A Health Maintenance Organization
Serving: Licking, Ottawa, Sandusky and Seneca Counties in Ohio
Enrollment in this Plan is limited; see page 5 for requirements.
Enrollment codes for this Plan:
MG1 Self Only
MG2 Self and Family
RI 73-508
Special Note: This Plan has reduced its service area for
2001. 1
1 Page 2
3
2001 Community Health Plan of Ohio 2 Table
of Contents
Table of Contents
Introduction…………………………………………………………………...................................................................
4
Plain
Language………………………………………………………………..................................................................
4
Section 1. Facts about this HMO plan
................................................................................................................................
5
How we pay providers
.......................................................................................................................................
5
Patients' Bill of Rights
.......................................................................................................................................
5
Service
Area........................................................................................................................................................
5
Section 2. How we change for
2001……………………………………….....................................................................
6
Program-wide
changes.......................................................................................................................................
6
Changes to this Plan
...........................................................................................................................................
6
Section 3. How you get care
…………..............................................................................................................................
7
Identification cards
.............................................................................................................................................
7
Where you get covered care
..............................................................................................................................
7
· Plan providers
..............................................................................................................................................
7
· Plan
facilities................................................................................................................................................
7
What you must do to get covered care
..............................................................................................................
7
· Primary care
.................................................................................................................................................
8
· Specialty
care...............................................................................................................................................
8
· Hospital care
................................................................................................................................................
8
Circumstances beyond our
control....................................................................................................................
9
Services requiring our prior
approval................................................................................................................
9
Section 4. Your costs for covered
services.......................................................................................................................
10
·
Copayments................................................................................................................................................
10
Your out-of-pocket
maximum.........................................................................................................................
10
Section 5.
Benefits…………………………………………………………..................................................................
11
Overview...........................................................................................................................................................
11
(a) Medical services and supplies provided by physicians and other health
care professionals ........... 12
(b) Surgical and anesthesia services
provided by physicians and other health care professionals ........ 20
(c)
Services provided by a hospital or other facility, and ambulance services
....................................... 23
(d) Emergency services/ accidents
..............................................................................................................
26
(e) Mental health and substance abuse benefits
........................................................................................
28
(f) Prescription drug benefits
.....................................................................................................................
30
(g) Special features
.....................................................................................................................................
32
(h) Dental
benefits.......................................................................................................................................
33
Section 6. General exclusions --things we don't
cover...................................................................................................
34
Section 7. Filing a claim for covered services
.................................................................................................................
34
Section 8. The disputed claims process
............................................................................................................................
35 2
2 Page 3 4
2001 Community Health Plan of Ohio 3 Table of
Contents
Section 9. Coordinating benefits with other coverage
.....................................................................................................
37
When you have…
·Other health coverage
...............................................................................................................................
37
·Original Medicare
.....................................................................................................................................
37
·Medicare Managed Care
Plan..................................................................................................................
39
TRICARE/ Workers' Compensation/
Medicaid...............................................................................................
40
Other Government agencies
............................................................................................................................
40
When others are responsible for injuries
........................................................................................................
41
Section 10. Definitions of terms we use in this brochure
................................................................................................
42
Section 11. FEHB
facts......................................................................................................................................................
42
Coverage
information.......................................................................................................................................
42
· No pre-existing condition limitation
......................................................................................................
42
· Where you get information about enrolling in the FEHB Program
..................................................... 42
· Types of
coverage available for you and your
family...........................................................................
42
· When benefits and premiums start
.........................................................................................................
43
· Your medical and claims records are confidential
................................................................................
43
· When you retire
.....................................................................................................................................
43
When you lose
benefits....................................................................................................................................
43
· When FEHB coverage ends
....................................................................................................................
43
· Spouse equity coverage
..........................................................................................................................
43
· Temporary Continuation of Coverage (TCC)
.......................................................................................
43
· Converting to individual
coverage.........................................................................................................
44
· Getting a Certificate of Group Health Plan Coverage
.......................................................................... 44
Inspector General advisory: Stop health care fraud!
......................................................................................
44
Index
...........................................................................................................................................................................
45
Summary of
benefits...........................................................................................................................................................
47
Rates......................................................................................................................................................................
Back cover 3
3 Page
4 5
2001 Community Health Plan of Ohio
4 Introduction/ Plain Language
Introduction
Community
Health Plan of Ohio
1915 Tamarack Rd.
Newark, Ohio 43055
This brochure describes the benefits of Community Health Plan of Ohio under
our contract (CS 2504) with the Office
of Personnel Management (OPM), as
authorized by the Federal Employees Health Benefits law. This brochure is the
official statement of benefits. No oral statement can modify or otherwise
affect the benefits, limitations, and
exclusions of this brochure.
A person enrolled in this Plan is entitled to the benefits described in this
brochure. If you are enrolled for Self and
Family coverage, each eligible
family member is also entitled to these benefits. You do not have a right to
benefits
that were available before January 1, 2001, unless those benefits
are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes
are effective January 1, 2001, and are
summarized on page 6. Rates are shown
at the end of this brochure.
Plain Language
The President and Vice President are making the
Government's communication more responsive, accessible, and
understandable
to the public by requiring agencies to use plain language. In response, a team
of health plan
representatives and OPM staff worked cooperatively to make
this brochure clearer. Except for necessary technical
terms, we use common
words. "You" means the enrollee or family member; "we" means
Community Health Plan of
Ohio.
The plain language team reorganized the brochure and the way we describe our
benefits. When you compare this Plan
with other FEHB plans, you will find
that the brochures have the same format and similar information to make
comparisons easier.
If you have comments or suggestions about how to improve this brochure, let
us know. Visit OPM's "Rate Us"
feedback area at www. opm. gov/
insure or e-mail us at fehbwebcomments@ opm. gov or write to OPM at Insurance
Planning and Evaluation Division, P. O. Box 436, Washington, DC 20044-0436.
4
4 Page 5 6
2001 Community Health Plan of Ohio 5 Section 1
Section 1. Facts about this HMO plan
This Plan is a health
maintenance organization (HMO). We require you to see specific physicians,
hospitals, and
other providers that contract with us. These Plan providers
coordinate your health care services.
HMOs emphasize preventive care such as routine office visits, physical exams,
well-baby care, and immunizations, in
addition to treatment for illness and
injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit
claim forms or pay bills. You only pay
the copayments described in this
brochure. When you receive emergency services from non-Plan providers, you may
have to submit claim forms.
You should join an HMO because you prefer the plan's benefits, not because
a particular provider is available.
You cannot change plans because a
provider leaves our Plan. We cannot guarantee that any one physician, hospital,
or other provider will be available and/ or remain under contract with us.
How we pay providers
We contract with individual physicians,
medical groups, and hospitals to provide the benefits in this brochure. These
Plan providers accept a negotiated payment from us, and you will only be
responsible for your copayments.
Patients' Bill of Rights
OPM requires that all FEHB Plans comply
with the Patients' Bill of Rights, recommended by the President's Advisory
Commission on Consumer Protection and Quality in the Health Care Industry.
You may get information about us, our
networks, providers, and facilities.
OPM's FEHB website (www. opm. gov/ insure) lists the specific types of
information that we must make available to you. Some of the required
information is listed below.
Community Health Plan of Ohio, a not for profit Health Insuring Corporation,
has been in existence since 1986.
Community Health Plan of Ohio (CHPO) is an
IPA Model (Individual Practice Association) where patient care is
obtained
in the privacy of a doctor's office. When you enroll in CHPO, each family member
must select a primary
care physician from the Plan's list of participating
providers.
All health services must be accessed from participating Plan providers,
except for the treatment of medical
emergencies. The services of providers
outside the network are covered only when there has been a referral by the
member's primary care physician. There is no limit on the number of primary
care physicians per family. There can
be one for each family member, or you
can all choose one doctor. The choice is yours. Primary care physicians are
defined as doctors specializing in family practice, general practice,
internal medicine, and pediatrics.
If members need to see a specialist, they will be referred by their primary
care physician. Members needing specialty
care not provided in the network
will be referred by their primary care physician to the appropriate specialist
outside
the network at no additional cost to the member.
You may review and obtain copies of your medical records on request. If you
want copies of your medical records,
ask your health care provider for them.
