Enrollment code for this plan: DA1 Self Only
DA2 Self and Family
BlueCHiP, Coordinated Health Partners, Inc.
http:// www. bcbsri. com
BlueC P SM Coordinated Health P tners, Inc. ar
2001
RI 73-489
For changes
in
benefits see page 7. 1
1 Page
2 3
2
Table of Contents
Page
Introduction
........................................................................................................................................................................
4
Plain Language
....................................................................................................................................................................
4
Section 1. Facts about this HMO plan
................................................................................................................................
5
We also have Point-of Service (POS)
benefits........................................................................................
5
How we pay providers
............................................................................................................................
5
Patients' Bill of Rights
............................................................................................................................
5
Service Area
............................................................................................................................................
6
Section 2. How we change for 2001
..................................................................................................................................
7
Program-wide changes
............................................................................................................................
7
Changes to this Plan
................................................................................................................................
7
Section 3. How you get care
..............................................................................................................................................
8
Identification cards
..................................................................................................................................
8
Where you get covered care
....................................................................................................................
8
Plan providers
......................................................................................................................................
8
Plan facilities
........................................................................................................................................
8
What you must do to get covered
care....................................................................................................
8
Primary care
..........................................................................................................................................
8
Specialty care
........................................................................................................................................
8
Hospital care
........................................................................................................................................
9
Circumstances beyond our
control........................................................................................................
10
Services requiring our prior
approval....................................................................................................
10
Section 4. Your costs for covered
services........................................................................................................................
11
Copayments
..............................................................................................................................................
11
Deductible
..........................................................................................................................................
11
Coinsurance
........................................................................................................................................
11
Your out-of-pocket maximum
......................................................................................................................
11
Section 5. Benefits
......................................................................................................................................................
12
Overview................................................................................................................................................
12
(a) Medical services and supplies provided by physicians and other
health care professionals
................................................................................................................
13
(b) Surgical and anesthesia services provided by physicians and other
health care
professionals....................................................................................................................................
19
(c) Services provided by a hospital or other facility, and ambulance
services .................................... 22
(d) Emergency services/
accidents
........................................................................................................
24
(e) Mental health and substance abuse benefits
..................................................................................
26
(f) Prescription drug benefits
..............................................................................................................
28
(g) Special features; Reciprocity benefit and high risk
pregnancies.................................................... 30
(h)
Dental benefits
................................................................................................................................
31
(i) Point-of-Service product
................................................................................................................
32
(j) Non-FEHB benefits available to Plan members
............................................................................ 34
2001 BlueCHiP, Coordinated Health Partners Table of Contents 2 2001 BlueCHiP, Coordinated Health Partners Table of Contents 3 This brochure describes the benefits of BlueCHiP, Coordinated Health Partners
under our contract (CS 2328) with the If you are enrolled in this Plan, you are entitled to the benefits described
in this brochure. If you are enrolled for Self OPM negotiates benefits and rates with each plan annually. Benefit changes
are effective January 1, 2001, and are sum-marized Plain Language The plain language team reorganized the brochure and the way we describe our
benefits. When you compare this Plan If you have comments or suggestions about how to improve this brochure, let
us know. Visit OPM's "Rate Us" feed-back 2001 BlueCHiP, Coordinated Health Partners Introduction/ Plain Language
4 HMOs emphasize preventive care such as routine office visits, physical exams,
well-baby care, and immunizations, in When you receive services from Plan providers, you will not have to submit
claim forms or pay bills. You only pay the You should join an HMO because you prefer the plan's benefits, not because
a particular provider is available. We also have Point-of-Service (POS) benefits: How we pay providers BlueCHiP, Coordinated Health Partners has a POS product which offers members
the flexibility of obtaining services Patients' Bill of Rights If you want more information about us, call 401-274-3500 or toll-free
1-800-564-0888, or write to 15 LaSalle Square, Ordinarily, you must get your care from providers who contract with us. If
you receive care outside of our service area, If you or a covered family member move outside of our service area, you can
enroll in another plan. If your dependents Speak up if you have questions or concerns. We clarified the language to show that anyone who needs a mastectomy may
Your share of BlueCHiP, Coordinated Health Partners' non-postal premium
will 7 2001 BlueCHiP, Coordinated Health Partners Section 2 Program-wide Changes to this If you do not receive your ID card within 30 days after the effective date of
your You get care from "Plan providers" and "Plan facilities." You will only pay
copay-ments Plan providers are physicians and other health care professionals in our
service area We list Plan providers in the provider directory, which we update
periodically. The Plan facilities are hospitals and other facilities in our service area that
we contract It depends on the type of care you need. First, you and each family member
must Your primary care physician can be an internist, pediatrician or family
practitioner. If you want to change primary care physicians or if your primary care
physician Your primary care physician will refer you to a specialist for needed care.
However, Where you get Plan providers What you must do Identification cards If you are seeing a specialist when you enroll in our Plan, talk to your
primary If you are seeing a specialist and your specialist leaves the Plan, call
your primary If you have a chronic or disabling condition and lose access to your
specialist terminate our contract with your specialist for other than cause; or
reduce our service area and you enroll in another FEHB Plan, If you are in the second or third trimester of pregnancy and you lose access
to your Your Plan primary care physician or specialist will make necessary hospital
arrange-ments If you are in the hospital when your enrollment in our Plan begins, call our
If you changed from another FEHB plan to us, your former plan will pay for
the Hospital care 9 2001 BlueCHiP, Coordinated Health Partners Section 3 9 Your primary care physician has authority to refer you for most services. For
certain We call this the authorization process. Your physician must obtain
authorization for Services requiring Plan authorization under the Plan's Standard HMO benefits
con-tinue 2001 BlueCHiP, Coordinated Health Partners Section 3 Circumstances beyond our control Example: When you see your primary care physician you pay a copayment of $10
We do not have a deductible. Be sure to keep accurate records of your copayments since you are responsible
for Copayments Diagnostic and treatment services (b) Surgical and anesthesia services provided by physicians and other health
care professionals .............................. 19-21 (c) Services provided by a hospital or other facility, and ambulance services
............................................................ 22-23 (d) Emergency services/ accidents
................................................................................................................................
24-25 (e) Mental health and substance abuse
benefits............................................................................................................
26-27 (h) Dental benefits
..............................................................................................................................................................
