages19 and over (except as provided for
under Childhood immunizations)
· Influenza/ Pneumococcal vaccines, annually, age 65 and over
$10 per office visit
Preventive care, children You pay
· Childhood immunizations
recommended by the American Academy of Pediatrics Nothing
· Examinations, such as:
·· Eye exams through age 17
to determine the need for vision correction.
·· Ear exams through age 17 to determine the need for hearing
correction
·· Examinations done on the day of immunizations (
through age 22)
· Well-child care charges for routine examinations,
immunizations and care (through age 22)
$10 per office visit 15
15 Page 16 17
2001 HMO-CNY
Section 5a 16
Maternity care You pay
Complete maternity
(obstetrical) care, such as:
· Prenatal care
· Delivery
· Postnatal care
Note: Here are some things to keep in mind:
· You do not need to precertify your normal delivery; see page xx for
other circumstances, such as extended stays for you or your baby.
· You may remain in the hospital up to 48 hours after a regular
delivery and 96 hours after a cesarean delivery. We will extend
your
inpatient stay if medically necessary.
· Routine nursery care of the
newborn child during the covered portion of the mother's maternity stay. We will
cover other care of
an infant who requires non-routine treatment only if we cover the infant
under a Self and Family enrollment.
· We pay hospitalization and surgeon services (delivery) the same as
for illness and injury. See Hospital benefits (Section 5c) and
Surgery
benefits (Section 5b).
Nothing
Not covered: Routine sonograms to determine fetal age, size or sex All
charges
Family planning
· Voluntary sterilization
· Surgically implanted contraceptives
· Injectable
contraceptive drugs
· Intrauterine devices (IUDs)
$10 per office visit
Not covered: reversal of voluntary surgical sterilization, genetic
counseling, All charges.
Infertility services You pay
Diagnosis and treatment of infertility, such as:
· Artificial
insemination:
·· intravaginal insemination (IVI)
·· intracervical insemination (ICI)
·· intrauterine insemination (IUI)
$10 for the initial diagnosis;
50% of the maximum amount payable per
treatment
Infertility services— Continued on next page 16
16 Page 17 18
2001 HMO-CNY Section 5a 17
Infertility services
(Continued) You pay
Not covered:
· Assisted
reproductive technology (ART) procedures, such as:
··
in vitro fertilization
·· embryo transfer and GIFT
· Services and supplies related to excluded ART procedures
· Cost of donor sperm
· Fertility drugs
All charges.
Allergy care
Testing and treatment $10 per office visit
· Allergy injection
· Allergy serum
Nothing
Not covered: provocative food testing and sublingual allergy
desensitization All charges.
Treatment therapies You pay
· Chemotherapy and radiation therapy
Note: High dose
chemotherapy in association with autologous bone marrow transplants are limited
to those transplants listed under
Organ/ Tissue Transplants on page xx.
· Respiratory and inhalation
therapy
· Dialysis – Hemodialysis and peritoneal dialysis
· Intravenous (IV)/ Infusion Therapy – Home IV and antibiotic
therapy
· Growth hormone therapy (GHT)
$10 per office visit
Not covered: All charges. 17
17 Page 18 19
2001 HMO-CNY
Section 5a 18
Rehabilitative therapies You pay
Physical therapy,
occupational therapy and speech therapy --
· 60 visits per condition
for the services of each of the following:
·· qualified
physical therapists;
·· speech therapists; and
·· occupational therapists.
Note: We only cover therapy to
restore bodily function or speech when there has been a total or partial loss of
bodily function or
functional speech due to illness or injury.
· Cardiac
rehabilitation following a heart transplant, bypass
surgery or a myocardial
infarction, is provided for up to 00 sessions
$10 per office visit
Not covered:
· long-term rehabilitative therapy
· exercise programs
All charges.
Hearing services (testing, treatment, and supplies)
· First
hearing aid and testing only when necessitated by accidental injury
· Hearing testing for children through age 17 (see Preventive care,
children)
$10 per office visit
Not covered: · all other hearing testing
·
hearing aids, testing and examinations for them
All charges. 18
18 Page 19 20
2001 HMO-CNY Section 5a 19
Vision services
(testing, treatment, and supplies) You pay
· One pair of
eyeglasses or contact lenses to correct an impairment directly caused by
accidental ocular injury or intraocular surgery
(such as for cataracts)
$10 per office visit
· Eye exam to determine the need for vision correction for children
through age 18 (see preventive care)
· Annual eye refractions (which
include the written lens prescription for eyeglasses) every 2 years for members
over age 18
$10 per office visit
Not covered:
· Eyeglasses or contact lenses and, after
age 17
· Eye exercises and orthoptics
·
Radial keratotomy and other refractive surgery
All charges.
Foot care
Routine foot care when you are under active treatment
for a metabolic or peripheral vascular disease, such as diabetes.
See orthopedic and prosthetic devices for information on podiatric shoe
inserts.
$10 per office visit
Not covered:
· Cutting, trimming or removal of corns,
calluses, or the free edge of toenails, and similar routine treatment of
conditions of the foot,
except as stated above
· Treatment of weak, strained or
flat feet or bunions or spurs; and of any instability, imbalance or subluxation
of the foot (unless the
treatment is by open cutting surgery)
All charges.
Orthopedic and prosthetic devices You pay
· Artificial
limbs and eyes; stump hose
· Externally worn breast prostheses and
surgical bras, including necessary replacements, following a mastectomy
· Internal prosthetic devices, such as artificial joints, pacemakers,
cochlear implants, and surgically implanted breast implant
following
mastectomy. Note: See 5( b) for coverage of the surgery to insert the device.
· Corrective orthopedic appliances for non-dental treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome.
Nothing 19
19 Page
20 21
2001 HMO-CNY Section 5a 20
Not covered:
· orthopedic and corrective shoes
· arch supports
· foot orthotics
· heel pads and heel cups
· lumbosacral
supports
· corsets, trusses, elastic stockings, support hose,
and other supportive devices
· prosthetic replacements provided less than 3 years after the last
one we covered
All charges.
Durable medical equipment (DME) You pay
Rental or purchase, at our
option, including repair and adjustment, of durable medical equipment prescribed
by your Plan physician, such as
oxygen and dialysis equipment. Under this benefit, we also cover:
· hospital beds;
· wheelchairs;
· crutches;
· canes
· walkers;
· blood glucose monitors;
and
· insulin pumps.
20% of covered charges
Not covered: · Motorized wheel chairs All charges.