You may ask that a physician amend a record that is not accurate, not
relevant, or incomplete. If the physician does not amend your record, you
may add a brief statement to it. If they do
not provide you your records,
call us and we will assist you.
If you want more information about us, call 740-348-1400 or 1-800-806-2756,
or write to Community Health Plan of
Ohio, 1915 Tamarack Road., Newark, Ohio
43055. You may also contact us by fax at 740-348-1500.
Service Area
To enroll in this Plan, you must live in or work
inside the service area. This is where our providers practice. Our
service
area is: Licking, Ottawa, Sandusky and Seneca Counties in Ohio. 5
5 Page 6 7
2001 Community Health Plan of Ohio 6 Section 2
If you receive care outside our service area, we will only pay for
emergency care, unless prior authorized by your PCP
and the Plan.
If you or a covered family member move outside of our service area, you can
enroll in another plan. If your
dependents live out of the area (example, if
your child goes to college in another state), you should consider enrolling
in a fee-for-service plan or an HMO that has agreements with affiliates in
other areas. If you or a family member
move, you do not have to wait until
Open Enrollment Season to change plans. Contact your employing or retirement
office.
Section 2. How we change for 2001
Program-wide changes
· The plain language team reorganized the brochure and the way we
describe our benefits. We hope this will make it easier for you to compare
plans.
· This year, the Federal Employees Health Benefits Program is
implementing network mental health and substance abuse parity. This means that
your coverage for mental health, substance abuse, medical, surgical, and
hospital
services from providers in our "plan network" will be the
same with regard to copays, and day and visit
limitations when you follow a
treatment plan that we approve. Previously, we placed shorter visit limitations
on
mental health and substance abuse services than we did on services to
treat physical illness, injury, or disease.
· Many healthcare organizations have turned their attention this past
year to improving healthcare quality and patient safety. OPM asked all FEHB
plans to join them in this effort. You can find specific information on our
patient safety activities by calling Community Health Plan of Ohio at
740-348-1400 or 1-800-806-2756. You can
find out more about patient safety
on the OPM website, www. opm. gov/ insure. To improve your healthcare, take
these five steps:
·· Speak up if you have questions or concerns.
·· Keep a list of all the medicines you take.
·· Make sure you get the results of any test or procedure.
·· Talk with your doctor and health care team about your
options if you need hospital care.
·· Make sure you understand
what will happen if you need surgery.
· We clarified the language to show that anyone that needs a
mastectomy may choose to have the procedure performed on an inpatient basis and
remain in the hospital for 48 hours after the procedure. Previously, the
language only referenced women.
Changes to this Plan
·
Your share of the non postal standard option premium will increase by 14.1% for
Self Only and 105.7% for Self and Family.
· We increased prescription drug copays from a $5 copay to a $10 copay
for generic drugs and a $15 copay for brand name drugs for a 30-day supply from
our retail pharmacies.
· We significantly reduced our service area.
The following Ohio counties remain: Licking, Ottawa, Sandusky and Seneca. 6
6 Page 7 8
2001 Community Health Plan of Ohio 7 Section 3
Section 3. How you get care
Identification cards We will send
you an identification (ID) card when you enroll. You should carry your ID card
with you at all times. You must show it
whenever you receive services from a
Plan provider or fill a prescription
at a Plan pharmacy. Until you receive
your ID card, use your copy of the
Health Benefits Election Form, SF-2809,
your health benefits enrollment
confirmation (for annuitants), or your
Employee Express confirmation
letter.
If you do not receive your ID card within 30 days after the effective date
of your enrollment, or if you need replacement cards, call us at
740-348-
1400.
Where you get covered care You get care from "Plan
providers" and "Plan facilities." You will only pay copayments
and you will not have to file claims.
· · Plan providers Plan providers are physicians and
other health care professionals in our service area that we contract with to
provide covered services to our
members. We credential Plan providers
according to national standards.
We list Plan providers in the provider
directory, which we update
periodically. The Plan's provider directory lists
primary care physicians
(general practitioners, pediatricians, and
internists) with their locations
and phone numbers. Directories are updated
on a regular basis and
available at the time of enrollment or upon request
by calling the
Member Services Department at 740-348-1400; you can also find
out if
your doctor participates with the Plan by calling this number.
· ·Plan facilities Plan facilities are hospitals and
other facilities in our service area that we contract with to provide covered
services to our members. We list these
in the provider directory, which we
update periodically.
What you must do It depends on the type of care you need. First, you
and each family member must choose a primary care physician. This decision is
important since your primary care physician provides or arranges for
most of your health care. If you are interested in receiving care from a
specific provider who is listed in the directory, call the provider to
verify
that he or she still participates with the Plan and is accepting new
patients. Important note: When you enroll in this Plan, services (except
for emergency benefits) are provided through the Plan's delivery system;
the continued availability and/ or participation of any one doctor,
hospital,
or other provider, cannot be guaranteed.
If you enroll, you will be asked to let the Plan know which primary care
physician( s) you've selected for you and each family member of your
family by sending a selection form to the Plan. If you need help in
choosing a doctor, call the Plan. Members may change their doctor
selection by notifying the Plan 30 days in advance.
If you doctor leaves the plan, you may receive services from your current
doctor until we can make arrangements for you to see someone else. 7
7 Page 8 9
2001 Community Health Plan of Ohio 8 Section 3
· ·Primary care Your primary care physician can be
a general practitioner, pediatrician or internist. Your primary care physician
will provide most of your health
care or give you a referral to see a
specialist.
If you want to change primary care physicians or if your primary
care
physician leaves the Plan, call us. We will help you select a new one.
· · Specialty care Your primary care physician will
refer you to a specialist for needed care. However, a woman may see her Plan
obstetrician/ gynecologist directly,
without a referral by her primary care
physician.
Here are other things you should know about specialty care:
· If you need to see a specialist frequently because of a chronic,
complex, or serious medical condition, your primary care physician
will work
with the specialist and the Plan to develop a treatment plan
that allows you
to see your specialist for a certain number of visits
without additional
referrals. Your primary care physician will use our
criteria when creating
your treatment plan (the physician may have to
get an authorization or
approval beforehand).
· If you are seeing a specialist when you enroll in our Plan, talk to
your primary care physician. Your primary care physician will decide
what
treatment you need. If he or she decides to refer you to a
specialist, ask
if you can see your current specialist. If your current
specialist does not
participate with us, you must receive treatment
from a specialist who does.
Generally, we will not pay for you to see
a specialist who does not
participate with our Plan.
· If you are seeing a specialist and your specialist leaves the Plan,
call your primary care physician, who will arrange for you to see another
specialist. You may receive services from your current specialist
until
we can make arrangements for you to see someone else.
· If you have a chronic or disabling condition and lose access to your
specialist because we:
·· terminate our contract with your specialist for other than
cause; or
·· drop out of the Federal Employees Health Benefits
(FEHB) Program and you enroll in another FEHB Plan; or
·· reduce our service area and you enroll in another FEHB Plan,
you may be able to continue seeing your specialist for up to 90 days
after you receive notice of the change. Contact us or, if we drop out
of
the Program, contact your new plan.
If you are in the second or third trimester of pregnancy and you lose
access to your specialist based on the above circumstances, you can
continue to see your specialist until the end of your postpartum care, even
if it is beyond the 90 days.
· · Hospital care Your Plan primary care physician or
specialist will make necessary hospital arrangements and supervise your care.
This includes admission
to a skilled nursing or other type of facility. 8
8 Page 9 10
2001 Community Health Plan of Ohio 9 Section
3
If you are in the hospital when your enrollment in our Plan begins,
call
our member service department immediately at 740-348-1400. If you are
new to the FEHB Program, we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay
for the hospital stay until:
· You are discharged, not merely moved to an alternative care center;
or
· The day your benefits from your former plan run out; or
· The 92 nd day after you become a member of this Plan, whichever
happens first.
These provisions apply only to the benefits of the hospitalized person.
Circumstances beyond our control Under certain extraordinary
circumstances, such as natural disasters, we may have to delay your services or
we may be unable to provide them.
In that case, we will make all reasonable
efforts to provide you with the
necessary care.
`
Services requiring our Your primary care physician has authority to
refer you for most
prior approval services. For certain services,
however, your physician must obtain approval from us. Before giving approval, we
consider if the service is
covered, medically necessary, and follows generally accepted medical
practice.