31 12 Hearing services (testing, treatment, and supplies) 2001 BlueCHiP, Coordinated Health Partners Section 5 12 I I Section 5 (a). Medical services and supplies provided by physicians and
other health care professionals Benefit Description You pay Professional services of physicians Professional services of physicians Professional services of physicians Lab, X-ray and other diagnostic tests Diagnostic and treatment services --Continued on next page 13 2001 BlueCHiP, Coordinated Health Partners Section 5 (a) 13 Sigmoidoscopy, screening every five years starting at age 50 Prostate Specific Antigen (PSA test) one annually for men age 40 and older
Nothing Routine mammogram covered for women age 35 and older, as follows: Nothing
Not covered: All charges Routine immunizations, limited to: Nothing Preventive care, children Examinations, such as: $10 per visit Not covered: All Charges Note: Here are some things to keep in mind: Not covered: Routine sonograms to determine fetal age, size or sex All
charges Injectible contraceptive drugs 20% Infertility services Note: We cover injectable fertility drugs under medical benefits and oral
fertility Allergy care Allergy serum Nothing Rehabilitative therapies Physical therapy, occupational therapy and speech therapy for services by $10
per visit on an You must show significant improvement within 60 days to receive
authorization Note: We only cover therapy to restore bodily function or speech when there
Cardiac rehabilitation following a heart transplant, bypass surgery or a
Nothing Hearing services (testing, treatment, and supplies) Hearing exams when referred by the primary care doctor $10 per visit
Vision services (testing, treatment, and supplies) Eye exam to determine the need for vision correction for children through
$10 per visit Not covered: All charges Foot care Not covered: All charges. Orthopedic and prosthetic devices Durable medical equipment (DME) Not covered: Home health services Home health care ordered by a Plan physician and provided by a registered
nurse Nothing Not covered: All charges Alternative treatments Chiropractic Services 6 self-referred visits per calendar year $10 per
visit Educational classes and programs Diabetes self-management $10 per visit 18 2001 BlueCHiP, Coordinated Health Partners Section 5( a) 18 I I Section 5 (b). Surgical and anesthesia services provided by physicians and
other health care professionals Benefit Description You pay Note: Generally, we pay for internal prostheses (devices) according to where
Not covered: All charges Note: If you need a mastectomy, you may choose to have the procedure
Not covered: All charges Oral and maxillofacial surgery Not covered: All charges Limited Benefits -Treatment for breast cancer, multiple myeloma, and
Note: We cover the donor's related medical and hospital expenses that are
strictly Not covered: All charges Anesthesia Professional services provided in: Nothing I Section 5 (c). Services provided by a hospital or other facility, and
ambulance services Benefit Description You pay Note: If you want a private room when it is not medically necessary, you
Other hospital services and supplies, such as: Nothing Not covered: All charges Note: We cover hospital services and supplies related to dental procedures
Not covered: All charges Extended care benefits/ skilled nursing care facility benefits
Hospice care Not covered: All charges Ambulance What to do in case of emergency: emergency system (e. g., the 911 telephone system) or go to the nearest
hospital emergency room. Be sure to tell the If you need to be hospitalized in a non-Plan facility, the Plan must be
notified within 48 hours or on the first working Benefits are available for care from non-Plan providers in a medical
emergency only if delay in reaching a Plan provider To be covered by this plan, any follow-up care recommended by non-Plan
providers must be approved by Plan Emergencies outside our service area: If you need to be hospitalized, the Plan must be notified within 48 hours or
on the first working day following your To be covered by this Plan, any follow-up care recommended by non-Plan
providers must be approved by Plan Here are some important things to keep in mind about these benefits:
I Section 5 (d). Emergency services/ accidents Not covered: Emergency outside our service area Not covered: All charges. Ambulance Note: See 5( c) for non-emergency service. 25 Note: Plan benefits are payable only when we determine the care is clinically
Professional services, including individual or group therapy by providers
$10 per visit Diagnostic tests Nothing Not covered: All charges Note: OPM will base its review of disputes about treatment plans on the
Parity When you get our approval for services and follow a treatment plan we
approve, cost-sharing and limitations Here are some important things to keep in mind about these benefits:
I Section 5 (e). Mental health and substance abuse benefits 2001 BlueCHiP, Coordinated Health Partners Section 5 (e) 26 Treatment for mental health conditions and substance abuse may be obtained
directly If a mental health or substance abuse professional provider is treating you
under our plan If your mental health or substance abuse professional provider with whom
you are cur-rently If this condition applies to you, we will allow you reasonable time to
transfer your care to We may limit your benefits if you do not follow your treatment plan. Preauthorization Limitation 27 I M 28 Section 5 (f). Prescription drug benefits There are important features you should be aware of. These include:
We use a formulary. BlueCHiP, Coordinated Health Partners uses a
drug formulary, which is a listing of quali-ty, These are the dispensing limitations. Prescription drugs prescribed
by a Plan or referral doctor will be dis-pensed When you have to file a claim. You will be required to submit a
claim for prescriptions purchased from a non-Plan Prescription drug benefits begin on the next page 2001 BlueCHiP, Coordinated Health Partners Section 5 (f) 28 $15 per prescription unit or $30 per prescription unit or Prescriptions filled at non-par-ticipating Benefit Description You pay Limited Benefit: Drugs to treat sexual dysfunction are subject to
dosage Note: If there is no generic Here are some things to keep in mind about our prescription drug program: See
Above Not covered: All Charges Reciprocity benefit BlueCHiP, Coordinated Health Partners offers the
HMO USA Away From Home Urgent Care program. When you or a cov-ered High risk pregnancies If you are pregnant, you will be part of our
Little Steps prenatal program. Little Steps is designed to work with you and
your 2001 BlueCHiP, Coordinated Health Partners Section 5 (g) 30 I 31 2001 BlueCHiP, Coordinated Health Partners Section 5 (h) Section 5 (h). Dental benefits Accidental injury benefit You Pay Dental benefits What is covered You are able to self-refer to a non-participating provider either inside or
outside of our service area. You must call Plan Authorization Deductible Coinsurance When you self-refer to non-Plan participating providers, the Plan pays 80% of
its fee allowance after the deductible is Maximum Benefit Prescription Drugs What is not covered How to obtain benefits This Plan offers Medicare recipients the opportunity to enroll in the Plan
through If you are Medicare eligible and are interested in enrolling in a Medicare
HMO Medicare prepaid plan We do not cover the following: In most cases, providers and facilities file claims for you. Physicians must
file on Covered member's name and ID number; Submit your claims to: 15 LaSalle Square Send us all of the documents for your claim as soon as possible. You must
submit Please reply promptly when we ask for additional information. We may delay
pro-cessing Medical, Hospital and Deadline for filing your When we need more Step Description 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 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 We will write to you with our decision. Write to OPM at: Office of Personnel Management, Office of Insurance
Programs, Contracts Division 3, P. O. Send OPM the following information: Note: If you want OPM to review different claims, you must clearly identify
which documents apply to which Note: The above deadlines may be extended if you show that you were unable to
meet the deadline because of 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
admin-istrative 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
You may not sue until you have completed the disputed claims process.
Further, Federal law governs your law-suit, NOTE: If you have a serious or life threatening condition (one that
may cause permanent loss of bodily functions or (a) We haven't responded yet to your initial request for care or
preauthorization/ prior approval, then call us at (b) We denied your initial request for care or preauthorization/ prior
approval, then: When you have double coverage, one plan normally pays its benefits in full as
the When we are the primary payer, we will pay the benefits described in this
brochure. Medicare is a Health Insurance Program for: Medicare has two parts: If you are eligible for Medicare, you may have choices in how you get your
health The Original Medicare Plan is available everywhere in the United States. It
is the When you are enrolled in this Plan and Original Medicare, you still need to
follow We will not waive any of our copayments, coinsurance, and deductibles.
When you have other What is Medicare? The Original Medicare Primary Payer Chart 1) Are an active employee with the Federal government (including 2) Are an annuitant, b) The position is not excluded from FEHB 4) Are a Federal judge who retired under title 28, U. S. C., or a Tax
5) Are enrolled in Part B only, regardless of your employment status,
6) Are a former Federal employee receiving Workers' Compensation B. When you or a covered family member have Medicare 1) Are within the first 30 months of eligibility to receive Part A
2) Have completed the 30-month ESRD coordination period and are 3) Become eligible for Medicare due to ESRD after Medicare became C. When you or a covered family member have FEHB and b) Are an active employee 40 2001 BlueCHiP, Coordinated Health Partners Section 9 40 This Plan and our Medicare managed care plan: You may enroll in our
This Plan and another Plan's Medicare managed care plan: You may
enroll in Suspended FEHB coverage and a Medicare managed care plan: If you are
an Note: If you choose not to enroll in Medicare Part B, you can still be
covered under TRICARE is the health care program for eligible dependents of military
persons and We do not cover services that: Once OWCP or similar agency pays its maximum benefits for your treatment, we
When you have this Plan and Medicaid, we pay first. Medicare managed Enrollment in TRICARE Workers' Medicaid 41 When you receive money to compensate you for medical or hospital care If you do not seek damages you must agree to let us try. This is called
When other Government When others are responsible A copayment is a fixed amount of money you pay when you receive covered
services A deductible is a fixed amount of covered expenses you must incur for certain
cov-ered Experimental or investigational services include any treatment, procedure,
facility, A Plan maintained by an employer to provide medical care, directly or
indirectly, to Medical necessity means the health care service provided to treat your
illness or 43 2001 BlueCHiP, Coordinated Health Partners Section 10 Calendar year Deductible Group health coverage Us and we refer to BlueCHiP, Coordinated Health Partners. Plan allowance See www. opm. gov/ insure. Also, your employing or retirement office can
answer When you may change your enrollment; When your enrollment ends; and Self Only coverage is for you alone. Self and Family coverage is for you and
your If you have a Self Only enrollment, you may change to a Self and Family
enroll-ment Your employing or retirement office will not notify you when a family member
is no If you or one of your family members is enrolled in one FEHB plan, that
person The benefits in this brochure are effective on January 1. If you are new to
this Plan, No pre-existing Where you can get Types of coverage When benefits and OPM, this Plan, and subcontractors when they administer this contract;
Law enforcement officials when investigating and/ or prosecuting alleged
civil or OPM and the General Accounting Office when conducting audits; OPM, when reviewing a disputed claim or defending litigation about a claim.
When you retire, you can usually stay in the FEHB Program. Generally, you
must You will receive an additional 31 days of coverage, for no additional
premium, when: If you are divorced from a Federal employee or annuitant, you may not
continue to If you leave Federal service, or if you lose coverage because you no longer
qualify You may not elect TCC if you are fired from your Federal job due to gross
misconduct. Your medical and When you retire Spouse equity TCC 46 You decided not to receive coverage under TCC or the spouse equity law;
or Your benefits and rates will differ from those under the FEHB Program;
however, If you leave the FEHB Program, we will give you a Certificate of Group Health
Plan If you have been enrolled with us for less than 12 months, but were
previously Stop health care fraud! Fraud increases the cost of health care for
everyone. If you Call the provider and ask for an explanation. There may be an error. Anyone who falsifies a claim to obtain FEHB Program benefits can be
prosecuted Converting to Getting a certificate Inspector General advisory Penalties for Fraud 47 Accidental injury .......................... 31 Family planning.............................. 15 Oxygen ............................................ 22 If you want to enroll or change your enrollment in this Plan, be sure to
put the correct enrollment code from the cover We only cover services provided or arranged by Plan physicians, except in
emergencies. Benefits You Pay Page Services provided by a hospital: Emergency benefits: $10 for an office visit; $20 for an 25 Mental health and substance abuse treatment Regular cost sharing 26
Dental Care
.......................................................................... No
benefit. 31 Special features: Reciprocity benefit; high risk pregnancy. 30
Some costs do not count toward
2 Page 3 4
3
Page
Section 6. General exclusions
--things we don't
cover................................................................................................