Home health services
· Home health care ordered by a
Plan physician and provided by a registered nurse (R. N.), licensed practical
nurse (L. P. N.), licensed
vocational nurse (L. V. N.), or home health aide.
· Services include oxygen therapy, intravenous therapy and
medications.
Nothing
Home health services (Continued) You pay
Not
covered: · nursing care requested by, or for the convenience of,
the patient or
the patient's family; · nursing care primarily for hygiene,
feeding, exercising, moving the
patient, homemaking, companionship or giving
oral medication.
All charges. 20
20 Page 21 22
2001 HMO-CNY
Section 5a 21
Alternative treatments
Acupuncture – by a
doctor of medicine or osteopathy for: anesthesia, pain relief $10 per office
visit
Not covered:
· naturopathic services ·
hypnotherapy
· biofeedback
All charges.
Educational classes and programs
Coverage is limited to:
· Smoking Cessation – Up to $100 for one smoking cessation
program per member per lifetime, including all related expenses
such as
drugs.
· Weight management
· Childbirth classes
· Diabetes self-management
$10 per office visit 21
21 Page 22 23
2001 HMO-CNY
Section 5b 22
Section 5 (b). Surgical and anesthesia services provided by
physicians and other health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
· Please remember that all benefits are subject to the
definitions, limitations, and exclusions in this brochure and are payable only
when we determine they are medically necessary.
· Plan physicians must provide or arrange your care.
· We
have no calendar year deductible.
· Be sure to read Section 4,
Your costs for covered services for valuable information about how cost
sharing works. Also read Section 9 about coordinating benefits with other
coverage, including with
Medicare.
· The amounts listed below are for the charges billed by
a physician or other health care professional for your surgical care. Look in
Section 5 (c). for charges associated with the facility charge (i. e.
hospital, surgical center, etc.)
· YOU MUST GET PRIOR APPROVAL FOR
SOME SURGICAL PROCEDURES. Please refer to the precertification information shown
in Section 3 to be sure which services require
precertification and identify which surgeries require precertification.
I M
P O
R T
A N
T
Benefit Description You pay After the calendar year deductible…
Surgical procedures
· Treatment of fractures, including
casting · Normal pre-and post-operative care by the surgeon
· Correction of amblyopia and strabismus · Endoscopy procedure
· Biopsy procedure · Removal of tumors and cysts
·
Correction of congenital anomalies (see reconstructive surgery) ·
Surgical treatment of morbid obesity --a condition in which an
individual
weighs 100 pounds or 100% over his or her normal weight according to current
underwriting standards; eligible
members must be age 18 or over
·
Insertion of internal prostethic devices. See 5( a) – Orthopedic braces
and prosthetic devices for device coverage information.
$10 per office visit
Surgical procedures You pay
· Voluntary sterilization
· Norplant (a surgically implanted contraceptive) and intrauterine
devices (IUDs) Note: Devices are covered under 5( a). · Treatment of
burns
Note: Generally, we pay for internal prostheses (devices) according to where
the procedure is done. For example, we pay Hospital benefits for
a pacemaker
and Surgery benefits for insertion of the pacemaker.
$10 per office visit
Not covered: · Reversal of voluntary sterilization
· Routine treatment of conditions of the foot; see Foot care.
All charges. 22
22 Page
23 24
2001 HMO-CNY Section 5b 23
Reconstructive surgery
· Surgery to correct a functional
defect
· Surgery to correct a condition caused by injury or illness
if:
·· the condition produced a major effect on the member's
appearance and
·· the condition can reasonably be expected to be corrected by
such surgery
· Surgery to correct a condition that existed at or from
birth and is a significant deviation from the common form or norm. Examples of
congenital anomalies are: protruding ear deformities; cleft lip; cleft
palate; birth marks; webbed fingers; and webbed toes.
$10 per office visit
Reconstructive surgery You pay
· All stages of breast
reconstruction surgery following a mastectomy, such as:
·· surgery to produce a symmetrical appearance on the other
breast;
·· treatment of any physical complications, such as
lymphedemas;
·· breast prostheses and surgical bras and
replacements (see Prosthetic devices)
Note: If you need a mastectomy, you may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to 48
hours
after the procedure.
See above.
Not covered: · Cosmetic surgery – any surgical
procedure (or any portion of a
procedure) performed primarily to improve
physical appearance through change in bodily form, except repair of accidental
injury
· Surgeries related to sex transformation
All charges
Oral and maxillofacial surgery
Oral surgical procedures, limited
to: · Reduction of fractures of the jaws or facial bones;
· Surgical correction of cleft lip, cleft palate or severe functional
malocclusion;
· Removal of stones from salivary ducts; ·
Excision of leukoplakia or malignancies;
· Excision of cysts and
incision of abscesses when done as independent procedures; and
·
Other surgical procedures that do not involve the teeth or their supporting
structures.
$10 per office visit
Not covered: · Oral implants and transplants
· Procedures that involve the teeth or their supporting
structures (such as the periodontal membrane, gingiva, and alveolar bone)
All charges. 23
23 Page
24 25
2001 HMO-CNY Section 5b 24
Organ/ tissue transplants You pay
Limited to:
· Cornea
· Heart
· Heart/ lung
· Kidney
·
Kidney/ Pancreas
· Liver
· Lung: Single –Double
· Pancreas
· Allogeneic (donor) bone marrow transplants
· Autologous bone marrow transplants (autologous stem cell and
peripheral stem cell support) for the following conditions: acute
lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's lymphoma;
advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer;
multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal,
retroperitoneal and ovarian germ
cell tumors
National Transplant Program
(NTP) – HMO-CNY utilizes a "Centers of Excellence" Program.
Limited Benefits -Treatment for breast cancer, multiple myeloma, and
epithelial ovarian cancer may be provided in an NCI-or NIH-approved
clinical
trial at a Plan-designated center of excellence and if approved by the Plan's
medical director in accordance with the Plan's protocols.
Note: We cover related medical and hospital expenses of the donor when we
cover the recipient.
Nothing
Not covered: · Donor screening tests and donor search
expenses, except those
performed for the actual donor ·
Implants of artificial organs
· Transplants not listed as covered
All charges
Anesthesia You pay
Professional services provided in –
· Hospital (inpatient) Nothing
Professional services provided in – · Hospital outpatient
department
· Skilled nursing facility · Ambulatory surgical
center
· Office
Nothing 24
24 Page
25 26
2001 HMO-CNY Section 5c 25
Section 5 (c). Services provided by a hospital or other facility, and
ambulance services
I M
P O
R T
A N
T
Here are some important things to remember about these benefits:
· Please remember that all benefits are subject to the
definitions, limitations, and exclusions in this brochure and are payable only
when we determine they are
medically necessary.