We call this review and approval process prior authorization. Your
physician must obtain prior authorization for services such as:
· Elective Inpatient Admission
· Elective Outpatient
Surgery · Extended Care Facility/ Skilled Nursing Facility
· Specialist Visits
· Durable Medical Equipment
Your physician must get the approval of the Plan before sending you to a
hospital, referring you to a specialist, or recommending follow-up care.
Before giving approval, we consider if the service is medically necessary,
if it is a covered benefit, and if it follows generally accepted medical
practice. If you seek the services of any provider without prior
authorization, you will be responsible for the cost of such services.
Referral to a participating specialist is given at the discretion of your
primary care physician and the Plan and is not open ended. The referral
will specify a number of visits and a time frame in which they may occur.
A specialist may not refer to another specialist without the prior
authorization of your primary care physician and the Plan except for
emergencies. All follow up care must be provided or authorized by your
primary care physician. If you go to the specialist for additional visits
without obtaining prior authorization from your primary care physician
and the Plan, you will be responsible for the cost of such services. 9
9 Page 10 11
2001 Community Health Plan of Ohio 10
Section 4
Section 4. Your costs for covered services
You
must share the cost of some services. You are responsible for:
·
· Copayments A copayment is a fixed amount of money you pay when you
receive services.
Example: When you see your primary care physician you pay a
copayment of
$10 per office visit and when you go in the hospital, you
pay $50 per day,
maximum $250 copay per admission.
· ·Coinsurance Coinsurance is the percentage of our
negotiated fee that you must pay for your care.
Example: In our Plan, you pay 30% of our allowance for infertility
services.
Your out-of-pocket maximum After your copayments total $500 per person
or $1,000 per family
for copayments in any calendar year, you do not
have to pay any more for covered services. However, copayments for the following
service do not count
toward your out-of-pocket maximum, and you must continue to pay
copayments for this service:
· Prescription drugs
Be sure to keep accurate records of your
copayments, since you are
responsible for informing us when you reach the
maximum. 10
10 Page
11 12
2001 Community Health Plan of
Ohio 11 Section 5
Section 5. Benefits --OVERVIEW
(See page 6 for how our benefits changed this year and page 47 for
a benefits summary.)
NOTE: This benefits section is divided into subsections. Please read
the important things you should keep in mind at
the beginning of each
subsection. Also read the General Exclusions in Section 6; they apply to the
benefits in the
following subsections. To obtain claims filing advice or
more information about our benefits, contact us at 740-348-
1400.
(a) Medical services and supplies provided by physicians and other health
care professionals ........................... 12-19
Diagnostic and
treatment services Lab, x-ray, and other diagnostic tests
Preventive care,
adult Preventive care, children
Maternity care Family planning
Infertility services Allergy care
Treatment therapies Rehabilitative
therapies
Hearing services (testing and treatment) Vision services (testing, treatment,
and supplies)
Foot care Orthopedic and prosthetic devices
Durable
medical equipment (DME) Home health services
Educational classes and
programs
(b) Surgical and anesthesia services provided by physicians and other health
care professionals........................ 20-22
Surgical procedures
Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and
ambulance services...................................................... 23-25
Inpatient hospital Outpatient hospital or ambulatory
surgical center
Extended care benefits/ skilled nursing care facility benefits
Hospice
care Ambulance
(d) Emergency services/ accidents
.........................................................................................................................
26-27
Medical emergency Ambulance
(e) Mental health and substance abuse benefits
....................................................................................................
28-29
(f) Prescription drug
benefits................................................................................................................................
30-31
(g) Special
features.....................................................................................................................................................
32
Flexible benefits option
24 hour nurse line
Services for deaf and hearing impaired
Centers of
excellence for transplants/ heart surgery/ etc.
Travel benefit/ services
overseas
(h) Dental
benefits......................................................................................................................................................
33
Summary of
benefits....................................................................................................................................................
47 11
11 Page 12
13
2001 Community Health Plan of Ohio 12
Section 5( a)
Section 5 (a) Medical services and supplies provided
by physicians and
other health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
We have no calendar
year deductible.
Be sure to read Section 4, Your costs for covered
services for valuable information about how cost sharing works. Also read
Section 9 about coordinating benefits with other
coverage, including with Medicare.
I M
P O
R T
A N
T
Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
In physician's office
Office
medical consultations
Second surgical opinion
$10 per office visit to your primary care
physician office
$20 per office visit to your specialist
Professional services of physicians
In an urgent care center
During a
hospital stay
In a skilled nursing facility
Initial examination of a
newborn child covered under a family enrollment
At home
Nothing
Not covered:
Chiropractic services;
Treatment that is not authorized by a Plan doctor.
All charges 12
12 Page
13 14
2001 Community Health Plan of
Ohio 13 Section 5( a)
Lab, x-ray and other diagnostic tests
You pay
Tests, such as:
Blood tests
Urinalysis
Non-routine
pap tests
Pathology
X-rays
Non-routine Mammograms
CAT Scans/ MRI
Ultrasound
Electrocardiogram and EEG
Nothing for the test.
$10 per office visit if provided in
your
primary care physician's
office
$20 per office visit if provided in
your specialist's office
Preventive care, adult You pay
Routine screenings, such as:
Blood lead level
Total Blood Cholesterol
Colorectal Cancer
Screening, including
Fecal occult blood test
Sigmoidoscopy screening
Nothing for the test.
$10 per office visit if provided in
your
primary care physician's
office
$20 per office visit if provided in
your specialist's office
Prostate Specific Antigen (PSA test)
Routine pap test
Routine
mammogram –covered for women age 35 and older, one every
calendar year
Routine Immunizations, limited to:
Tetanus-diphtheria (Td) booster – once every 10 years, ages19 and over
(except as provided for under Childhood immunizations)
Influenza/ Pneumococcal vaccines, annually, age 65 and over
Nothing for the test.
$10 per office visit if provided in
your
primary care physician's
office
$20 per office visit if provided in
your specialist's office
Not covered: Physical exams required for obtaining or continuing
employment or insurance, attending schools or camp, or travel.
All
charges.
Preventive care, children You pay
Childhood immunizations
recommended by the American Academy of Pediatrics $10 per office visit if
provided in your primary care physician's
office
$20 per office visit if provided in
your specialist's office 13
13 Page 14 15
2001 Community Health Plan of Ohio 14
Section 5( a)
Preventive care, children (Continued)
You pay
Examinations, such as:
Eye exams through age 17 to
determine the need for vision correction.
Ear exams through age 17 to determine the need for hearing correction
Examinations done on the day of immunizations (through age 22)
Well-child care charges for routine examinations, immunizations and care
(through age 22)
$10 per office visit if provided in
your primary care physician's
office
$20 per office visit if provided in
your specialist's office
Maternity care You pay
Complete maternity (obstetrical) care, such
as:
Prenatal care
Delivery
Postnatal care
Routine sonograms
Note: Here are some things to keep in mind:
You do not need to precertify your normal delivery; see page 9 for other
circumstances, such as extended stays for you or your baby.
You may remain in the hospital up to 48 hours after a regular delivery and 96
hours after a cesarean delivery. We will extend
your inpatient stay if
medically necessary.
We cover routine nursery care of the newborn child
during the covered portion of the mother's maternity stay. We will cover other
care of an infant who requires non-routine treatment only if we
cover the
infant under a Self and Family enrollment.
We pay hospitalization and surgeon services (delivery) the same as for
illness and injury. See Hospital benefits (Section 5c) and
Surgery benefits (Section 5b).
$20 single copay for the entire
pregnancy
Family planning You pay
Voluntary sterilization
Injectable
contraceptive drugs
IUDs
$10 per office visit if provided in
your primary care physician's
office
$20 per office visit if provided in
your specialist's office 14
14 Page 15 16
2001 Community Health Plan of Ohio 15
Section 5( a)
Family planning (Continued) You pay
Not covered:
Reversal of voluntary surgical sterilization, genetic counseling;
Procedures, services, drugs and 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;
All charges.
Infertility services You pay
Diagnosis and treatment of
infertility, such as:
Artificial insemination:
intravaginal insemination
(IVI)
intracervical insemination (ICI)
intrauterine insemination (IUI)
30% of charges
Not covered:
Assisted reproductive technology (ART) procedures,
such as:
in vitro fertilization
embryo transfer and GIFT
Services and supplies related to excluded ART procedures
Cost of donor sperm
Fertility drugs
All charges.