35
Section 8. The disputed claims process
........................................................................................................................
37
Section 9. Coordinating benefits with other coverage
..................................................................................................
39
When you have...
Other health coverage
........................................................................................................................
39
Original Medicare
..............................................................................................................................
39
Medicare managed care plan
..............................................................................................................
41
TRICARE/ Workers'Compensation/ Medicaid
..............................................................................................
41
Other Government agencies
........................................................................................................................
42
When others are responsible for
injuries......................................................................................................
42
Section 10. Definitions of terms we use in this brochure
..............................................................................................
43
Section 11. FEHB facts
..................................................................................................................................................
45
Coverage information
No pre-existing condition limitation
..................................................................................................
45
Where you get information about enrolling in the FEHB Program
.................................................. 45
Types of coverage
available for you and your family
........................................................................ 45
When benefits and premiums
start......................................................................................................
45
Your medical and claims records are confidential
..............................................................................
46
When you retire
..................................................................................................................................
46
When you lose benefits
................................................................................................................................
46
When FEHB coverage ends
................................................................................................................
46
Spouse equity coverage
......................................................................................................................
46
Temporary Continuation of Coverage (TCC)
....................................................................................
46
Converting to individual coverage
......................................................................................................
47
Getting a Certificate of Group Health Plan
Coverage........................................................................
47
Inspector General
Advisory................................................................................................................................................
47
Index
..................................................................................................................................................................................
48
Summary of benefits
..........................................................................................................................................................
49
Rates
....................................................................................................................................................................
Back cover
3 Page 4 5
4
Introduction
BlueCHiP, Coordinated
Health Partners, Inc.
15 LaSalle Square
Providence, RI 02903
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 exclu-sions
of this
brochure.
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.
on page 7. Rates are
shown at the end of this brochure.
The President and Vice President are making the
Government's communication more responsive, accessible, and under-standable
to the public by requiring agencies to use plain language. In response, a
team of health plan representatives
and OPM staff worked cooperatively to
make this brochure clearer. Except for necessary technical terms, we use com-mon
words. "You" means the enrollee or family member; "we" means BlueCHiP,
Coordinated Health Partners.
with other FEHB plans, you will find
that the brochures have the same format and similar information to make
compar-isons
easier.
area at www. opm. gov/ insure,
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 Page 5 6
2001 BlueCHiP, Coordinated Health Partners Section 1
5
Section 1. Facts about this HMO plan
This Plan is a health
maintenance organization (HMO). We require you to see specific physicians,
hospitals, and other
providers that contract with us. These Plan providers
coordinate your health care services.
addition to treatment for illness and
injury. Our providers follow generally accepted medical practice when
prescribing
any course of treatment.
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 cannot change plans because a
provider leaves our Plan. We cannot guarantee that any one physician, hos-pital,
or other provider will be available and/ or remain under contract with us.
Our HMO offers
Point-of-Service (POS) benefits. This means you can receive covered services
from a participating
provider without a required referral, or from a
non-participating provider. These out-of-network benefits have higher
out-of-pocket costs than our in-network benefits.
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 coinsur-ance.
BlueCHiP, Coordinated
Health Partners is affiliated with Blue Cross & Blue Shield of Rhode Island.
BlueCHiP,
Coordinated Health Partners provides care through over 900 primary
care doctors (internists, pediatricians and family
practitioners) and over
1,900 specialists, along with a full range of hospitals and other health care
providers across the
state. When specialist services are needed, your
primary care doctor will refer you to a BlueCHiP, Coordinated Health
Partners specialist. All participating primary care doctors practice out of
offices in the community. Each member selects
a primary care doctor who acts
as a personal doctor working with you to coordinate all of your health care
needs.
outside of the primary care doctor
system and receiving an allowance for services. For more information regarding
this
benefit, see page 32.
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.
Providence, RI 02903. You may
also contact us by fax at 401-459-5089 or visit our website at www. bcbsri. com.
5
5 Page 6 7
6 2001 BlueCHiP, Coordinated Health Partners Section
1
Service Area
To enroll with us, you must live or work in
our service area. This is where our providers practice. Our service area is:
the State of Rhode Island and the following cities and towns in the state of
Massachusetts: Acushnet, Attleboro,
Bellingham, Blackstone, Dartmouth,
Dighton, Fall River, Fairhaven, Foxborough, Franklin, Mansfield, Medway,
Mendon, Millville, New Bedford, North Attleboro, Norton, Plainville,
Raynham, Rehoboth, Seekonk, Somerset,
Swansea, Taunton, Uxbridge, Westport,
Wrentham.
we will pay only for emergency
care or Point-of-Service benefits. We will not pay for any other health care
services.
live out of the area (for
example, if your child goes to college in another state), you should consider
enrolling in a fee-for-
service plan or an HMO that has agreements with
affiliates in other areas. BlueCHiP, Coordinated Health Partners
offers the
HMO USA Away from Home Care Guest Membership Program. To enroll in this program,
please contact
Customer Service at 401-274-3500 or toll-free at
1-800-564-0888. If you or a family member move, you do not have to
wait
until the Open Season to change plans. Contact your employing or retirement
office. 6
6 Page 7
8
Section 2. How we change for 2001
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
net-work
mental health and substance abuse parity. This means that your
coverage
for mental health, substance abuse, medical, surgical, and hospital
services from
providers in our Plan network will be the same with regard to
deductibles, coin-surance,
copays, and day and visit limitations when you
follow a treatment plan
that we approve. Previously, we placed shorter day
or visit limitatons on mental
health and substance abuse services than we
did on services to treat physical ill-ness,
injury, or disease.
Many
health care organizations have turned their attention this past year to
improving health care quality and patient safety. OPM asked all FEHB plans
to join them in this effort. You can find specific information on our
patient
safety activities by calling Customer Service at 401-274-3500 or
toll-free at
1-800-564-0888, or checking our website at www. bcbsri. com.
You can find out
more about patient safety on the OPM website, www. opm.
gov/ insure. To
improve your health care, take these five steps:
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.
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.
increase by 28.4% for Self Only or 34.2% for Self and Family.
changes
plan 7
7 Page 8 9
8
Section 3.
How you get care
We will send you an identification (ID) card. 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.
enrollment, or if you need replacement cards, call us at 401-274-3500
or toll-free at
1-800-564-0888.
and/ or coinsurance, and you will not have to file claims. If
you use our
Point-of-Service program, you can also get care from non-Plan
providers, or from
participating providers without a required referral, but
it will cost you more. You
may have to file claims when you use the
Point-of-Service option or when you
receive emergency services from a
provider who doesn't contract with us.
that we contract with to provide covered services to our
members. We credential
Plan providers according to national standards.
list is also on our website.
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.
choose a primary care physician. This decision is important since your
primary care
physician provides or arranges for most of your health care.
You will select a prima-ry
care physician for you and each covered member of
your family when you enroll
by completing the primary care physician
selection card provided by the Plan. If
you want to change your primary care
physician at any time, you must contact
Customer Service at 401-274-3500 or
toll-free at 1-800-564-0888 prior to receiving
any services. The change will
not become effective until the first day of the follow-ing
month.
Your primary care physician will provide most of your health
care, or give you a
referral to see a specialist.
leaves the Plan, call us. We will help you select a new one.
you may see your OB-GYN, go for your annual eye exam and receive up
to six (6)
chiropractic visits per year without a referral.
covered care
Plan facilities
Primary care
Specialty care
2001 BlueCHiP, Coordinated Health Partners Section 3
8
8 Page 9 10
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 work
with your specialist to
develop a treatment plan that allows you to see your
specialist for a certain num-ber
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).
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.
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.
because we:
drop out of the Federal Employees Health Benefits (FEHB) Program and you
enroll in another FEHB Plan; or
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.
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.
and supervise your care. This includes admission to a skilled
nursing or other
type of facility.
Customer Service Department immediately at 401-274-3500 or toll-free at
1-800-564-0888. If you are new to the FEHB Program, we will arrange for you
to
receive care.
hospital stay until:
9 Page 10 11
10
you are discharged, not merely moved to an
alternative care center; or
the day your benefits from your former plan
run out; or
the 92nd day after you become a member of this Plan, whichever
happens first.
These provisions apply only to the benefits of the
hospitalized person.