· Plan physicians must provide or arrange
your care and you must be hospitalized in a Plan facility.
· Unlike Sections (a) and (b), in this section the calendar year
deductible applies to only a few benefits. In that case, we added "(
calendar year deductible
applies)". {Be sure to notice this is a
different bullet}
· Be sure to read Section 4, Your costs
for covered services for valuable information about how cost sharing works.
Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
· The amounts listed below are for the charges billed by the facility
(i. e., hospital or surgical center) or ambulance service for your surgery or
care. Any costs
associated with the professional charge (i. e., physicians, etc.) are covered
in Section 5( a) or (b).
I M
P O
R T
A N
T
Benefit Description You pay
Inpatient hospital
Room and board,
such as · ward, semiprivate, or intensive care accommodations;
· general nursing care; and · meals and special diets.
NOTE: If you want a private room when it is not medically necessary, you pay
the additional charge above the semiprivate room rate.
Nothing
Inpatient hospital continued on next page. 25
25 Page 26 27
2001 HMO-CNY Section 5c 26
Inpatient hospital
(Continued) You pay
Other hospital services and supplies,
such as: · Operating, recovery, maternity, and other treatment rooms
· Prescribed drugs and medicines · Diagnostic laboratory tests
and X-rays
· Administration of blood and blood products ·
Blood or blood plasma, if not donated or replaced
· Dressings,
splints, casts, and sterile tray services · Medical supplies and
equipment, including oxygen
· Anesthetics, including nurse
anesthetist services · Take-home items
· Medical supplies,
appliances, medical equipment, and any covered items billed by a hospital for
use at home
.
Nothing
Not covered: · Custodial care
·
Non-covered facilities, such as nursing homes, extended care facilities,
schools
· Personal comfort items, such as telephone,
television, barber services, guest meals and beds
· Private
nursing care
All charges.
Outpatient hospital or ambulatory surgical center
·
Operating, recovery, and other treatment rooms · Prescribed drugs and
medicines
· Diagnostic laboratory tests, X-rays, and pathology services ·
Administration of blood, blood plasma, and other biologicals
· Blood
and blood plasma, if not donated or replaced · Pre-surgical testing
· Dressings, casts, and sterile tray services · Medical
supplies, including oxygen
· Anesthetics and anesthesia service
NOTE: – We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment. We
do not
cover the dental procedures.
Nothing
Not covered: blood and blood derivatives not replaced by the member All
charges 26
26 Page
27 28
2001 HMO-CNY Section 5c 27
Extended care benefits/ skilled nursing care facility benefits You pay
Extended care benefit:
· Up to 240 days per admission when full-time skilled nursing care is
necessary;
· Must be determined to be medically necessary by Plan doctor, and
approved by the Plan.
· The benefit renews after 90 days (only if the
member has received no hospital care, home health care, or skilled nursing care
within
that time.
· All necessary services are covered,
including:
·· Bed, board and general nursing care
··
Drugs, biologicals, supplies, and equipment ordinarily provided or arranged by
the skilled nursing facility when prescribed by a
Plan doctor.
Nothing
Not covered: custodial care All charges
Hospice care
· A maximum of 210 hospice days
· Supportive and
palliative care for a terminally ill member is covered in the home or hospice
facility
· Services include inpatient and outpatient care, and family
counseling
· 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.
Nothing
Not covered: Independent nursing, homemaker services All charges
Ambulance
· Local professional ambulance service when
medically appropriate Nothing 27
27 Page 28 29
2001 HMO-CNY
Section 5d 28
Section 5 (d). Emergency services/ accidents
I M
P
O
R T
A N
T
Here are some important things to keep in mind about these benefits:
· Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure.
· We have no calendar year deductible
· Be sure to read
Section 4, Your costs for covered services for valuable information about
how cost sharing works. Also read Section 9 about coordinating benefits with
other
coverage, including with Medicare.
I M
P O
R T
A N
T
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or
an injury that you believe endangers your life or could result in serious injury
or disability, and requires immediate medical or
surgical care. Some problems are emergencies because, if not treated
promptly, they might become more serious; examples include deep cuts and broken
bones. Others are emergencies because they are
potentially life-threatening,
such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability
to breathe. There are many other acute conditions that we may determine are
medical emergencies – what
they all have in common is the need for
quick action.
What to do in case of emergency:
Emergencies within our service area:
· In an emergency situation, call your primary care doctor
· In an extreme emergency, if you are unable to contact your doctor,
contact the local emergency system (e. g., the 911-telephone system) or go to
the nearest hospital emergency room or medical
facility. Be sure to advise
medical personnel that you are a Plan member. · You or someone on your
behalf must notify your primary care physician within 2 business days, or as
soon as is reasonably possible. · You pay $50 copayment per
emergency; if the emergency results in admission to a hospital, the copay
is
waived.
Emergencies outside our service area: · Benefits are
available for any medically necessary health service that is immediately
required because
of injury or unforeseen illness. If an emergency situation occurs, call the
local emergency system (e. g., the 911-telephone system) or go immediately to
the nearest hospital emergency room or medical
facility · You or
someone on your behalf must notify your primary care physician within 2 business
days, or as
soon as is reasonably possible. · You pay $50 copayment
per emergency; if the emergency results in admission to a hospital, the copay
is waived. · Claims for care in non-life threatening emergency
medical situations which are not authorized by your
primary care physician
will be denied.
To be covered by this Plan, any follow-up care must be
approved by the Plan. Contact your primary care physician if the emergency room
or medical facility recommends additional care outside of the visit. 28
28 Page 29 30
2001 HMO-CNY Section 5d 29
Benefit Description
You pay
Emergency within our service area
· Emergency care at a doctor's office
· Emergency care at
an urgent care center
Emergency care as an outpatient or inpatient at a
hospital, including doctors' services
$50 per office visit
Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area
· Emergency care at a doctor's office · Emergency care at an
urgent care center
· Emergency care as an outpatient or inpatient at a hospital,
including doctors' services
$50 per office visit
Not covered:
· Elective care or non-emergency care
· Emergency care provided outside the service area if the need for
care could have been foreseen before leaving the service area
All charges.
Ambulance
Professional ambulance service when medically
appropriate.
See 5( c) for non-emergency service.
Nothing
Not covered: air ambulance All charges. 29
29 Page 30 31
2001 HMO-CNY 30 Section 5e
Section 5 (e).
Mental health and substance abuse benefits
I M
P O
R T
A N
T
Parity
Beginning in 2001, all FEHB plans' mental health and
substance abuse benefits will achieve "parity" with other benefits.