Allergy care You pay
Testing and treatment
Allergy injection
$10 per office visit if provided in
your primary care physician's
office
$20 per office visit if provided in
your specialist's office
Allergy serum Nothing
Not covered: provocative food testing and
sublingual allergy
desensitization
All charges. 15
15 Page 16 17
2001 Community Health Plan of Ohio 16
Section 5( a)
Treatment therapies You pay
Chemotherapy and
radiation therapy
Note: High dose chemotherapy in association with
autologous bone
marrow transplants are limited to those transplants listed
under
Organ/ Tissue Transplants on page 22.
Respiratory and inhalation therapy
Dialysis – Hemodialysis and
peritoneal dialysis
Intravenous (IV)/ Infusion Therapy – Home IV and
antibiotic therapy
Growth hormone therapy (GHT); covered under prescription drug benefit
$10 per office visit if provided in
your primary care physician's
office
$20 per office visit if provided in
your specialist's office
Rehabilitative therapies You pay
Physical therapy, occupational
therapy and speech therapy --
Up to 90 treatments per contract year combined,
per condition, if significant improvement can be expected within two months for
each of the following:
qualified physical therapists;
speech
therapists; and
occupational therapists.
Note: We cover short–
term rehabilitative therapy . Speech Therapy
is limited to treatment of
certain speech impairments of organic
origin. Occupational Therapy is
limited to services that assist the
member to achieve and maintain self-care
and improved
functioning in other activities of daily living.
Cardiac rehabilitation following a heart transplant, bypass surgery or a
myocardial infarction.
Non-surgical spinal treatment limited to 20 visits for Primary Care
Physician or Specialist.
$20 per treatment
Not covered:
Long-term rehabilitative therapy
Outpatient exercise programs without cardiac monitoring
All charges.
Hearing services (testing, treatment, and supplies) You pay
First
hearing aid and testing only when necessitated by accidental injury
Hearing testing for children through age 17 (see Preventive care,
children)
$10 per office visit if provided in
your primary care physician's
office
$20 per office visit if provided in
your specialist's office 16
16 Page 17 18
2001 Community Health Plan of Ohio 17
Section 5( a)
Hearing services (testing, treatment, and supplies)
(Continued)
You pay
Not covered:
all other hearing testing hearing aids,
testing and examinations for them All charges.
Vision services (testing, treatment, and supplies) You pay
Eye
exam to determine the need for vision correction for children through age 17
(see preventive care)
Annual eye refractions
$10 per office visit if provided in
your primary care physician's
office
$20 per office visit if provided in
your specialist's office
Not covered:
Eyeglasses or contact lenses and, after age 17,
examinations for them
Eye exercises and orthoptics
Radial keratotomy and other
refractive surgery
All charges.
Foot care You pay
Routine foot care when you are under active
treatment for a metabolic
or peripheral vascular disease, such as diabetes.
See orthopedic and prosthetic devices for information on podiatric shoe
inserts.
$10 per office visit if provided in
your primary care physician's
office
$20 per office visit if provided in
your specialist's office
Not covered:
Cutting, trimming or removal of corns, calluses,
or the free edge of toenails, and similar routine treatment of conditions of the
foot,
except as stated above
Treatment of weak, strained or flat feet
or bunions or spurs; and of any instability, imbalance or subluxation of the
foot (unless the
treatment is by open cutting surgery)
All charges.
Orthopedic and prosthetic devices You pay
Artificial limbs and
eyes; stump hose
Externally worn breast prostheses and surgical bras,
including necessary replacements, following a mastectomy. Surgical bras
were shown last year under DME.
Internal prosthetic devices, such as
artificial joints, pacemakers, cochlear implants, and surgically implanted
breast implant
following mastectomy. Note: See 5( b) for coverage of the surgery
to
insert the device.
Nothing up to $500, all charges
thereafter 17
17 Page 18 19
2001 Community Health Plan of Ohio 18
Section 5( a)
Orthopedic and prosthetic devices (Continued)
You pay
Corrective orthopedic appliances for non-dental treatment
of temporomandibular joint (TMJ) pain dysfunction syndrome. Nothing up to $500,
all charges thereafter
Not covered:
orthopedic and corrective shoes
arch
supports
foot orthotics
heel pads and heel cups
lumbosacral supports
corsets, trusses, elastic stockings,
support hose, and other supportive devices
prosthetic replacements
All charges.
Durable medical equipment (DME) You pay
Rental or purchase, at our
option, including repair and adjustment, of
durable medical equipment
prescribed by your Plan physician, such as
oxygen and dialysis equipment.
Under this benefit, we also cover:
hospital beds
wheelchairs;
crutches;
walkers;
blood glucose
monitors; and
insulin pumps.
Note: Call us at 740-348-1400 as soon as your Plan physician
prescribes
this equipment. We will arrange with a health care provider
to rent or sell
you durable medical equipment at discounted rates and
will tell you more
about this service when you call.
Nothing up to $500, all charges
thereafter 18
18 Page 19 20
2001 Community Health Plan of Ohio 19
Section 5( a)
Home health services You pay
Home health
care ordered by a Plan physician and provided by a registered nurse (R. N.),
licensed practical nurse (L. P. N.), licensed
vocational nurse (L. V. N.),
or home health aide.
Services include oxygen therapy, intravenous therapy
and medications.
Nothing
Not covered:
nursing care requested by, or for the convenience
of, the patient or the patient's family;
nursing care primarily for hygiene, feeding, exercising, moving the
patient, homemaking, companionship or giving oral medication.
All charges.
Alternative treatments You pay
Not covered: All charges.
Educational classes and programs You pay
None All charges.
19
19 Page 20
21
2001 Community Health Plan of Ohio 20
Section 5( b)
Section 5 (b). Surgical and anesthesia services
provided by physicians and other
health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
Be sure to read
Section 4, Your costs for covered services for valuable information about
how cost sharing works. Also read Section 9 about coordinating benefits with
other coverage, including with
Medicare.
The amounts listed below are for the charges billed by a
physician or other health care professional for your surgical care. Any costs
associated with the facility charge (i. e. hospital, surgical center, etc.)
are covered in Section 5 (c).
YOU MUST GET PRIOR AUTHORIZATION OF SOME
SURGICAL PROCEDURES. Please refer to the precertification information shown in
Section 3 to be sure which services require
precertification and identify which surgeries require prior authorization.
I M
P O
R T
A N
T
Benefit Description You pay
Surgical procedures
Treatment of fractures, including casting Normal pre and post-operative care
by the surgeon
Correction of amblyopia and strabismus Endoscopy procedure
Biopsy
procedure Removal of tumors and cysts
Correction of congenital anomalies
(see reconstructive surgery) Surgical treatment of morbid obesity --a condition
in which an
individual weighs 100 pounds or 100% over his or her normal
weight according to current underwriting standards; eligible
members
must be age 18 or over
Insertion of internal prosthetic devices. See 5( a) – Orthopedic braces
and prosthetic devices for device coverage information.
Voluntary sterilization Treatment of burns
Note: Generally, we pay for internal prostheses (devices) according
to
where the procedure is done. For example, we pay Hospital
benefits for a
pacemaker and Surgery benefits for insertion of the
pacemaker.
$10 per office visit if provided in
your primary care physician's
office
$20 per office visit if provided in
your specialist's office
Nothing Inpatient
Outpatient surgery is $50 per
procedure
Not covered:
Reversal of voluntary sterilization Routine
treatment of conditions of the foot; see Foot care. All charges.
Surgical procedures continued on next page. 20
20 Page 21 22
2001 Community Health Plan of Ohio 21
Section 5( b)
Reconstructive surgery You pay
Surgery to
correct a functional defect
Surgery to correct a condition caused by injury
or illness if:
the condition produced a major effect on the member's
appearance and
the condition can reasonably be expected to be corrected by such surgery
Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form or norm. Examples of
congenital anomalies are: protruding ear deformities; cleft lip; cleft
palate; birth marks; webbed fingers; and webbed toes.
All stages of breast reconstruction surgery following a mastectomy, such as:
surgery to produce a symmetrical appearance on the other breast;
treatment of any physical complications, such as lymphedemas;
breast
prostheses and surgical bras and replacements (see Prosthetic devices)
Note: If you need a mastectomy you may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to 48
hours after the procedure.