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, 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.
the following services: hospital admissions, referrals to
specialists and follow-up
care. You may be responsible for payment of
services that are not Plan authorized.
to require authorization under the POS benefit. When utilizing
non-Plan
participating providers, you are responsible for assuring that Plan
authorization is
obtained in advance for such services.
Services requiring our prior approval
10
10 Page 11
12
11 2001 BlueCHiP, Coordinated Health Partners
Section 4
Section 4. Your costs for covered services
You must
share the cost of some services. You are responsible for:
A copayment is a
fixed amount of money you pay to the provider when you receive
services.
per office visit and when you go to the emergency room, you pay a copayment
of
$25 per visit.
We do not have coinsurance.
After your
copayments and deductibles total $2,294 per person or $5,874 per family
enrollment in any calendar year, you do not have to pay any more for covered
ser-vices.
Charges over the usual and customary allowance cannot be applied
to the out-of-
pocket maximum.
informing us when you reach the maximum.
Deductible
Coinsurance
Your out-of-pocket
maximum 11
11 Page
12 13
Section 5. Benefits --OVERVIEW
(See page 4 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. To obtain claims forms, claims filing advice, or
more information about our benefits,
contact us at 401-274-3500 or toll-free
at 1-800-564-0888 or at our website at www. bcbsri. com.
(a) Medical
services and supplies provided by physicians and other health care
professionals.................................. 13-18
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
Surgical
procedures Organ/ tissue transplants
Oral and maxillofacial surgery
Anesthesia
Reconstructive surgery
Inpatient hospital Extended care benefits/ skilled nursing care facility
benefits
Outpatient hospital or ambulatory surgical center Hospice care
Ambulance
Medical emergency
Ambulance
(f) Prescription drug benefits
........................................................................................................................................
28-29
(g) Special features
............................................................................................................................................................
30
Reciprocity benefit, high risk pregnancies
(i) Point-of-Service
Product..........................................................................................................................................
32-33
(j) Non-FEHB benefits available to Plan members
..........................................................................................................
34
Summary of benefits
..........................................................................................................................................................
49
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
12 Page 13 14
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 for services received by Plan participating providers. Please see
Section 5( i) regarding your Point-of-Service benefits.
Be sure to
read Section 4, "Your costs for covered services" for valuable information about
how cost shar-ing
works. Also read Section 9 about coordinating benefits
with other coverage, including with Medicare.
M
P
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M
P
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A
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T
Diagnostic and treatment services
Professional services of physicians $10 per visit
In physician's
office
At home
Initial examination of a newborn
child covered under a family enrollment
Office medical consultations
Second surgical opinion $10 per visit
In an urgent care center $20 per
visit
During a hospital stay
In a
skilled nursing facility Nothing
Tests, such as: Nothing
Blood tests
Urinalysis
Non-routine Pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG
13 Page 14 15
14 2001 BlueCHiP, Coordinated Health Partners
Section 5( a)
Preventive care, adult You pay
Routine
screenings, such as: Nothing
Blood lead level one annually
Total
Blood Cholesterol once every three years, ages 19 through 64
Colorectal
Cancer Screening, including
Fecal occult blood test
Routine Pap test Nothing
Note: The office visit is covered if
Pap test is received on the same day;
see Diagnosis and Treatment on
previous page.
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
Physical exams and/ or immunizations
required for obtaining or continuing
employment or insurance, attending
schools or camp, or travel
Weight Reduction Programs, including laboratory
tests related to programs
designed for the purposes of weight reduction
Tetanus-diphtheria (Td)
booster once every 10 years, ages 19 and over
(except as provided for
under Childhood immunizations)
Influenza/ Pneumococcal vaccines, annually,
age 65 and over
Childhood immunizations recommended by
the American Academy
of Pediatrics Nothing
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)
Physical exams and/ or immunizations
required for obtaining or continuing
employment or insurance, attending
schools or camp, or travel
Weight Reduction Programs, including laboratory
tests related to programs
designed for the purposes of weight reduction
Examinations, evaluations or services performed solely for educational or
developmental purposes 14
14 Page 15 16
15 2001
BlueCHiP, Coordinated Health Partners Section 5( a)
Maternity care
You pay
Complete maternity (obstetrical) care, such as: $10 for initial
visit, you pay
Prenatal care nothing thereafter
Delivery
Postnatal care
You do not need to
precertify your normal delivery; see page 6 for other
circumstances, such as
extended stays for you or your baby
You may remain in the hospital up to
48 hours after a regular delivery and 96
hours after a cesarean delivery. We
will extend your inpatient stay if medically
necessary
We cover
routine nursery care of the newborn child during the covered portion
of the
mother's hospital confinement for maternity will be covered under either
a
Self Only or Self and Family enrollment; in addition, coverage of injury or
sickness including necessary care and treatment of medically diagnosed
congenital defects and birth abnormalities will be covered for the first 31
days
of a newborn's life; all care after the first 31 days will be covered
only if the
infant is covered 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)
Family planning
Voluntary sterilization Nothing
Surgically implanted contraceptives
Intrauterine devices (IUDs)
Not covered: All charges
Reversal of voluntary surgical sterilization, genetic counseling
Diagnosis and treatment of infertility, such
as: 20%
Artificial insemination:
intravaginal insemination (IVI)
intra-cervical insemination (ICI)
intrauterine insemination
(IUI)
Fertility drugs
Assisted reproductive technology (ART)
procedures, such as:
in vitro fertilization
embryo transfer and
GIFT
Services and supplies related to ART procedure
drugs under the prescription drug benefit. 15
15 Page 16 17
16 2001 BlueCHiP, Coordinated Health Partners
Section 5 (a)
Infertility Services (continued) You pay
Not
covered: All charges
Cost of donor sperm
Treatment for infertility
when the cause of the infertility was a
previous sterilization
Testing and treatment $10 per visit
Allergy
injection
Not covered: Provocative food testing and
sublingual allergy desensitization All charges
Treatment therapies
Chemotherapy and radiation therapy Nothing
Note: High dose
chemotherapy in association with autologous bone marrow
transplants are
limited to those transplants listed under Organ/ Tissue Transplants
on page
21.
Respiratory and inhalation therapy
Dialysis Hemodialysis and
peritoneal dialysis
Intravenous (IV)/ Infusion Therapy Home IV and
antibiotic therapy
Growth hormone therapy (GHT)
Note: We will only
cover GHT when we preauthorize the treatment.
each of the following: outpatient basis
qualified
physical therapists; Nothing on an inpatient basis
speech therapists;
and
occupational therapists.
for additional treatment.
has been a total or partial loss of bodily function or functional speech due
to
illness or injury.
myocardial infarction, is provided for up to 32 sessions 16
16 Page 17 18
17 2001 BlueCHiP, Coordinated Health Partners
Section 5( a)
Rehabilitative therapies (continued) You pay
Not covered: All charges
long-term rehabilitative therapy
exercise programs
massage therapy
recreational therapy
Not covered:
hearing aids, testing and examinations All charges
One pair of
eyeglasses or contact lenses to correct an impairment directly Nothing
caused by intraocular surgery (such as for cataracts)
age 17 (see preventive care)
Annual eye refractions
Eyeglasses or contact lenses
Eye
exercises and orthoptics
Radial keratotomy and other refractive surgery
Routine foot care when you are under active treatment
for a metabolic or $10 per visit
peripheral vascular disease, such as
diabetes
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 other routine foot care
Artificial limbs and eyes;
stump hose $20 per item
Externally worn breast prostheses and surgical
bras, including necessary
replacements, following a mastectomy
Internal prosthetic devices, such as artificial joints, pacemakers, cochlear
implants, and surgically implanted breast implant following mastectomy.
Note: We pay internal prosthetic devices as hospital benefits; see Section
5( c) for payment information
See 5( b) for coverage of the surgery to
insert the device.
Corrective orthopedic appliances for non-dental
treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome 17
17 Page 18 19
Orthopedic and prosthetic devices
(continued) You pay
Not covered: All charges
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
Rental or purchase, at our option,
including repair and adjustment, of durable $20 per item
medical equipment
prescribed by your Plan physician, such as oxygen and
dialysis equipment.
Under this benefit, we also cover:
hospital beds
wheelchairs
(the type of wheelchair we allow depends on your medical condition)
crutches
walkers
blood glucose monitors
insulin pumps
Power Operated Vehicles All charges
(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
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
Not covered: All charges
Acupuncture
Naturopathic
services
Hypnotherapy
Biofeedback
Christian Science services
Asthma self-management Nothing
18 Page 19 20
19 2001 BlueCHiP, Coordinated Health Partners
Section 5 (b)
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 for
services received by Plan participating providers. Please see Section
5( i)
regarding your Point-of-Service benefits.
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 sur-gical
care. Look in Section 5( c) for charges associated with the facility (i. e.,
hospital, surgical center, etc.).