This means that we will provide mental health and substance abuse
benefits differently than in the past.
When you get our approval for
services and follow a treatment plan we approve, cost-sharing and limitations
for Plan mental health and substance abuse benefits will be no greater than for
similar benefits for other illnesses and conditions.
Here are some
important things to keep in mind about these benefits:
· All
benefits are subject to the definitions, limitations, and exclusions in this
brochure.
· Be sure to read Section 4, Your costs for covered services
for valuable information about how cost sharing works. Also read Section 9
about coordinating benefits with other
coverage, including with Medicare.
· YOU MUST GET
PREAUTHORIZATION OF THESE SERVICES. See the instructions after the benefits
description below.
I M
P O
R T
A N
T
Benefit Description You pay After the calendar year
deductible…
Mental health and substance abuse benefits
All diagnostic and
treatment services recommended by a Plan provider and contained in a treatment
plan that we approve. The treatment plan
may include services, drugs, and supplies described elsewhere in this
brochure.
Note: Plan benefits are payable only when we determine the care is clinically
appropriate to treat your condition and only when you receive
the care as
part of a treatment plan that we approve.
Your cost sharing responsibilities are no
greater than for other illness
or conditions.
· Professional services, including individual or group therapy by
providers such as psychiatrists, psychologists, or clinical social workers
· Medication management
$10 per visit
Mental health and substance abuse benefits -Continued on next page 30
30 Page 31 32
2001 HMO-CNY 31 Section 5e
Mental health and
substance abuse benefits (Continued) You pay
·
Diagnostic tests Nothing if you receive these
services during your office
visit; otherwise, $10 per visit
· Services provided by a hospital or other facility
·
Services in approved alternative care settings such as partial
hospitalization, half-way house, residential treatment, full-day
hospitalization, facility based intensive outpatient treatment
Nothing
Not covered: Services we have not approved.
Note: OPM will base its
review of disputes about treatment plans on the treatment plan's clinical
appropriateness. OPM will generally not
order us to pay or provide one clinically appropriate treatment plan in
favor of another.
All charges.
Preauthorization To be eligible to receive these benefits you must
follow your treatment plan and all the following authorization processes:
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 these conditions apply to you, we will allow you reasonable time to
transfer your care to a Plan mental health or substance abuse professional
provider. During the transitional period, you may continue to see your
treating provider and will not pay any more out-of-pocket than you did in
the year 2000 for services. This transitional period will begin with our
notice to you of the change in coverage and will end 90 days after you
receive our notice. If we write to you before October 1, 2000, the 90-day
period ends before January 1 and this transitional benefit does not apply.
Limitation We may limit your benefits if you do not follow your
treatment plan. 31
31 Page
32 33
2001 HMO-CNY 32 Section 5f
Section 5 (f). Prescription drug benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
· We cover prescribed drugs and medications, as described in the
chart beginning on the next page.
· All benefits are subject to the definitions, limitations and
exclusions in this brochure and are payable only when we determine they are
medically necessary.
· Be sure to read Section 4, Your costs for
covered services for valuable information about how cost sharing works. Also
read Section 9 about coordinating benefits with
other coverage, including
with Medicare.
I M
P O
R T
A N
T
There are important features you
should be aware of. These include:
· Who can write your
prescription. A licensed physician must write the prescription – or
– A plan physician or licensed dentist must write the prescription.
· Where you can obtain them. You may fill the prescription at a
Plan pharmacy, a non-network pharmacy, or by mail. We pay a higher level of
benefits when you use a network pharmacy.
· We use a formulary.
A formulary is a list of the most commonly prescribed brand name drugs. If a
provider prescribes a name brand drug that is not on our formulary (preferred
drug list), you will pay
the $35 non-preferred drug copay.
·
These are the dispensing limitations. You will be charged 1 copay for
each 30 day supply, retail or mail order. If there is no generic equivalent, you
will pay the brand (preferred or non-preferred)
copay.
· When you have to file a claim. If you do not use
Plan pharmacies, you will need to pay up front, and submit a claim.
Prescription drug benefits begin on the next page. 32
32 Page 33 34
2001 HMO-CNY 33 Section 5f
Benefit Description
You pay After the calendar year deductible…
Covered medications and
supplies
We cover the following medications and supplies prescribed by a
Plan physician and obtained from a Plan pharmacy or through our mail order
program:
· Drugs and medicines that by Federal law of the United States require
a physician's prescription for their purchase, except as
excluded below.
· Oral and injectable drugs
· Implanted, time release contraceptive medications, such as Norplant
· Smoking cessation drugs and medication including nicotine patches
· Enteral formulas for home use when prescribed in writing by a Plan
doctor for poor nourishment or a disorder which would cause
chronic physical
disability, mental retardation, or death · Medically necessary modified
solid food products with low or
modified protein for treatment of inherited
diseases of amino acids and organic acid metabolism
· Drugs for
sexual dysfunction (see Prior authorization below) · Contraceptive drugs
and devices
Insulin, diabetic supplies and disposable needles and syringes needed to
inject covered prescribed medication are available through the Plan's
medical and surgical benefits and are subject to the doctor's office visit
copayment
$ 5 copay per prescription unit or refill for generic drugs per each 30
day supply
$20 copay per prescription unit or refill for brand name
drugs on our
preferred drug list per each 30 day supply
$35 copay per prescription unit or refill for brand name drugs not on
our
preferred drug list per each 30 day supply
Note: If there is no generic equivalent available, you will still
have to
pay the brand name copay.
Covered medications and supplies (continued) You pay
Here are some things to keep in mind about our prescription drug
program:
· A generic equivalent will be dispensed if it is available, unless
your physician specifically requires a name brand. If you receive a
name
brand drug when a Federally-approved generic drug is available, and your
physician has not specified Dispense as Written
for the name brand drug, you
have to pay the difference in cost between the name brand drug and the generic.
· We have an open formulary. If your physician believes a name brand
product is necessary or there is no generic available, your
physician may
prescribe a name brand drug from a formulary list. This list of name brand drugs
is a preferred list of drugs that we
selected to meet patient needs at a
lower cost 33
33 Page
34 35
2001 HMO-CNY 34 Section 5g
Not covered:
· Drugs and supplies for cosmetic purposes
· Vitamins, nutrients and food supplements even if a physician
prescribes or administers them
· Nonprescription medicines
All Charges
Section 5 (g). Special Features
Feature Description
Flexible
benefits option Under the flexible benefits option, we determine the most
effective way to provide services.