$10 per office visit if provided in
your primary care physician's
office
$20 per office visit if provided in
your specialist's office
Nothing Inpatient
Outpatient surgery is $50 per
procedure
Not covered:
Cosmetic surgery – any surgical procedure
(or any portion of a procedure) performed primarily to improve physical
appearance
through change in bodily form, except repair of accidental injury
Surgeries related to sex transformation
All charges
Oral and maxillofacial surgery You pay
Oral surgical procedures,
limited to:
Reduction of fractures of the jaws or facial bones; Surgical
correction of cleft lip, cleft palate or severe functional
malocclusion;
Removal of stones from salivary ducts; Excision of
leukoplakia or malignancies;
Excision of cysts and incision of abscesses when done as independent
procedures; and
Other surgical procedures that do not involve the teeth or
their supporting structures.
$20 per office visit if provided in
your specialist's office
Medical Services for Temporomandibular Joint Dysfunction 30% copayment up to
$500, all charges thereafter
Not covered:
Oral implants and
transplants Procedures that involve the teeth or their supporting
structures
(such as the periodontal membrane, gingiva, and alveolar bone)
All charges. 21
21 Page 22 23
2001 Community
Health Plan of Ohio 22 Section 5( b)
Organ/ tissue transplants
You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single –Double
Pancreas
Allogenic (donor) bone marrow transplants
Autologous bone marrow transplants (autologous stem cell and peripheral stem
cell support) for the following conditions: acute
lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's
lymphoma;
advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer;
multiple myeloma; epithelial ovarian
cancer; and testicular, mediastinal,
retroperitoneal and ovarian germ
cell tumors
Note: We cover related medical and hospital expenses of the donor
when we
cover the recipient.
$10 per office visit if provided in
your primary care physician's
office
$20 per office visit if provided in
your specialist's office
Nothing Inpatient
Outpatient surgery is $50 per
procedure
Not covered:
Donor screening tests and donor search expenses,
except those performed for the actual donor
Implants of artificial organs
Transplants not listed as covered
All charges
Anesthesia You pay
Professional services provided in –
Hospital (inpatient) Nothing
Professional services provided in –
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center Office
Nothing 22
22 Page
23 24
2001 Community Health Plan of
Ohio 23 Section 5( c)
Section 5 (c). Services provided by a
hospital or other facility, and
ambulance services
I M
P O
R T
A N
T
Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are
medically necessary.
Plan physicians must provide or arrange your care
and you must be hospitalized in a Plan facility.
Be sure to read Section 4, Your costs for covered services for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
The
amounts listed below are for the charges billed by the facility (i. e., hospital
or surgical center) or ambulance service for your surgery or care. Any costs
associated with the professional charge (i. e., physicians, etc.) are covered
in
Section 5( a) or (b).
YOU MUST GET PRIOR AUTH0RIZATION FOR HOSPITAL STAYS. Please refer to
Section 3 to be sure which services require prior authorization.
I M
P O
R T
A N
T
Benefit Description You pay
Inpatient hospital
Room and board,
such as
semiprivate, or intensive care accommodations; general nursing care;
and
meals and special diets.
NOTE: If you want a private room when it is not medically necessary,
you
pay the additional charge above the semiprivate room rate.
$50 copay per day; maximum
$250 copay per admission
Other hospital services and supplies, such as:
Operating, recovery,
maternity, and other treatment rooms Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays Administration of blood and blood
products
Blood or blood plasma, if not donated or replaced Dressings,
splints, casts, and sterile tray services
Medical supplies and equipment,
including oxygen Anesthetics, including nurse anesthetist services
Take-home
items Medical supplies, appliances, medical equipment, and any covered
items
billed by a hospital for use at home
Nothing
Not covered:
Custodial care Non-covered facilities, such
as nursing homes, extended care
facilities, schools
Personal comfort items, such as telephone,
television, barber services, guest meals and beds
Private nursing care
All charges. 23
23 Page 24 25
2001 Community
Health Plan of Ohio 24 Section 5( c)
Outpatient hospital or
ambulatory surgical center You pay
Operating, recovery, and other
treatment rooms Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services Administration of
blood, blood plasma, and other biologicals
Blood and blood plasma, if not
donated or replaced Pre-surgical testing
Dressings, casts, and sterile tray
services Medical supplies, including oxygen
Anesthetics and anesthesia
service
NOTE: – We cover hospital services and supplies related to
dental
procedures when necessitated by a non-dental physical impairment. We
do not cover the dental procedures.
Nothing
Not covered: blood and blood derivatives not replaced by the member All
charges
Extended care benefits/ skilled nursing care facility
benefits You pay
Extended care benefit/ Skilled Nursing Facility (SNF):
The Plan provides a comprehensive range of benefits for up to 60 days
per
contract year when full-time skilled nursing care is necessary
and
confinement in a skilled nursing facility is medically
appropriate as
determined by a Plan doctor and approved by the
Plan. All necessary services
are covered, including:
Bed, board and general nursing care
Drugs, biologicals, supplies, and
equipment ordinarily provided or arranged by the skilled nursing facility when
prescribed by a Plan doctor.
Nothing
Not covered: custodial care All charges
Hospice care You pay
Supportive and palliative care for a terminally ill member is covered in
the home or hospice facility. Services include inpatient and outpatient
care, and family counseling; these services are provided under the
direction of a Plan doctor who certifies that the patient is in the terminal
stages of illness, with a life expectancy of approximately six months or
less.
Nothing
Not covered: Independent nursing, homemaker services All charges 24
24 Page 25 26
2001 Community Health Plan of Ohio 25
Section 5( c)
Ambulance You pay
Transportation by
professional ground ambulance or air ambulance when transportation is medically
necessary. $100 per trip
Not covered:
Ambulette transportation
All charges 25
25 Page 26 27
2001 Community Health Plan of Ohio 26
Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure.
We have no calendar year deductible.
Be sure to read Section 4, Your
costs for covered services for valuable information about how cost sharing
works. Also read Section 9 about coordinating benefits with other
coverage, including with Medicare.
I M
P O
R T
A N
T
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or
an injury that you believe endangers your
life or could result in serious
injury or disability, and requires immediate medical or surgical care. Some
problems are
emergencies because, if not treated promptly, they might become
more serious; examples include deep cuts and
broken bones. Others are
emergencies because they are potentially life-threatening, such as heart
attacks, strokes,
poisonings, gunshot wounds, or sudden inability to
breathe. There are many other acute conditions that we may
determine are
medical emergencies – what they all have in common is the need for quick
action.
______________________________________________________________________________________________
What to do in case of emergency:
Emergencies within our service area: If you are in an emergency
situation, please call your physician. In extreme
emergencies, if you are
unable to contact your doctor, contact the local emergency system (e. g., the
911 telephone
system) or go to the nearest hospital emergency room. Be sure
to tell the emergency room personnel that you are a
Plan member so they can
notify the Plan. You or a family member should notify your physician within 24
hours.
Emergencies outside our service area: Benefits are available for any
medically necessary health service that is
immediately required because of
injury or unforeseen illness. If you obtain emergency care while temporarily
outside
the service area, inform your Primary Care Physician within 24 hours
or as soon as possible. Should you become
hospitalized, your Primary Care
Physician must be notified within 24 hours unless it is not reasonably possible
to do
so. To be covered by this Plan, any follow-up care recommended by
non-Plan providers must be approved by the
Plan or provided by Plan
providers. Your Primary Care Physician cannot retroactively authorize emergency
room
visits that are not emergency conditions.
Benefit Description You pay
Emergency within our service area
Emergency care at a doctor's office $10 per office visit if provided in your
primary care physician's
office
$20 per office visit if provided in
your specialist's office
Emergency care at an urgent care center $30 per office visit, waived if
admitted
Emergency care as an outpatient or inpatient at a hospital, including
doctors' services $50 per office visit, waived if admitted
Not covered: Elective care or non-emergency care All charges 26
26 Page 27 28
2001 Community Health Plan of Ohio 27
Section 5( d)
Emergency outside our service area You pay
Emergency care at a doctor's office $10 per office visit if provided in
your primary care physician's
office
$20 per office visit if provided in
your specialist's office
Emergency care at an urgent care center $30 per office visit, waived if
admitted
Emergency care as an outpatient or inpatient at a hospital,
including doctors' services $50 per office visit, waived if
admitted
Not covered:
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care
could have been foreseen before leaving the service area
Medical and hospital costs resulting from a normal full-term delivery of a
baby outside the service area
All charges.