M
P
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T
A
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M
P
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A
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T
Surgical procedures
Treatment of
fractures, including casting $10 per office visit;
Normal pre-and
post-operative care by the surgeon nothing for surgery
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
Insertion of internal prosthetic devices. See 5( a) Orthopedic braces and
prosthetic devices for device coverage information.
Voluntary
sterilization
Norplant (a surgically implanted contraceptive) and
intrauterine devices
(IUDs)
Note: Devices are covered under 5( a).
Treatment of burns
Surgical treatment of morbid obesity
the procedure is done. For example, we pay Hospital benefits for a pacemaker
and Surgery benefits for insertion of the pacemaker.
Reversal of voluntary sterilization
Routine treatment of conditions of the foot; see Foot care 19
19 Page 20 21
20 2001 BlueCHiP, Coordinated Health Partners
Section 5( b)
Reconstructive surgery You pay
Surgery to
correct a functional defect Nothing
Surgery to correct a condition caused
by injury or illness if:
the condition produced a major effect on the
member's appearance, and
the condition can reasonably be expected to be
corrected by such surgery
Surgery to correct a condition that existed at
or from birth and is a significant
deviation from the common form or norm.
Examples of congenital anomalies
are: protruding ear deformities, cleft lip,
cleft palate, birth marks,
webbed fingers and webbed toes
All stages
of breast reconstruction surgery following a mastectomy, such as:
surgery to produce a symmetrical appearance on the other breast
treatment of any physical complications, such as lymphedemas
breast
prostheses and surgical bras and replacements (see Prosthetic devices)
performed on an inpatient basis and remain in the hospital up to 48 hours
after the procedure.
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
Oral surgical procedures, limited
to: $10 per office visit
Reduction of fractures of the jaws or facial
bones Nothing for surgery
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
Other
surgical procedures that do not involve the teeth or their supporting
structures;
Treatment of tumors or cysts requiring pathological
examination of the jaws,
cheeks, lips, tongue, roof and floor of mouth
Oral implants and transplants
Procedures that involve the teeth or their supporting structures (such as the
periodontal membrane, gingiva, and alveolar bone) 20
20 Page 21 22
21 2001 BlueCHiP, Coordinated Health Partners
Section 5( b)
Organ/ tissue transplants You pay
Limited to:
Nothing
Cornea
Heart
Heart/ lung
Kidney
Kidney/
Pancreas
Liver
Lung: Single Double
Pancreas
Allogeneic
(donor) bone marrow transplants
Autologous bone marrow transplants
(autologous stem cell and peripheral
stem cell support) for the following
conditions: acute lymphocytic 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
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.
related to the donation when we cover the recipient.
Donor screening tests and donor search
expenses, except those performed
for the actual donor
Implants of
artificial organs
Transplants not listed as covered
Professional services provided in: Nothing
Hospital (inpatient)
Hospital outpatient
department
Skilled nursing facility
Ambulatory surgical center
Office 21
21 Page
22 23
22 2001 BlueCHiP, Coordinated
Health Partners Section 5( c)
Here are some important things to
remember about these benefits:
Please remember that all benefits are
subject to the definitions, limitations, and exclusions in this brochure
and
are payable only when we determine they are medically necessary.
Plan
physicians must provide or arrange your care and you must be hospitalized in a
Plan facility.
Be sure to read Section 4, "Your costs for covered
services" for valuable information about how cost shar-ing
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.,
physi-cians,
etc.) are covered in Section 5( a) or (b).
M
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T
A
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I
M
P
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T
A
N
T
Inpatient hospital
Room and board,
such as Nothing
ward, semiprivate, or intensive care accommodations;
general nursing care; and
meals and special diets
pay the additional charge above the semiprivate room rate.
Operating,
recovery, maternity, and other treatment rooms
Prescribed drugs and
medicines
Diagnostic laboratory tests and X-rays
Administration of
blood and blood products
Blood or blood plasma, if not donated or replaced
Dressings, splints, casts, and sterile tray services
Medical
supplies and equipment, including oxygen
Anesthetics, including nurse
anesthetist services
Take-home items
Medical supplies, appliances,
medical equipment, and any covered items
billed by a hospital for use at
home (Note: calendar year deductible applies.)
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 22
22 Page 23 24
23 2001 BlueCHiP, Coordinated Health Partners
Section 5( c)
Outpatient hospital or ambulatory surgical center You
pay
Operating, recovery, and other treatment rooms Nothing
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and
pathology services
Administration of blood, blood plasma, and other
biologicals
Blood and blood plasma, if not donated or replaced
Pre-surgical testing
Dressings, casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia service
when necessitated by a non-dental physical impairment. We do not cover the
dental procedures.
Blood and blood derivatives not replaced by
the member
Extended care/ skilled nursing facility (SNF) benefit: Nothing
Bed, board and general nursing care
Drugs, biologicals, supplies, and
equipment ordinarily provided or arranged
by the skilled nursing facility
when prescribed by a Plan doctor
.
Not covered: All charges
Custodial care
Supportive and palliative care for a terminally ill
member is covered in the Nothing
home or hospice facility. Services include:
Inpatient care (21-day limit per calendar year)
outpatient care
family counseling
Hospice 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.
Independent nursing, homemaker services
Local professional ambulance service when medically
appropriate and Nothing
authorized by the Plan 23
23 Page 24 25
24 2001 BlueCHiP, Coordinated Health Partners
Section 5 (d)
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 med-ical
emergencies what
they all have in common is the need for quick action.
Emergencies within our service area:
Please call your primary care doctor. In extreme emergencies, if you are
unable to contact your doctor, contact the local
emergency room personnel that
you are a Plan member so they can notify the Plan. You or a family member should
notify the Plan within 48 hours unless it is not reasonably possible to do
so. It is your responsibility to ensure that the
Plan has been timely
notified.
day following your
admission, unless it was not reasonably possible to notify the Plan within that
time. If you are hos-pitalized
in non-Plan facilities and Plan doctors
believe care can be better provided in a Plan hospital, you will be trans-ferred
when medically feasible with any ambulance charges covered in full.
would result in death,
disability or significant jeopardy to your condition (except as shown on page
25)
providers except as covered under POS
benefits.
Benefits are available for
any medically necessary health service that is immediately required because of
injury or
unforeseen illness.
admission, unless it was not
reasonably possible to notify the Plan within that time. If a Plan doctor
believes care can
be better provided in a Plan hospital, you will be
transferred when medically feasible with any ambulance charges cov-ered
in
full.
providers except as covered under POS
benefits.
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure.
We have no calendar year
deductible for services received by Plan participating providers. Please see
Section 5( i) regarding your Point-of-Service benefits.
Be sure to
read Section 4, "Your costs for covered services" for valuable information about
how cost shar-ing
works. Also read Section 9 about coordinating benefits
with other coverage, including with Medicare.
M
P
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T
A
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T
I
M
P
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T
A
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24 Page 25 26
25 2001
BlueCHiP, Coordinated Health Partners Section 5 (d)
Benefit
Description You pay
Emergency within our service area
Emergency
care at a doctor's office $10 per visit
Emergency care at an urgent care
center $20 per visit
Emergency care as an outpatient or inpatient at a
hospital, including doctor's $25 per hospital emergency
services room visit.
If emergency
results in an admission to a
hospital, the copay is waived.
Elective care or non-emergency care All charges.
Emergency care at a doctor's
office $10 per visit
Emergency care at an urgent care center $20 per visit
Emergency care as an outpatient or inpatient at a hospital, including
doctor's $25 per hospital emergency
services room visit. If emergency
results in an admission to a
hospital, the copay is waived.
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care could
have been foreseen before leaving the service area
Medical and
hospital costs resulting from a normal full-term delivery of a
baby outside
the service area
Professional ambulance service when medically
appropriate Nothing
Air ambulance
25
Page 26 27
26
Benefit Description You pay
Mental health and substance abuse
benefits
Diagnostic and treatment services recommended by a Plan
provider and Your cost sharing responsi-contained
in a treatment plan that
we approve. The treatment plan may include bilities are no greater than
services, drugs, and supplies described elsewhere in this brochure. for
other illness or conditions
appropriate to treat your condition and only when you receive the care as
part
of a treatment plan that we approve.
such as psychiatrists, psychologists, or clinical social
workers
Medication management
Services provided by a hospital or other
facility Nothing
Services in approved alternative care settings such as
partial hospitalization,
half-way house, residential treatment, full-day
hospitalization, facility based
intensive outpatient treatment
Services we have not approved.
treatment plan's clinical appropriateness. OPM will generally not order us
to
pay or provide one clinically appropriate treatment plan in favor of
another.
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.
for Plan mental health and substance
abuse benefits will be no greater than for similar benefits for other ill-nesses
and conditions.
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 shar-ing
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.