· We may identify medically
appropriate alternatives to traditional care and coordinate other benefits as a
less costly alternative
benefit.
· Alternative benefits are subject to our ongoing review.
· By approving an alternative benefit, we cannot guarantee you will
get it in the future.
· The decision to offer an alternative benefit is solely ours, and we
may withdraw it at any time and resume regular contract benefits.
·
Our decision to offer or withdraw alternative benefits is not subject to OPM
review under the disputed claims process.
Services for deaf and hearing impaired You may communicate with us
using a TDD by calling 315/ 448-6764.
Reciprocity benefit When
traveling in the U. S., BluesConnect (formerly HMO-USA) is available to assist
members to seek medical care. Members call 800/ 4-HMO-USA to locate the nearest
HMO provider or facility.
Centers of excellence for transplants/ heart
surgery/ etc
HMO-CNY utilizes Centers of Excellence and has specific criteria &
quality measures that must be met which ensures the best care for
you.
Travel benefit/ services overseas BlueCard Worldwide is a service that
is available to members traveling outside the U. S. Members call 800/ 810-BLUE
(2583) for available providers. 34
34 Page 35 36
2001 HMO-CNY
Section 6 35
Section 6. General exclusions --things we don't cover
The exclusions in this section apply to all benefits. Although we may
list a specific service as a benefit, we will not cover it unless your Plan
doctor determines it is medically necessary to prevent, diagnose, or
treat
your illness, disease, injury, or condition.
We do not cover the
following:
· Care by non-Plan providers except for authorized
referrals or emergencies (see Emergency Benefits);
· Services, drugs, or supplies you receive while you are not enrolled
in this Plan;
· Services, drugs, or supplies that are not medically
necessary;
· Services, drugs, or supplies not required according to
accepted standards of medical, dental, or psychiatric practice;
· Experimental or investigational procedures, treatments, drugs or
devices;
· Services, drugs, or supplies related to abortions, except
when the life of the mother would be endangered if the fetus were carried to
term or when the pregnancy is the result of an act of rape or
incest;
· Services, drugs, or supplies related to sex
transformations; or
· Services, drugs, or supplies you receive from a
provider or facility barred from the FEHB Program. 35
35 Page 36 37
2001 HMO-CNY Section 7 36
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,
coinsurance, or deductible.
You will only need to file a claim when you receive emergency services from
non-plan providers. Sometimes these providers bill us directly. Check with the
provider. If you need to file the claim, here is the process:
Medical, Hospital and Drug In most cases, providers and facilities
file claims for you. Physicians Benefit must file on the form HCFA-1500,
Health Insurance Claim Form.
Facilities will file on the UB-92 form. For
claims questions and assistance, call us at 800/ 447-6269.
When you must file a claim --such as for out-of-area care --submit it on the
HCFA-1500 or a claim form that includes the information shown
below. Bills
and receipts should be itemized and show:
· Covered member's name and
ID number;
· Name and address 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: HMO-CNY
P. O. Box 4712, 344 S. Warren Street
Syracuse, NY 13221-4712
Deadline for filing your claim Send us all of the documents for your
claim as soon as possible. You must submit the claim by December 31 of the year
after the year you
received the service, unless timely filing was prevented
by administrative operations of Government or legal incapacity, provided the
claim was
submitted as soon as reasonably possible.
When we need more information Please reply promptly when we ask for
additional information. We may delay processing or deny your claim if you do not
respond. 36
36 Page
37 38
2001 HMO-CNY Section 8 37
Section 8. The disputed claims process
Follow this Federal
Employees Health Benefits Program disputed claims process if you disagree with
our decision on your claim or request for services, drugs, or supplies –
including a request for preauthorization:
Step Description
1 Ask us in writing to reconsider our initial
decision. You must: (a) Write to us within 6 months from the date of our
decision; and
(b) Send your request to us at: HMO-CNY, P. O. Box 4712, 344
S. Warren Street, Syracuse, NY 13221-4712; and
(c) Include a statement about why you believe our initial decision was wrong,
based on specific benefit provisions in this brochure; and
(d) Include
copies of documents that support your claim, such as physicians' letters,
operative reports, bills, medical records, and explanation of benefits (EOB)
forms.
2 We have 30 days from the date we receive your request to: (a) Pay
the claim (or, if applicable, arrange for the health care provider to give you
the care); or (b) Write to you and maintain our denial --go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider,
we will send you a copy of our request— go to step 3.
3 You or your provider must send the information so that we receive it
within 60 days of our request. We will then decide within 30 more days. If we do
not receive the information within 60 days, we will decide within 30 days of the
date the
information was due. We will base our decision on the information
we already have.
We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
· 90 days after the date of our letter
upholding our initial decision; or
· 120 days after you first wrote
to us --if we did not answer that request in some way within 30 days; or
· 120 days after we asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance
Programs, Contracts Division xx, P. O. Box 436, Washington, D. C. 20044-0436. 37
37 Page 38 39
2001 HMO-CNY Section 8 38
Send OPM the
following information:
· A statement about why you believe our
decision was wrong, based on specific benefit provisions in this brochure;
· Copies of documents that support your claim, such as physicians'
letters, operative reports, bills, medical records, and explanation of benefits
(EOB) forms;
· Copies of all letters you sent to us about the claim;
· Copies of all letters we sent to you about the claim; and
· Your daytime phone number and the best time to call.
Note: If you want OPM to review different claims, you must clearly identify
which documents apply to which claim.
Note: You are the only person who has a right to file a disputed claim with
OPM. Parties acting as your representative, such as medical providers, must
provide a copy of your specific written consent with the
review request.
Note: The above deadlines may be extended if you show that you were unable
to meet the deadline because of reasons beyond your control.
5 OPM will review your disputed claim request and will use the
information it collects from you and us to decide whether our decision is
correct. OPM will send you a final decision within 60 days. There are no other
administrative appeals.
6 If you do not agree with OPM's decision, your only recourse is to
sue. If you decide to sue, you must file the suit against OPM in Federal court
by December 31 of the third year after the year in which you received the
disputed services or supplies. This is the only deadline that may not be
extended.
OPM may disclose the information it collects during the review
process to support their disputed claim decision. This information will become
part of the court record.
You may not sue until you have completed the
disputed claims process. Further, Federal law governs your lawsuit, benefits,
and payment of benefits. The Federal court will base its review on the record
that was
before OPM when OPM decided to uphold or overturn our decision. You
may recover only the amount of benefits in dispute.