Ambulance You pay
Professional ground and air ambulance service
when medically
appropriate.
See 5( c) for non-emergency service.
$100 per trip
Not covered:
Ambulette transportation
All charges. 27
27 Page 28 29
2001 Community Health Plan of Ohio 28
Section 5( e)
Section 5 (e). Mental health and substance abuse
benefits
I M
P O
R T
A N
T
Parity
Beginning in 2001, all FEHB plans' mental health and
substance abuse benefits will achieve
"parity" with other
benefits. This means that we will provide mental health and substance abuse
benefits differently than in the past.
When you get our approval for services and follow a treatment plan we
approve, cost-sharing
and limitations for Plan mental health and substance
abuse benefits will be no greater than for
similar benefits for other
illnesses and conditions.
Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and exclusions
in this brochure.
Be sure to read Section 4, Your costs for covered
services for valuable information about how cost sharing works. Also read
Section 9 about coordinating benefits with other
coverage, including with Medicare.
YOU MUST GET PREAUTHORIZATION OF
THESE SERVICES. See the
instructions after the benefits description
below.
I M
P O
R T
A N
T
Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider
and contained in a treatment plan that we approve. The treatment plan
may include services, drugs, and supplies described elsewhere in this
brochure.
Note: Plan benefits are payable only when we determine the care is
clinically appropriate to treat your condition and only when you receive
the care as part of a treatment plan that we approve.
Your cost sharing
responsibilities are no greater
than for other
illness or
conditions.
Professional services, including individual or group therapy by
providers
such as psychiatrists, psychologists, or clinical social
workers
Medication management
$10 per office visit if provided in
your primary care physician's
office
$20 per office visit if provided in
your specialist's office
Diagnostic tests Nothing
Services provided by a hospital or other
facility
Services in approved alternative care settings such as partial
hospitalization, half-way house, residential treatment, full-day
hospitalization, facility based intensive outpatient treatment
$50 copay per day; maximum
$250 copay per admission
Mental health and substance abuse benefits – Continued on next page
28
28 Page 29
30
2001 Community Health Plan of Ohio 29
Section 5( e)
Mental health and substance abuse benefits
(Continued) You pay
Not covered: Services we have not
approved.
Note: OPM will base its review of disputes about treatment plans
on the
treatment plan's clinical appropriateness. OPM will generally not
order us to pay or provide one clinically appropriate treatment plan in
favor of another.
All charges.
Preauthorization To be eligible to receive these benefits you must
follow your treatment plan and all the following authorization processes:
Your physician must get the approval of the Plan before sending you to a
hospital, referring you to a specialist, or recommending follow-up care.
Before giving approval, we consider if the service is medically necessary,
if
it is a covered benefit, and if it follows generally accepted medical
practice.
If you seek the services of any Provider without Prior
Authorization, you
will be responsible for the cost of such services.
Referral to a participating
specialist is given at the discretion of your
Primary Care Physician and the
Plan and is not open ended. The referral will
specify a number of visits and
a time frame in which they may occur. A
specialist may not refer to another
specialist without the Prior
Authorization of your Primary Care Physician
and the Plan except for
emergencies. All follow up care must be provided or
authorized by your
Primary Care Physician. If you go to the specialists for
additional visits
without obtaining Prior authorization from your Primary
Care Physician and
the Plan, you will be responsible for the cost of such
services. Contact our
Member Services department at 740-348-1400 or 1-
800-806-2756 for a listing
of providers or any questions you may have.
Special transitional benefit If a mental health or substance abuse
professional provider is treating you under our plan as of January 1, 2001, you
will be eligible for continued
coverage with your provider for up to 90 days
under the following condition:
If your mental health or substance abuse professional provider with
whom
you are currently in treatment leaves the Plan at our request for
other than
cause.
If this condition applies to you, we will allow you reasonable time to
transfer your care to a Plan mental health or substance abuse professional
provider. During the transitional period, you may continue to see your
treating provider and will not pay any more out-of-pocket than you did in
the
year 2000 for services. This transitional period will begin with our
notice to
you of the change in coverage and will end 90 days after you
receive our
notice. If we write to you before October 1, 2000, the 90-day
period ends
before January 1 and this transitional benefit does not apply.
Limitation We may limit your benefits if you do not follow your
treatment plan. 29
29 Page
30 31
2001 Community Health Plan of
Ohio 30 Section 5( f)
Section 5 (f). Prescription drug
benefits
I
M
P
O
R
T
A
N
T
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart
beginning on the next page.
All benefits are subject to the definitions, limitations and exclusions in
this brochure and are payable only when we determine they are medically
necessary.
Be sure to read Section 4, Your costs for covered services
for valuable information about how cost sharing works. Also read Section 9
about coordinating benefits with
other coverage, including with Medicare.
I
M
P
O
R
T
A
N
T
There are important features you should be aware of. These include:
Who can write your prescription. Prescription drugs prescribed by a
Plan or referral doctor.
Where you can obtain them. You must fill the
prescription at a plan pharmacy.
We use a formulary. Drugs are
prescribed by Plan doctors and dispensed in accordance with the Plan's drug
formulary. Your doctor can ask for exceptions to the formulary. Non-formulary
drugs
will be covered when prescribed by a Plan doctor. The Plan uses a formulary
that includes generic
and preferred name brand drugs.
These are the dispensing limitations. Prescription drugs prescribed
will be dispensed for up to a 30-day supply or 100-unit supply, whichever is
less; 240 milliliters of liquid (8oz.); 60 grams of
ointment; creams or topical preparation; or one commercially prepared unit
(e. g. one inhaler, one
vial ophthalmic medication or insulin). You pay a
$10 copay per prescription unit or refill for
generic drugs and a $15 copay
for brand drugs. If there is no generic equivalent available, you will
still
have to pay the brand name copay.
When you have to file a claim. If you are required to pay for a
prescription up front when out of the service area, please submit your receipt(
s) to Community Health Plan of Ohio, 1915
Tamarack Road, Newark, Ohio, 43055. You will be reimbursed the full amount
minus the
copayment.
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan
physician and obtained from a Plan pharmacy.
Drugs and medicines that by Federal law of the United States require a
physician's prescription for their purchase, except as
excluded below.
Diabetic supplies, including insulin syringes, needles, glucose test tablets
and test tape, Benedict's solution or equivalent and acetone
test tablets
Insulin, with a copay charge applied to each vial Disposable
needles and syringes for the administration of covered
medications
Drugs for sexual dysfunction Oral and injectable
contraceptive drugs
Intravenous fluids and medications for home use Glucometers are covered for
one per family per lifetime
Immunosuppressant drugs
$ 10 per generic prescription
$ 15 per brand name
prescription
Note: If there is no generic
equivalent available, you will
still
have to pay the brand name
copay.
30% of charges
50% of charges 30
30 Page 31 32
2001 Community
Health Plan of Ohio 31 Section 5( f)
Covered medications and
supplies (Continued) You Pay
Growth hormone therapy (GHT)
Note: – We will only cover GHT when we preauthorize the treatment.
Call 740-348-1400 for preauthorization. We will ask you to submit
information that establishes that the GHT is medically necessary. Ask
us
to authorize GHT before you begin treatment; otherwise, we will
only cover
GHT services from the date you submit the information. If
you do not ask or
if we determine GHT is not medically necessary, we
will not cover the GHT or
related services and supplies. See Services
requiring our prior approval
in Section 3.
20% of charges
Here are some things to keep in mind about our prescription drug
program:
A generic equivalent will be dispensed if it is available, unless your
physician specifically requires a name brand. If you receive a
name brand
drug when a Federally-approved generic drug is
available, and your physician
has not specified Dispense as Written
for the name brand drug, you have to
pay the difference in cost
between the name brand drug and the generic.
We administer an open formulary. If your physician believes a name brand
product is necessary or there is no generic available,
your physician may
prescribe a name brand drug from a formulary
list. This list of name brand
drugs is a preferred list of drugs that
we selected to meet patient needs at
a lower cost.