M
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T
A
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T
I
M
P
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T
A
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26 Page 27 28
27 2001 BlueCHiP, Coordinated Health Partners
Section 5 (e)
To be eligible to receive these benefits you must follow
your treatment plan and all the
following authorization processes:
from Continuum Behavioral Care or other mental health
administrator, as determined by
the Plan; you must call 1-800-544-5977 or
401-276-4052 prior to services being ren-dered.
Continuum Behavioral Care
will determine and authorize the appropriate number
of visits and determine
the appropriate specialist. A referral from your PCP is not
required.
as of January 1, 2001, you will be eligible for continued
coverage with your provider for
up to 90 days under the following
conditions:
in treatment leaves the plan at our request for other
than cause
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.
Special transitional
benefit
27 Page
28 29
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P O
R T
A N
T
Here are some important
things to keep in mind about these benefits:
We cover prescribed drugs
and medications, as described in the chart beginning on the next page.
All
benefits are subject to the definitions, limitations and exclusions in this
brochure and are
payable only when we determine they are medically
necessary.
We have no calendar year deductible for services received by
Plan participating providers. Please
see Section 5( i) regarding your
Point-of-Service benefits.
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, includ-ing
with Medicare.
Who can write your prescription. A licensed physician must write
the prescription
Where you can obtain them. You may fill the
prescription at a Plan pharmacy. Plan pharmacies include CVS
and Brooks
pharmacies as well as additional independent pharmacies. Prescriptions filled at
non-participating
pharmacies will be covered at 80% of BlueCHiP, Coordinated
Health Partners' allowance after a $30 copay.
cost effective medications
that are covered under your prescription drug benefit for a lower copay. You are
still covered for medications that are not on the Plan's formulary; however,
you will be responsible for a higher
copay. If your physician prescribes a
medication that is not listed on the Plan's formulary, there is a two-month
grace period for non-formulary drugs, during which you will only be charged
a generic or brand name copay,
whichever applies. If you meet the
pre-established medical criteria for the non-formulary drug, you will only be
required to pay the applicable generic or brand name copay. If you do not
meet the pre-established medical cri-teria
or your physician does not submit
the necessary information for medical necessity to be determined, you
will
be responsible for the non-formulary copay after the two-month grace period has
ended.
for up to a 34-day supply
for non-maintenance drugs or the greater of a 34-day supply or 100 units for
maintenance drugs. If there is no generic equivalent available, you will
still have to pay the brand name copay.
pharmacy. You will be
required to pay the non-Plan pharmacy directly and the Plan will reimburse you
once you have submitted the receipt, your name and identification number to
BlueCHiP, 15 LaSalle Square,
Providence, RI 02903.
28 Page 29 30
29 2001 BlueCHiP, Coordinated Health Partners
Section 5 (f)
$5 per prescription unit or refill
for generic drugs
refill for brand name drugs on
the
Plan's formulary( see note
below)
refill for brand name drugs not
listed
on the Plan's formulary,
unless you meet certain criteria
for the
prescription drug (see
note below)
pharmacies will be
covered
at 80% of BlueCHiP,
Coordinated Health Partners'
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan
physician
and obtained from a Plan pharmacy:
Drugs and medicines that
by Federal law of the United States require a
physician's prescription for
their purchase, except as excluded below.
Insulin
Disposable needles
and syringes for the administration of covered medications
Fertility drugs
(non-injectibles)
Implanted time-released medications, such as Norplant
(included with office
visit copay covered under Medical/ Surgical benefits)
All FDA approved contraceptive drugs and devices
Prenatal vitamins
limitations. Contact the Plan for specific dosage limitations.
equivalent available, you will still
have to pay the brand name copay.
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.
Drugs and supplies for cosmetic purposes
All other vitamins, nutrients and food supplements even if a physician
prescribes or administers them
Drugs available without a prescription
or for which there is a non-prescription
equivalent avaiable
Drugs to
enhance athletic performance
Injectible fertility drugs
Medical
supplies such as dressings and antiseptics
Drugs and supplies for the
purposes of weight reduction 29
29 Page 30 31
30
Section
5 (g). Special Features
Feature Description
member
are travelling throughout the United States, and
need medical care before
you return home, call the Away From
Home Coordinator at 1-800-4-HMO-USA
(1-800-446-6872).
The Away From Home Coordinator will assist you with
schedul-ing
an appointment with a qualified doctor during normal busi-ness
hours and give you directions to a doctor's office.
physician to help you have the healthiest baby possible. Little
Steps includes free classes on parenting, newborn care, and
breast-feeding. The classes are held at participating hospitals
throughout Rhode Island. For more information, please contact
Customer
Service at 1-800-564-0888.
30 Page 31 32
I
M
P
O
R
T
A
N
T
M
P
O
R
T
A
N
T
Here are some important things to keep
in mind about these benefits:
Please remember that all benefits are
subject to the definitions, limitations, and exclusions in this
brochure and
are payable only when we determine they are medically necessary.
Plan
dentists must provide or arrange your care.
We have no calendar year
deductible.
We cover hospitalization for dental procedures only when a
non-dental physical impairment exists
which makes hospitalization necessary
to safeguard the health of the patient; we do not cover the dental
procedure
unless it is described below.
Be sure to read Section 4, "Your costs for
covered services" for valuable information about how cost
sharing works.
Also read Section 9 about coordinating benefits with other coverage, including
with
Medicare.
We cover restorative services
and supplies necessary to promptly repair Nothing
(but not replace) sound
natural teeth. The need for these services must result from
an accidental
injury. You pay nothing.
We have no other dental benefits. 31
31 Page 32 33
32 2001 BlueCHiP, Coordinated Health Partners
Section 5 (i)
Section 5 (i). Point of service benefits
Facts
about this Plan's POS option
At your option, you may choose to obtain
benefits covered by this Plan from non-Plan doctors and hospitals whenever
you need care, except for the benefits listed below under "What is not
covered." Benefits not covered under Point-of-Service
must either be
received from or arranged by Plan doctors to be covered. When you obtain covered
non-emer-gency
medical treatment from a non-Plan doctor without a referral
from a Plan doctor, you are subject to the
deductibles, coinsurance and
maximum benefit stated below.
Under the Point-of-Service benefit, you are covered for
medically necessary, covered health services when you self-refer
to a
non-participating provider or to a BlueCHiP provider without a referral. You may
receive medically necessary cov-ered
health services listed in this
brochure, except for the services listed under what is not covered. Once you use
the
Point-of-Service benefit, all services associated with the episode of
care (i. e., lab, X-ray, hospitalization) will be paid
according to your
Point-of-Service benefit. If you choose to use the Point-of-Service benefit, you
will receive a lower
allowance than when the standard HMO benefit is
utilized.
BlueCHiP for authorization for
hospitalizations.
Services requiring Plan authorization under the Plan's
standard HMO benefits continue to require authorization under
the POS
benefit. When you utilize a non-participating provider, you are responsible for
assuring that Plan authorization
is obtained in advance for such services.
If you do not obtain Plan authorization for services that require Plan
autho-rization,
we will not cover the service.
When the Point-of-Service benefit is utilized, you pay
a $250 deductible per member per calendar year or a $500
deductible per
family per calendar year for doctor's visits, other outpatient services, and
hospital services. The
deductible is not reimbursable by the Plan. If you
decide to use non-participating providers or self-refer to a participat-ing
provider, this deductible applies to all covered benefits. Copays under the
BlueCHiP, Coordinated Health Partners'
Point-of-Service benefit cannot be
used to meet your calendar year deductible.
When you self-refer to Plan participating providers, the Plan
pays 80% of its fee allowance after the deductible is met;
you pay
20% of the fee allowance.
met; you pay 20% of the fee
allowance and all charges over and above the fee allowance.
You are protected by an out-of-pocket maximum of $3,000
per person, per calendar year and $6,000 per family per
calendar year. This
includes deductibles and copayments. Charges over the fee allowance cannot be
applied to the
out-of-pocket maximum. 32
32
Page 33 34
33
2001 BlueCHiP, Coordinated Health Partners Section 5( i)
Emergency
Benefits
True, medically necessary emergency care (even if received from a
non-participating provider) is always covered as a
standard HMO benefit.
You may have prescriptions filled when utilizing the
Point-of-Service benefit. You will be covered at 80% of the
BlueCHiP,
Coordinated Health Partners after a $30 copay. The benefits and requirements are
the same as those for the
standard HMO Prescription Drug Benefit.