NOTE: If you have a serious or life threatening condition (one that
may cause permanent loss of bodily functions or death if not treated as soon as
possible), and
(a) We haven't responded yet to your initial request for care
or preauthorization/ prior approval, then call us at (315) 448-6820 or
1-800-447-6269 and we will expedite our review; or
(b) We denied your
initial request for care or preauthorization/ prior approval, then:
·· If we expedite our review and maintain our denial, we will
inform OPM so that they can give your claim expedited treatment too, or
·· You can call OPM's Health Benefits Contracts Division III at
202/ 606-0755 between 8 a. m. and 5 p. m. eastern time. 38
38 Page 39 40
2001 HMO-CNY 39 Section 9
Section
9. Coordinating benefits with other coverage
When you have other health
coverage You must tell us if you are covered or a family member is covered
under another group health plan or have automobile insurance that pays health
care 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 either what is left of our
allowance, up to
our regular benefit, whichever is less. 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.
When you are enrolled in this Plan and Original Medicare, you still need to
follow the rules in this brochure for us to cover your care. We will not
waive any of our copayments, coinsurance, and deductibles.
(Primary
payer chart begins on next page.) 39
39 Page 40 41
2001 HMO-CNY
40 Section 9
The following chart illustrates whether Original
Medicare or this Plan should be the primary payer for you according to your
employment status and other factors determined by Medicare. It is critical that
you tell us if you or a covered
family member has Medicare coverage so we
can administer these requirements correctly.
Primary Payer Chart
Then
the primary payer is… A. When either you --or your covered spouse --are
age 65 or over and …
Original Medicare This Plan
1) Areanactiveemployee
withtheFederalgovernment (includingwhenyouor a family member are eligible for
Medicare solely because of a disability), ü
2) Are an annuitant, ü
3) Are a reemployed annuitant with the
Federal government when…
a) The position is excluded from
FEHB…………………………………
……….. ü
b) Or, the position is not excluded from
FEHB………………………….
Ask your employing office which of these applies to you.
……………………..
……… ü
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), ü
5) Are enrolled in Part B
only, regardless of your employment status, ü (for Part B
services)
ü (for other
services)
6) Are a former Federal employee
receiving Workers'Compensation and the Office of Workers'Compensation Programs
has determined
that you are unable to return to duty,
ü (except for claims
related to Workers' Compensation.)
B. When you --or a covered family member --have Medicare based on end
stage renal disease (ESRD) and…
1) Are within the first 30 months of eligibility to receive Part A benefits
solely because of ESRD, ü
2) Have completed the 30-month ESRD
coordination period and are still eligible for Medicare due to ESRD, ü
3) Become eligible for Medicare due to ESRD after Medicare became primary
for you under another provision, ü
C. When you or a covered family
member have FEHB and…
1) Are eligible for Medicare based on
disability, and
a) Are an
annuitant…………………………………………………
………. ü
b) Are an active
employee…………………………………………
………………………..
……. ü
Please note, on occasion you may have to file a Medicare claim form (e. g.,
if your Plan physician does not participate in Medicare) 40
40 Page 41 42
2001 HMO-CNY 41 Section 9
· Medicare managed care plan If you are eligible for
Medicare, you may choose to enroll in and get your Medicare benefits from a
Medicare managed care plan. These are health
care choices (like HMOs) in
some areas of the country. In most Medicare managed care plans, you can only go
to doctors, specialists, or
hospitals that are a part of the plan. Medicare
managed care plans cover all Medicare Part A and B benefits. Some cover extras,
like prescription
drugs. To learn more about enrolling in a Medicare managed
care plan, contact Medicare at 1-800-MEDICARE (1-800-633-4227) or at
www.
medicare. gov. If you enroll in a Medicare managed care plan, the following
options are available to you:
This Plan and our Medicare managed care plan: You may enroll in our
Medicare managed care plan and also remain enrolled in our FEHB
plan. In
this case, we do/ do not waive any of our copayments, coinsurance, or
deductibles for your FEHB coverage.
HMO-CNY does not offer a Medicare managed care plan option.
This Plan
and another Plan's Medicare managed care plan: You may enroll in another
plan's Medicare managed care plan and also
remain enrolled in our FEHB plan.
We will still provide benefits when your Medicare managed care plan is primary,
but we will not waive any
of our copayments.
Suspended FEHB coverage
and a Medicare managed care plan: If you are an annuitant or former spouse,
you can suspend your FEHB
coverage to enroll in a Medicare managed care
plan, eliminating your FEHB premium. (OPM does not contribute to your Medicare
managed
care plan premium.) For information on suspending your FEHB
enrollment, contact your retirement office. If you later want to re-enroll
in the FEHB Program, generally you may do so only at the next open season
unless you involuntarily lose coverage or move out of the
Medicare managed
care plan.
· Enrollment in Note: If you choose not to enroll
in Medicare Part B, you can still be Medicare Part B covered under the
FEHB Program. We cannot require you to enroll in
Medicare.
TRICARE TRICARE is the health care program for eligible dependents of
military persons and retirees of the military. TRICARE includes the CHAMPUS
program. If both TRICARE and this Plan cover you, we pay first. See your
TRICARE Health Benefits Advisor if you have questions about
TRICARE
coverage.
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. 41
41 Page 42 43
2001 HMO-CNY 42 Section 9
Medicaid When you have this Plan and Medicaid, we pay first. 42
42 Page 43 44
2001 HMO-CNY 43 Section 9
When
other Government agencies We do not cover services and supplies when a
local, State, are responsible for your care or Federal Government agency
directly or indirectly pays for them.
When others are responsible
When you receive money to compensate you for for injuries medical or
hospital care for injuries or illness caused by another person,
you must
reimburse us for any expenses we paid. However, we will cover the cost of
treatment that exceeds the amount you received in the
settlement.
If you
do not seek damages you must agree to let us try. This is called subrogation. If
you need more information, contact us for our
subrogation procedures. 43
43 Page 44 45
2001 HMO-CNY 44 Section 10
Section 10. Definitions of terms we use in this brochure
Calendar
year January 1 through December 31 of the same year. For new enrollees, the
calendar year begins on the effective date of their enrollment and ends on
December 31 of the same year.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services. See page 13.
Coinsurance Coinsurance is the percentage of our allowance that you
must pay for your care. See page 13.
Covered services Care we provide
benefits for, as described in this brochure.
Custodial care Board,
room, and other personal assistance services generally provided on a long-term
basis, which do not include medical care.
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 13.