Not covered:
Drugs and supplies for cosmetic purposes
Vitamins, nutrients and food supplements even if a physician
prescribes or administers them
Drugs available without a prescription or for which there is a
nonprescription equivalent available
Fertility drugs
Drugs obtained at a non-Plan pharmacy except
for out-of-area emergencies
Medical supplies such as dressings and antiseptics
Drugs to
enhance athletic performance
Drugs to aid in smoking cessation
All Charges 31
31 Page 32 33
2001 Community
Health Plan of Ohio 32 Section 5( g)
Section 5 (g). Special
Features
Feature Description
Flexible benefits
option
Under the flexible benefits option, we determine the most effective
way
to provide services.
We may identify medically appropriate alternatives to traditional care and
coordinate other benefits as a less costly alternative
benefit.
Alternative benefits are subject to our ongoing review.
By
approving an alternative benefit, we cannot guarantee you will get it in the
future.
The decision to offer an alternative benefit is solely ours, and we may
withdraw it at any time and resume regular contract benefits.
Our decision
to offer or withdraw alternative benefits is not subject to OPM review under the
disputed claims process.
24 hour nurse line For any of your health concerns, 24 hours a day, 7
days a week, you may call 1-740-348-4968 and talk with a registered nurse who
will
discuss treatment options and answer your health questions.
Services for deaf and
hearing impaired TDD# 1-740-348-4729
Centers of excellence
for transplants/ heart
surgery/ etc
Community Health Plan of Ohio contracts with various Centers of
Excellence for services your local hospital is unable to provide. Call
your member services representative at 1-800-806-2756 or 1-740-348-
1400
for more information.
Travel benefit/ services
overseas
Emergency and urgent health services are covered worldwide, unless
you
have traveled outside the service area for the purpose of receiving
such
treatment. 32
32 Page
33 34
2001 Community Health Plan of
Ohio 33 Section 5( h)
Section 5 (h). Dental benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
We cover hospitalization for dental procedures only when a nondental physical
impairment exists which makes hospitalization necessary to safeguard the health
of the patient; we do not
cover the dental procedure unless it is described
below.
Be sure to read Section 4, Your costs for covered services for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage,
including with Medicare.
I M
P O
R T
A N
T
Accidental injury benefit You pay
We cover restorative services and supplies necessary to promptly repair
(but not replace) sound natural teeth. The need for these services must
result from an accidental injury
Nothing
Dental benefits You pay
We have no other dental benefits. All
charges 33
33 Page
34 35
2001 Community Health Plan of
Ohio 34 Section 6/ 7
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 9.
We do not cover the following:
Care by non-Plan providers except for authorized referrals or emergencies
(see Emergency Benefits);
Services, drugs, or supplies you receive while you are not enrolled in this
Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of
medical, dental, or psychiatric practice;
Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or supplies related to abortions, except when the life of
the mother would be endangered if the fetus were carried to term or when the
pregnancy is the result of an act of rape or
incest
Services, drugs, or supplies related to sex transformations; or
Services, drugs, or supplies you receive from a provider or facility barred
from the FEHB Program.
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 copayments.
You will only need to file a claim when you receive emergency services from
non-plan providers. Sometimes these
providers bill us directly. Check with
the provider. If you need to file the claim, here is the process:
Medical, hospital & drug benefits In most cases, providers and
facilities file claims for you. Physicians must file on the form HCFA-1500,
Health Insurance Claim Form.
Facilities will file on the UB-92 form. For
claims questions and
assistance, call us at 740-348-1400.
When you must file a claim --such as for out-of-area care --submit it on
the HCFA-1500 or a claim form that includes the information shown
below.
Bills and receipts should be itemized and show:
Covered member's name and ID number;
Name and address physician or
facility that provided the service or supply;
Dates you received the services or supplies;
Diagnosis;
Type of each
service or supply;
The charge for each service or supply; 34
34 Page 35 36
2001 Community Health Plan of Ohio 35
Section 8
A copy of the explanation of benefits, payments, or denial
from any primary payer --such as the Medicare Summary Notice (MSN); and
Receipts, if you paid for your services.
Submit your claims to:
Community Health Plan of Ohio
1915 Tamarack Rd.
Newark, Ohio 43055
Deadline for filing your claim Send us all of the documents for your
claim as soon as possible. You must submit the claim by December 31 of the year
after the year you
received the service, unless timely filing was prevented
by administrative
operations of Government or legal incapacity, provided the
claim was
submitted as soon as reasonably possible.
When we need more information Please reply promptly when we ask for
additional information. We may delay processing or deny your claim if you do not
respond.
Section 8. The disputed claims process
Follow this Federal
Employees Health Benefits Program disputed claims process if you disagree with
our decision on
your claim or request for services, drugs, or supplies
– including a request for preauthorization:
Step Description
1 Ask us in writing to reconsider our initial decision. You must: (a)
Write to us within 6 months from the date of our decision; and
(b) Send your
request to us at: Community Health Plan of Ohio, 1915 Tamarack Rd., Newark, Ohio
43055
(c) Include a statement about why you believe our initial decision was
wrong, based on specific benefit
provisions in this brochure; and
(d) Include copies of documents that support your claim, such as physicians'
letters, operative reports, bills,
medical records, and explanation of
benefits (EOB) forms.
2 We have 30 days from the date we receive your request to: (a) Pay
the claim (or arrange for the health care provider to give you the care); or
(b) Write to you and maintain our denial --go to step 4; or
(c) Ask you
or your medical provider for more information. If we ask your provider, we will
send you a
copy of our request— go to step 3.
3 You or your provider must send the information so that we receive it
within 60 days of our request. We will then decide within 30 more days. If we do
not receive the information within 60 days, we will decide within 30 days of the
date the
information was due. We will base our decision on the information
we already have.
We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it.
35
35 Page 36 37
2001 Community Health Plan of Ohio 36
Section 8
The disputed claims process (continued)
You must write to OPM within:
90 days after the date of our
letter upholding our initial decision; or
120 days after you first wrote to
us --if we did not answer that request in some way within 30 days; or
120
days after we asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance
Programs, Contracts Division III,
P. O. Box 436, Washington, D. C.
20044-0436.
Send OPM the following information:
A statement about why you believe our
decision was wrong, based on specific benefit provisions in this brochure;
Copies of documents that support your claim, such as physicians' letters,
operative reports, bills, medical records, and explanation of benefits (EOB)
forms;
Copies of all letters you sent to us about the claim;
Copies of
all letters we sent to you about the claim; and
Your daytime phone number
and the best time to call.
Note: If you want OPM to review different claims, you must clearly identify
which documents apply to
which claim.
Note: You are the only person who has a right to file a disputed claim with
OPM. Parties acting as your
representative, such as medical providers, must
provide a copy of your specific written consent with the
review request.
Note: The above deadlines may be extended if you show that you were unable to
meet the deadline because
of reasons beyond your control.
5 OPM will review your disputed claim request and will use the
information it collects from you and us to decide whether our decision is
correct. OPM will send you a final decision within 60 days. There are no other
administrative appeals.
6 If you do not agree with OPM's decision, your only recourse is to
sue. If you decide to sue, you must file the suit against OPM in Federal court
by December 31 of the third year after the year in which you received the
disputed services or supplies. This is the only deadline that may not be
extended.
OPM may disclose the information it collects during the review
process to support their disputed claim
decision. This information will
become part of the court record.
You may not sue until you have completed the disputed claims process.
Further, Federal law governs your
lawsuit, benefits, and payment of
benefits. The Federal court will base its review on the record that was
before OPM when OPM decided to uphold or overturn our decision. You may
recover only the amount of
benefits in dispute.
NOTE: If you have a serious or life threatening condition (one that
may cause permanent loss of bodily
functions or death if not treated as soon
as possible), and
(a) We haven't responded yet to your initial request for care or
preauthorization/ prior approval, then call us at
740-348-1400 or
1-800-806-2756 and we will expedite our review; or
(b) We denied your initial request for care or preauthorization/ prior
approval, then: 36
36 Page
37 38
2001 Community Health Plan of
Ohio 37 Section 9
If we expedite our review and maintain our
denial, we will inform OPM so that they can give your claim expedited treatment
too, or
You can call OPM's Health Benefits Contracts Division III at
202-606-0737 between 8 a. m. and 5 p. m. eastern time.