Anesthesia consultations
Chiropractic care
Diagnostic procedures, such as laboratory tests and X-rays
Durable
Medical Equipment (DME) and medical supplies
Emergency room visits
Home health services
Infertility services
Mental conditions/
substance abuse benefits
Outpatient physical, speech and occupational
therapies, cardiac rehabilitation
Rehabilitation hospitalizations
Skilled nursing facility care
Transplant coverage
Vision care
benefits
If you receive services from a non-participating
provider, you may be required to pay up front and submit to us for
reimbursement. Please call Customer Service at 401-274-3500 or toll free at
1-800-564-0888 for a claim form. We will
provide you with a form within 15
days of your request. Submit the claim to BlueCHiP, Coordinated Health Partners,
15 LaSalle Square, Providence, RI 02903 as soon as possible. You must submit
a complete claim form by December
31 of the year after the year you received
the service. Either OPM or we can extend this deadline if you show that
cir-cumstances
beyond your control prevented you from filing on time. 33
33 Page 34 35
34 2001 BlueCHiP, Coordinated Health Partners
Section 5 (j)
Section 5 (j). Non-FEHB benefits available to Plan
members
The benefits on this page are not part of the FEHB contract or
premium, and you cannot file an FEHB disputed claim
about them. Fees
you pay for these services do not count toward FEHB deductibles or out-of-pocket
maximums.
Medicare. As indicated on page 41, annuitants and former spouses
with FEHBP
coverage and Medicare Part B may elect to drop their FEHBP
coverage and enroll
in a Medicare prepaid plan when one is available in
their area. They may then later
re-enroll in the FEHBP Program. Most federal
annuitants have Medicare Part A.
Those without Medicare Part A may join this
Medicare prepaid plan but will proba-bly
have to pay for hospital coverage
in addition to the Part B premium. Before
you join the plan, ask whether the
plan covers hospital benefits and, if so, what
you will have to pay. Contact
your retirement system for informaton on dropping
your FEHBP enrollment and
changing to a Medicare prepaid plan. Contact us at
1-800-505-2583 for
information on the Medicare prepaid plan and the cost of that
enrollment.
sponsored by this Plan without dropping your enrollment in this Plan's
FEHB plan,
call 1-800-505-2583 for information on the benefits available
under the Medicare
HMO.
Enrollment 34
34
Page 35 36
35
2001 BlueCHiP, Coordinated Health Partners Section 6
Section 6.
General exclusions things we don't cover
The exclusions in this
section apply to all benefits. Although we may list a specific service as a
benefit, we will not
cover it unless your Plan doctor determines it is
medically necessary to prevent, diagnose, or treat your illness,
disease,
injury or condition and we agree, as discussed under What Services
Require Our Prior Approval on page
10.
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 that is barred from the FEHB Program. 35
35 Page 36 37
36 2001 BlueCHiP, Coordinated Health Partners
Section 7
Section 7. Filing a claim for covered services
When
you see Plan physicians, receive services at Plan hospitals and facilities, or
obtain your prescription drugs at Plan
pharmacies, you will not have to file
claims. Just present your identification card and pay your copayment,
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:
the form HCFA-1500, Health Insurance Claim Form. Facilities will
file on the UB-92
form. For claims questions and assistance, call us at
401-274-3500 or toll-free at
1-800-564-0888. 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:
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.
Providence, RI 02903
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.
or deny your claim if you do not respond.
Drug benefits
claim
information 36
36
Page 37 38
37
2001 BlueCHiP, Coordinated Health Partners Section 8
Section 8.
The disputed claims process
Follow this Federal Employees Health
Benefits Program disputed claims process if you disagree with our decision on
your claim or request for services, drugs, or supplies including a request
for preauthorization:
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: 15 LaSalle Square, Providence,
RI 02903; 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.
(b) Write to you and maintain our denial go to step 4; or
(c) Ask you or your medical provider for more information. If we ask your
provider, we will send you a copy
of our request go to step 3.
was due. We will base our decision on the
information we already have.
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.
Box 436, Washington, D. C. 20044-0436.
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.
claim. 37
37
Page 38 39
38
2001 BlueCHiP, Coordinated Health Partners Section 8
Note: You are
the only person who has a right to file a disputed claim with OPM. Parties
acting as your repre-sentative,
such as medical providers, must provide a
copy of your specific written consent with the review
request.
reasons beyond your control.
appeals.
disputed services, drugs or supplies. This is the only deadline that may not
be extended.
OPM may disclose the information it collects during the review
process to support their disputed claim deci-sion.
This information will
become part of the court record.
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.
death if not treated as soon
as possible), and
401-274-3500 or toll-free
at 1-800-564-0888 and we will expedite our review; or
If we expedite our review and maintain our denial, we
will inform OPM so that they can give your
claim expedited treatment, too,
or
You can call OPM's Health Benefits Contracts Division 3 at
202-606-0755 between 8 a. m. and 5 p. m.
Eastern time. 38
38 Page 39 40
39 2001 BlueCHiP, Coordinated Health Partners
Section 9
Section 9. Coordinating benefits with other coverage
You must tell us if you are covered or a family member is covered under
another
group health plan or have automobile insurance that pays medical
expenses without
regard to fault. This is called "double coverage."
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 secondary payer, we will determine our allowance.
After the pri-mary
plan pays, we will pay what is left of our allowance, up
to our regular benefit.
We will not pay more than our allowance. If we are
the secondary payer, we may
be entitled to receive payment from your primary
plan.
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)
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.
care. Medicare + Choice is the term used to describe the various
health plan choices
available to Medicare beneficiaries. The information in
the next few pages shows
how we coordinate benefits with Medicare, depending
on the type of Medicare man-aged
care plan you have.
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 pre-scription
drugs.
the rules in this brochure for us to cover your care.
(Primary payer chart begins on next page.)
health coverage
Plan 39
39
Page 40 41
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.
A. When either you or your covered spouse are
age 65 or over Then the primary payer is
and... Original Medicare This Plan
when you
or a family member are eligible for Medicare solely
because of a
disability),
3) Are a reemployed annuitant with the Federal
government when
a) The position is excluded from FEHB, or
Ask your employing office which
of these applies to you.
Court judge who retired under Section 7447 of title 26, U. S. C.
(or if
your covered spouse is this type of judge),
(for Part B services) (for other services)
and the
Office of Workers' Compensation Programs has (except for claims
determined
that you are unable to return to duty. related to Workers'
Compensation.)
based on
end-stage renal disease (ESRD) and
benefits solely because of ESRD,
still
eligible for Medicare due to ESRD,
primary
for you under another provision
1) Are
eligible for Medicare based on disability, and
a) Are an annuitant
40 Page 41 42
41 2001 BlueCHiP, Coordinated Health Partners
Section 9
If you are eligible for Medicare, you may choose to enroll in
and get your Medicare
benefits from a Medicare managed care plan. These are
health care choices (like
HMOs) in some areas of the country. In most
Medicare managed care plans, you
can only go to doctors, specialists, or
hospitals that are part of the plan. Medicare
managed care plans cover all
Medicare Part A and 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:
Medicare managed care plan and also remain enrolled in our FEHB Plan. In
this
case, we do not waive any of our copayments, coinsurance, or
deductibles for your
FEHB coverage.
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 pri-mary,
but we will not waive any of our copayments,
coinsurance, or deductibles.
annuitant or former spouse, you can suspend your FEHB coverage and enroll
in a
Medicare managed care plan. For information on suspending your FEHB
enroll-ment,
contact your retirement office. If you later want to re-enroll
in the FEHB
Program, generally you may do so only at the next open season
unless you involun-tarily
lose coverage or move out of the Medicare managed
care plan's service area.
the FEHB Program. We cannot require you to enroll in Medicare.
retirees of the military. TRICARE includes the CHAMPUS program.
If both TRI-CARE
and this Plan cover you, we pay first. See your TRICARE
Health Benefits
Advisor if you have questions about TRICARE coverage.
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.
will cover your benefits. You must use our providers.
care plan
Medicare Part B
Compensation
41 Page
42 43
42 2001 BlueCHiP, Coordinated
Health Partners Section 9
We do not cover services and supplies when a
local, State, or Federal
Government agency directly or indirectly pays for
them.
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.
subrogation. If you need more information, contact us for our subrogation
procedures.
agencies are responsible for
your care
for injuries 42
42 Page 43 44
Section 10. Definitions of terms we use in this
brochure
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.
Coinsurance is the percentage of our allowance that you must pay
for your care.
Care we provide benefits for, as described in this brochure.
Custodial care means non-medical care, including room and board, provided to
you
if you have a mental or physical condition and require assistance in
your daily liv-ing
or personal needs. Custodial care can be provided by
persons without profes-sional
skills or training who can assist you with
dressing, bathing, eating, taking
medication and preparation of special
diets.
services and supplies before we start paying benefits for those
services. See
page 32.
equipment, drug, device, supply or service (herinafter referred to
collectively as
"service") when the service has progressed to limited human
application, but has
not been recognized as proven effective in clinical
medicine. A service is consid-ered
experimental or investigational if the
Plan determines that one or more of the
following circumstances are true: 1)
the service is the subject of an ongoing clini-cal
trial or is under study
to determine the maximum tolerated dose, toxicity, safety,
efficacy, or
efficacy as compared with a standard means of treatment or diagnosis;
or 2)
the prevailing opinion among experts regarding the service is that further
stud-ies
or clinical trials are necessary; or 3) the current belief in the
pertinent specialty
of the medical profession in the United States is that
the service or supply should
not be used for the diagnosis or indications
being requested outside of clinical trials
or other research settings
because it requires further evaluation for that diagnosis or
indications.
employees, ex-employees and their families.
injury. The services must: 1) be essential or diagnosis,
treatment, or care of your
condition; 2) be commonly and customarily
recognized in your provider's profes-sion
as appropriate for your diagnosis;
3) be performed in the most cost-effective
manner or at a location providing
a less intensive level of care; and 4) not be deter-mined
by us to be
experimental or investigational.