Experimental or investigational services We consider any service
(treatment, procedure, facility, equipment, drug,
device, or supply) to be
experimental or investigational if:
· It is considered to be so by
the BlueCross and BlueShield Association or any appropriate technical assessment
body; or
· It does not have the appropriate governmental or
regulatory approval; or
· Reliable evidence (defined below) shows
that it is not generally recognized as standard medical treatment; or
· Experts agree that it should be the subject of further study or
ongoing clinical trials.
Reliable evidence is: the opinions and practices of medical groups throughout
the country, or published reports and articles in authoritative
medical
journals, or written procedures used by medical providers.
Group health coverage A set package of benefits chosen for all
employees of a group, union, association or other organization.
Medical necessity The treatment, tests, services and supplies must be
consistent with the diagnosis and treatment of an illness or injury; generally
accepted by the
medical profession as approved standard treatment for the
medical condition; and considered therapeutic or rehabilitative.
Plan allowance Plan allowance is the amount we use to determine our
payment and your coinsurance for covered services. Fee-for-service plans
determine their
allowances in different ways. We determine our allowance as
follows:
· Professional providers (e. g., physicians and other
licensed health care professionals): fee schedule developed for each procedure
or
service. · Participating hospitals : negotiated rate for inpatient
and outpatient
services. 44
44 Page 45 46
2001 HMO-CNY
45 Section 10
· Participating institutional/ facility
based providers (e. g., ambulance, home health agencies, free standing ambulance
surgery centers,
hospices): negotiated rate or fee schedule developed for
each procedure or service.
Us/ We Us and we refer to HMO-CNY
You You refers to the
enrollee and each covered family member. 45
45
Page 46 47
2001
HMO-CNY 46 Section 11
Section 11. FEHB facts
No
pre-existing condition We will not refuse to cover the treatment of a
condition that you had limitation before you enrolled in this Plan solely
because you had the condition
before you enrolled.
Where you can get
information See www. opm. gov/ insure. Also, your employing or retirement
office about enrolling in the can answer your questions, and give you
a Guide to Federal Employees
FEHB Program Health Benefits Plans, brochures for other plans,
and other materials you need to make an informed decision about:
· When you may change your enrollment;
· How you can cover
your family members;
· What happens when you transfer to another
Federal agency, go on leave without pay, enter military service, or retire;
· When your enrollment ends; and
· When the next open
season for enrollment begins.
We don't determine who is eligible for
coverage and, in most cases, cannot change your enrollment status without
information from your
employing or retirement office.
Types of coverage available Self Only coverage is for you alone. Self
and Family coverage is for for you and your family you, your spouse, and
your unmarried dependent children under age 22,
including any foster
children or stepchildren your employing or retirement office authorizes coverage
for. Under certain circumstances,
you may also continue coverage for a
disabled child 22 years of age or older who is incapable of self-support.
If you have a Self Only enrollment, you may change to a Self and Family
enrollment if you marry, give birth, or add a child to your family. You
may
change your enrollment 31 days before to 60 days after that event. The Self and
Family enrollment begins on the first day of the pay period
in which the
child is born or becomes an eligible family member. When you change to Self and
Family because you marry, the change is effective
on the first day of the
pay period that begins after your employing office receives your enrollment
form.
Your employing or retirement office will not notify you when a family
member is no longer eligible to receive health benefits, nor will we.
Please
tell us immediately when you add or remove family members from your coverage for
any reason, including divorce, or when your child
under age 22 marries or
turns 22.
If you or one of your family members is enrolled in one FEHB plan,
that person may not be enrolled in or covered as a family member by another
FEHB plan. 46
46 Page
47 48
2001 HMO-CNY 47 Section
11
When benefits and The benefits in this brochure are effective
on January 1. If you are new premiums start to this Plan, your coverage
and premiums begin on the first day of your first pay
period that starts on
or after January 1. Annuitants' premiums begin on January 1.
Your medical
and claims We will keep your medical and claims information confidential.
Only records are confidential the following will have access to it:
· OPM, this Plan, and subcontractors when they administer this
contract;
· This Plan, and appropriate third parties, such as other
insurance plans and the Office of Workers' Compensation Programs (OWCP), when
coordinating benefit payments and subrogating claims;
· Law
enforcement officials when investigating and/ or prosecuting alleged civil or
criminal actions;
· OPM and the General Accounting Office when conducting audits;
· Individuals involved in bona fide medical research or education
that does not disclose your identity; or
· OPM, when reviewing a disputed claim or defending litigation about a
claim.
When you retire When you retire, you can usually stay in the
FEHB Program. Generally, you must have been enrolled in the FEHB Program for the
last five years of your
Federal service. If you do not meet this
requirement, you may be eligible for other forms of coverage, such as temporary
continuation of coverage (TCC).
When you lose benefits
· When FEHB coverage ends You will
receive an additional 31 days of coverage, for no additional premium, when:
·· Your enrollment ends, unless you cancel your enrollment, or
·· You are a family member no longer eligible for coverage.
You may be eligible for spouse equity coverage or Temporary Continuation of
Coverage.
· Spouse equity If you are divorced from a Federal employee or
annuitant, you may not coverage continue to get benefits under your
former spouse's enrollment. But, you
may be eligible for your own FEHB
coverage under the spouse equity law. If you are recently divorced or are
anticipating a divorce, contact
your ex-spouse's employing or retirement
office to get RI 70-5, the Guide to Federal Employees Health Benefits Plans for
Temporary
Continuation of Coverage and Former Spouse Enrollees, or other
information about your coverage choices.
· TCC If you leave Federal service, or if you lose coverage
because you no longer qualify as a family member, you may be eligible for
Temporary
Continuation of Coverage (TCC). For example, you can receive TCC
if you are not able to continue your FEHB enrollment after you retire.
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. 47
47 Page 48 49
2001 HMO-CNY
48 Section 11
· Converting to You may convert to a
non-FEHB individual policy if: individual coverage ·· Your
coverage under TCC or the spouse equity law ends. If you
canceled your
coverage or did not pay your premium, you cannot convert;
·· You decided not to receive coverage under TCC or the spouse
equity law; or
·· You are not eligible for coverage under TCC
or the spouse equity law.
If you leave Federal service, your employing
office will notify you of your right to convert. You must apply in writing to us
within 31 days
after you receive this notice. However, if you are a family member who is
losing coverage, the employing or retirement office will not notify
you. You must apply in writing to us within 31 days after you are no longer
eligible for coverage.
Your benefits and rates will differ from those under the FEHB Program;
however, you will not have to answer questions about your health, and
we
will not impose a waiting period or limit your coverage due to pre-existing
conditions.