Copayment
Coinsurance
Covered services
Custodial care
Experimental or Investigational
services
Medical necessity 43
43 Page 44 45
44 2001 BlueCHiP, Coordinated Health Partners
Section 10
Plan allowance is the amount we use to determine our payment
and your coinsur-ance
for covered services. Fee-for-service plans determine
their allowances in dif-ferent
ways. We determine our allowance as follows:
for Plan participating
providers, our allowance is the amount the physician
charges for the covered service
or the amount that Plan has negotiated to
pay for the covered service; for no-Plan
participating providers, our
allowance is the the amount the physician charges for
the covered service,
the amount the Plan determines to be appropriate based on our
list of
allowances for the covered service or procedure or the maximum amount the
Plan pays any doctor for the covered service or procedure.
You refers to
the enrollee and each covered family member.
Us/ We
You 44
44
Page 45 46
45
2001 BlueCHiP, Coordinated Health Partners Section 11
Section 11.
FEHB facts
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.
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:
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 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.
family, 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 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 enroll-ment
begins on the first day of the pay period in which
the child is born or becomes
an eligible family member. When you change to
Self and Family because you marry,
the change is effective on the first day
of the pay period that begins after your
employing office receives your
enrollment form; benefits will not be available to
your spouse until you
marry.
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.
may not be enrolled in or covered as a family member by another FEHB
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.
condition limitation
information about
enrolling in the FEHB
Program
available for you and
your family
premiums start 45
45
Page 46 47
46
2001 BlueCHiP, Coordinated Health Partners Section 11
We will keep
your medical and claims information confidential. Only the following
will
have access to it:
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;
criminal actions;
Individuals involved in bona fide medical research or education that does not
dis-close
your identity; or
have been enrolled in the FEHB Program for the last five years of your
Federal ser-vice.
If you do not meet this requirement, you may be eligible
for other forms of
coverage, such as Temporary Continuation of Coverage
(TCC).
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.
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 infor-mation
about your
coverage choices.
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.
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.
claims records are
confidential
When you lose benefits
When FEHB
coverage
ends
coverage
46 Page
47 48
47 2001 BlueCHiP, Coordinated
Health Partners Section 11
You may convert to a non-FEHB individual
policy if:
Your coverage under TCC or the spouse equity law ends. If you
canceled your
coverage or did not pay your premium, you cannot convert;
You 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.
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.
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.
enrolled in other FEHB plans, you may also request a certificate
from those plans.
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 informa-tion,
do the following:
If the provider does not resolve the matter, call us at 401-274-3500 ot
toll-free at
1-800-564-0888 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.
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 mem-ber,
or is no longer enrolled in the Plan and
tries to obtain benefits. Your agency
may also take administrative action
against you.
individual coverage
of group health plan
coverage
47 Page 48 49
48 2001
BlueCHiP, Coordinated Health Partners Index
Index
Do not rely
on this page; it is for your convenience and does not explain your benefit
coverage.
Allergy tests
.................................. 16
Alternative treatment
...................... 18
Ambulance .............................. 23, 25
Anesthesia ...................................... 21
Autologous bone
marrow transplant 21
Biopsies .......................................... 19
Blood and blood plasma ................ 23
Breast cancer screening
................ 14
Casts ................................................
23
Catastrophic protection .................. 11
Changes for 2001
............................ 7
Chemotherapy ................................
16
Childbirth ...................................... 15
Cholesterol
tests ............................ 14
Claims
............................................ 36
Coinsurance
...................... 11, 32, 43
Colorectal cancer screening .......... 14
Congenital anomalies ...................... 20
Contraceptive devices and
drugs .... 29
Coordination of benefits .................. 39
Covered
providers.............................. 8
Crutches
.......................................... 18
Deductible............................ 11, 32, 43
Definitions
.................................. 43-44
Dental care
...................................... 31
Diagnostic services
.......................... 13
Disputed claims review.............. 37-38
Donor expenses (transplants) .......... 21
Dressings.......................................... 23
Durable medical
equipment (DME).......................... 18
Educational classes
and
programs .................................. 18
Effective date of enrollment
.............. 8
Emergency ................................ 24-25
Experimental or investigational 35, 43
Eyeglasses
...................................... 17
Fecal occult blood test
.................... 14
General Exclusions .......................... 35
Hearing services .............................. 17
Home health services
...................... 18
Hospice care ....................................
23
Home nursing care .......................... 18
Hospital
.................................. 9-10, 22
Immunizations
................................ 14
Infertility
.................................... 15-16
Inhospital physician care
................ 13
Inpatient Hospital Benefits .............. 22
Insulin .............................................. 29
Laboratory and
pathological
services ...................................... 13-14
Magnetic Resonance Imagings
(MRIs)
................................................ 13
Mammograms.................................. 14
Maternity Benefits
.......................... 15
Medicaid
.......................................... 41
Medically necessary
........................ 43
Medicare ....................................
39-41
Members .......................................... 44
Mental
Conditions/ Substance Abuse
Benefits ......................................
26-27
Newborn care .................................. 15
Non-FEHB
Benefits ........................ 34
Nurse
................................................ 18
Licensed Practical Nurse
................ 18
Registered Nurse ............................ 18
Nursery charges .............................. 15
Obstetrical care
.............................. 15
Occupational therapy
...................... 16
Office visits
...................................... 13
Oral and maxillofacial
surgery........ 20
Orthopedic devices .......................... 17
Out-of-pocket expenses ............ 11,32
Outpatient facility care
.................... 23
Pap test
...................................... 13, 14
Physical examination
...................... 13
Physical therapy .............................. 16
Physician ............................................ 5
Point of
service (POS) .............. 32-33
Pre-admission testing
...................... 23
Preventive care, adult ...................... 14
Preventive care, children.................. 14
Prescription drugs
...................... 28,33
Prior approval
.................................. 10
Prostate cancer screening
.............. 14
Prosthetic devices ............................ 17
Psychologist .................................... 26
Radiation therapy
............................ 16
Rehabilitation therapies ..................
16
Renal dialysis .................................. 16
Room and board
........................ 22,23
Second surgical opinion .................. 13
Skilled nursing facility care ............ 23
Speech therapy
................................ 16
Sterilization procedures
.................. 15
Subrogation ...................................... 42
Substance abuse .............................. 26
Surgery
............................................ 19
Anesthesia
.................................. 21
Oral
............................................ 20
Outpatient
.................................. 19
Reconstructive............................ 20
Syringes............................................ 29
Temporary
continuation of
coverage .......................................... 46
Transplants ...................................... 21
Treatment
therapies.......................... 16
Vision services
................................ 17
Wheelchairs
.................................... 18
Workers' compensation
.................. 41
X-rays .................................. 13, 22-23 48
48 Page 49 50
49 2001 BlueCHiP, Coordinated Health Partners
Summary
Summary of benefits for BlueCHiP, Coordinated Health
Partners, Inc. -2001
Do not rely on this chart alone. All
benefits are provided in full unless indicated and are subject to the
definitions,
limitations, and exclusions in this brochure. On this page we
summarize specific expenses we cover; for more detail,
look inside.
on your enrollment form.
Medical services provided by physicians:
Diagnostic and treatment services provided in the office.. Office visit
copay: $10 13
Inpatient..............................................................................
Nothing 22
Outpatient
..........................................................................
Nothing 23
In-area
................................................................................
urgent care visit; $25 for an
emergency room visit.
Out-of-area
........................................................................ $10 for
an office visit; $20 for an 25
urgent care visit; $25 for an
emergency
room visit.
Prescription drugs
................................................................ $5 for generic
drugs; $15 for
brand name drugs; $30 for
non-formulary drugs. 29
Vision Care:
Eye
Exams..........................................................................
$10 17
Eye Glasses
........................................................................ Nothing
for one pair of eye glasses 17
to correct an impairment directly
caused
by intraocular surgery; No
other benefit for eye glasses.
Point-of-Service benefits --................................................
Yes 32
Protection against catastrophic costs Nothing after $2,294/ Self Only
or
(your out-of-pocket maximum) ............................................
$5,874/ Family enrollment per year. 11
this protection. 49
49 Page 50 51
2001 BlueCHiP, Coordinated Health Partners 50