Getting a Certificate of If you leave the FEHB Program, we will give
you a Certificate of Group Group Health Plan Coverage 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 315/ 448-6820
or 1/ 800-447-6269 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. 48
48 Page 49 50
2001 HMO-CNY
49 Index
Index
Do not rely on this page; it is for
your convenience and does not explain your benefit coverage.
Accidental injury 28 Allergy tests 17
Alternative treatment 21
Ambulance 27
Anesthesia 24 Autologous bone marrow
transplant 24
Biopsies 22
Blood and blood plasma 26 Breast cancer screening 15
Changes for 2001 8 Chemotherapy 17
Childbirth 16 Cholesterol tests 15
Claims 36 Colorectal cancer screening 15
Congenital anomalies 23
Contraceptive devices and drugs 16
Coordination of benefits 39 Crutches 20
Definitions 44 Diagnostic services 14
Disputed claims review x Donor
expenses (transplants) 37
Dressings 26 Durable medical equipment
(DME)
20 Educational classes and programs 20
Effective date of enrollment
45 Emergency 28
Family planning 16 Fecal occult blood test 15
General Exclusions 35 Hearing services 18
Home health
services 20
Hospice care 27 Home nursing care 20
Hospital 25 Immunizations 15
Infertility 16 Inhospital physician care 14
Inpatient Hospital Benefits
14 Insulin 32
Laboratory and pathological services 14
Machine
diagnostic tests 14 Magnetic Resonance Imagings
(MRIs) 14 Mail Order
Prescription Drugs 32
Mammograms 15 Maternity Benefits 16
Medicaid 41
Medicare 41
Mental Conditions/ Substance Abuse Benefits 30
Newborn care
46 Nurse
Licensed Practical Nurse 20 Nurse Practitioner 20
Registered
Nurse 20 Nursery charges 16
Obstetrical care 16 Occupational therapy
18
Office visits 14 Oral and maxillofacial surgery 23
Orthopedic devices
19 Outpatient facility care 26
Oxygen 20 Pap test 15
Physical
examination 15
Physical therapy 18 Physician 14
Pre-admission testing 26 Preventive
care, adult 15
Preventive care, children 15 Prescription drugs 32
Prior
approval 22 Prostate cancer screening 15
Prosthetic devices 19 Radiation
therapy 17
Rehabilitation therapies 18 Room and board 25
Second
surgical opinion 14 Skilled nursing facility care 26
Smoking cessation
21 Speech therapy 18
Sterilization procedures 16 Substance abuse 30
Surgery 22 · Anesthesia 24
· Oral 23 · Outpatient
22
· Reconstructive 23 Temporary continuation of
coverage
45 Transplants 24
Treatment therapies 17 Vision services 19
Well child care 15 Wheelchairs 20
Workers' compensation 45
X-rays 14 49
49 Page
50 51
2001 HMO-CNY 50
NOTES: 50
50 Page
51 52
2001 HMO-CNY 51 Summary
___________________________________________________________
Summary of Benefits for HMO-CNY -2001
___________________________________________________________
Do not rely on this chart alone. All benefits are provided in full
unless otherwise indicated subject to the limitations and exclusions set forth
in the brochure. This chart merely summarizes certain important expenses covered
by the
Plan. If you wish to enroll or change your enrollment in this Plan,
be sure to indicate the correct enrollment code on your enrollment form (codes
appear on the cover of this brochure). ALL SERVICES COVERED UNDER THIS
PLAN, WITH THE EXCEPTION OF EMERGENCY CARE, ARE COVERED ONLY WHEN PROVIDED
OR ARRANGED BY PLAN DOCTORS.
_______________________________________________________________________________
Benefits Plan pays/ provides Page
_______________________________________________________________________________
Inpatient Care Hospital Comprehensive range of medical and surgical services
Without dollar or day limit. Includes in-hospital doctor Care, room and
board, general nursing care, private room and
private nursing care if
medically necessary, diagnostic test, drugs and medical supplies, use of
operating room, intensive
care and complete maternity care. You pay
nothing………………………………………..
…… 14
Extended All necessary services, up to 240 days per admission. Care
You pay
nothing……………………………………………..
26
______________________________________________________________________________________________
Outpatient Care Comprehensive range of services such as diagnosis and
treatment of illness or injury, including specialist's care, including
well-baby care, periodic check-ups and routine
immunizations; laboratory
tests and x-rays, complete maternity care. You pay a $10 copay per office
visit; nothing per
housecall by a doctor. For maternity care, you pay a $10
copay for the initial office visit only. Well-baby care is included in
well
child services for children through age 19; you pay
nothing………………………………………………………..
26
Home Health All necessary visits by nurses and skilled health aides.
Care You pay
nothing………………………………………………
20
Emergency Care Reasonable charges for services and supplies
required because of a medical emergency. You pay a $50 copay to the
hospital
for each emergency room visit and any charges for services that are
not covered by this
Plan…………………………..
………. 28
_______________________________________________________________________________________________
Prescription Drugs Prescription drugs prescribed by a Plan or referral
doctor and
Obtained at a Plan pharmacy will be dispensed for up to a 30-day
supply. You pay $5 copay for generic drugs. Brand name
drugs on our
preferred drug list will require a $20 copay per 30-day supply. Brand name drugs
not on our preferred list will
require a $35 copayment per 30-day supply.
This applies to both retail and mail order pharmacies.
………………………………………………………………..
32
_______________________________________________________________________________________________
Out-of-pocket maximum Your out-of-pocker expenses for benefits
covered under this Plan are limited to the stated copayments which are required
for
a few
benefits………………………………………………….
12 51
51 Page 52
2001 HMO-CNY 52
2001 Rate Information for
HMO-CNY
Non-Postal rates apply to most non-Postal enrollees. If you are in a
special enrollment category, refer to the FEHB Guide for that category or
contact the agency that maintains your health benefits
enrollment.
Postal rates apply to career Postal Service employees. Most employees
should refer to the FEHB Guide for United States Postal Service Employees, RI
70-2. Different postal rates apply and
special FEHB guides are published for
Postal Service Nurses and Tool & Die employees (see RI 70-2B); and for
Postal Service Inspectors and Office of Inspector General (OIG) employees (see
RI 70-2IN).
Postal rates do not apply to non-career postal employees,
postal retirees, or associate members of any postal employee organization. Refer
to the applicable FEHB Guide.
Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type
of Enrollment Code Gov't Share Your Share Gov't Share Your Share USPS Share Your
Share
Self Only EB1 $83.12 $27.71 $180.10 $60.03 $98.36 $12.47
Self and
Family EB2 $195.82 $98.01 $424.28 $212.35 $231.17 $62.66 52