Section 9. Coordinating benefits with other coverage
When you have
other health coverage You must tell us if you are covered or a family member
is covered under another group health plan or have automobile insurance that
pays health
care expenses without regard to fault. This is called
"double coverage."
When you have double coverage, one plan
normally pays its benefits in
full as the primary payer and the other plan
pays a reduced benefit as the
secondary payer. We, like other insurers,
determine which coverage is
primary according to the National Association of
Insurance
Commissioners' guidelines.
When we are the primary payer, we will pay the benefits described in this
brochure.
When we are the secondary payer, we will determine our allowance.
After
the primary plan pays, we will pay what is left of our allowance, up
to our
regular benefit. We will not pay more than our allowance.
What is Medicare? Medicare is a Health Insurance Program for:
People 65 years of age and older.
Some people with disabilities, under
65 years of age.
People with End-Stage Renal Disease (permanent kidney
failure requiring dialysis or a transplant).
Medicare has two parts:
Part A (Hospital Insurance). Most people do not
have to pay for Part A.
Part B (Medical Insurance). Most people pay monthly
for Part B.
If you are eligible for Medicare, you may have choices in how you get your
health
care. Medicare managed care plan is the term used to describe the
various health
plan choices available to Medicare beneficiaries. The
information in the next few
pages shows how we coordinate benefits with
Medicare, depending on the type of
Medicare managed care plan you have.
The Original Medicare Plan The Original Medicare Plan is available
everywhere in the United States. It is the way most people get their Medicare
Part A and Part B benefits. You
may go to any doctor, specialist, or
hospital that accepts Medicare. Medicare
pays its share and you pay your
share. Some things are not covered under
Original Medicare, like
prescription drugs. When you are enrolled inthis
Plan and Original Medicare,
you still need still need to follow the rules in
this brochure for us to
cover your care.
We will not waive any of our copayment when our plan is primary.
(Primary payer chart begins on next page.) 37
37 Page 38 39
2001 Community Health Plan of Ohio 38
Section 9
The following chart illustrates whether Original Medicare
or this Plan should be the primary payer for you according
to your
employment status and other factors determined by Medicare. It is critical that
you tell us if you or a covered
family member has Medicare coverage so we
can administer these requirements correctly.
Primary Payer Chart
Then the primary payer is… A. When either
you --or your covered spouse --are age 65 or over and …
Original Medicare This Plan
1) Are an active employee with the
Federal government (including when you or
a family member are eligible for
Medicare solelybecause of a disability), !
2) Are an annuitant, !
3) Are a reemployed annuitant with the Federal
government when…
a) The position is excluded from FEHB, or !
b) The position is not excluded from FEHB
Ask your employing office which
of these applies to you.
!
4) Are a Federal judge who retired under title 28, U. S. C., or a Tax
Court judge who retired under Section 7447 of title 26, U. S. C. (or if
your covered spouse is this type of judge), !
5) Are enrolled in Part B only, regardless of your employment status, ! (for
Part B
services)
!
(for other
services)
6) Are a former Federal employee receiving Workers' Compensation
and the
Office of Workers' Compensation Programs has determined
that you are unable
to return to duty,
!
(except for claims
related to Workers'
Compensation.)
B. When you --or a covered family member --have Medicare
based on end
stage renal disease (ESRD) and…
1) Are within the first 30 months of eligibility to receive Part A
benefits solely because of ESRD, !
2) Have completed the 30-month ESRD coordination period and are
still
eligible for Medicare due to ESRD, !
3) Become eligible for Medicare due to ESRD after Medicare became
primary
for you under another provision, !
C. When you or a covered family member have FEHB and…
1)
Are eligible for Medicare based on disability, and
a) Are an annuitant or, !
b) Are an active employee ! 38
38 Page 39 40
2001 Community Health Plan of Ohio 39 Section 9
Claims
process --You probably will never have to file a claim form
when you
have both our Plan and Medicare.
When we are the primary payer, we process the claim first.
When Original
Medicare is the primary payer, Medicare processes
your claim first. In most
cases, your claims will be coordinated
automatically and we will pay the
balance of covered charges. You
will not need to do anything. To find out if
you need to do something
about filing your claims, call us at 740-348-1400
or 1-800-806-2756.
We waive some costs when you have Medicare --When Medicare is
the
primary payer, we will waive some out-of-pocket costs, as follows:
When we are secondary, our payments will be based on the
remaining
balance after the primary plan has paid. We will pay no
more than that
balance. In no event will we pay more than we would
have paid had we been
primary.
We will pay only for health care expenses that are covered by the
Plan.
We will pay no more than the "allowable expenses" for health care
involved. If our allowable expense is lower than the primary plan's,
we
will use the primary plan's allowable expenses. That may be less
than the
actual bill.
Medical services and supplies provided by physicians and other
health
care professionals. If you are enrolled in Medicare Part B, we
will waive
the office visit copay.
Medicare managed care plan If you are eligible for Medicare, you may
choose to enroll in and get your Medicare benefits from a Medicare managed care
plan. These are health
care choices (like HMOs) in some areas of the
country. In most
Medicare managed care plans, you can only go to doctors,
specialists, or
hospitals that are part of the plan. Medicare managed care
plans cover all
Medicare Part A and B benefits. Some cover extras, like
prescription
drugs. To learn more about enrolling in a Medicare managed care
plan,
contact Medicare at 1-800-MEDICARE (1-800-633-4227) or at
www. medicare. gov. If you enroll in a
Medicare managed care plan, the
following options are available to you:
This Plan and our Medicare managed care plan: You may enroll in
our Medicare managed care plan and also remain enrolled in our FEHB
plan. In this case, we do not waive any of our copayments or
coinsurance, for your FEHB coverage.
This Plan and another Plan's Medicare managed care plan: You
may
enroll in another plan's Medicare managed care plan and also
remain enrolled
in our FEHB plan. We will still provide benefits when
your Medicare managed
care plan is primary, even out of the managed
care plan's network and/ or
service area (if you use our Plan providers),
but we will waive any of our
copayments or coinsurance. We will pay
only if you have followed all of our
procedural requirements. Care
must be prior authorized by your primary
physician and the Plan.
Suspended FEHB coverage and a Medicare managed care plan: If
you
are an annuitant or former spouse, you can suspend your FEHB 39
39 Page 40 41
2001 Community Health Plan of Ohio 40
Section 9
coverage to enroll in a Medicare managed care plan,
eliminating your
FEHB premium. (OPM does not contribute to your Medicare
managed
care plan premium.) For information on suspending your FEHB
enrollment, contact your retirement office. If you later want to re-enroll
in the FEHB Program, generally you may do so only at the next open
season unless you involuntarily lose coverage or move out of the
Medicare Managed Care Plan service area.
Enrollment in Note: If you choose not to enroll in Medicare Part B,
you can still be Medicare Part B covered under the FEHB Program. We
cannot require you to enroll in
Medicare.
TRICARE TRICARE is the health care program for eligible dependents of
military persons, and retirees of the military. TRICARE includes the CHAMPUS
program. If both TRICARE and this Plan cover you, we pay first. See
your
TRICARE Health Benefits Advisor if you have questions about
TRICARE
coverage.
Workers' Compensation We do not cover services that:
you need
because of a workplace-related disease or injury that the Office of Workers'
Compensation Programs (OWCP) or a similar
Federal or State agency determines
they must provide; or
OWCP or a similar agency pays for through a third party injury settlement or
other similar proceeding that is based on a claim you
filed under OWCP or
similar laws.
Once OWCP or similar agency pays its maximum benefits for your
treatment, we will cover your benefits. You must use our providers.
Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies We do not cover services and supplies
when a local, State,
are responsible for your care or Federal
Government agency directly or indirectly pays for them.
When others are responsible When you receive money to compensate you
for medical or
for injuries hospital care for injuries or illness
caused by another person, you must reimburse us for any expenses we paid.
However, we will cover the cost
of treatment that exceeds the amount you received in the settlement.
If
you do not seek damages, you must agree to let us try. This is called
subrogation. If you need more information, contact us for our
subrogation procedures. 40
40 Page 41 42
2001 Community
Health Plan of Ohio 41 Section 10
Section 10. Definitions of
terms we use in this brochure
Calendar year January 1 through December
31 of the same year. For new enrollees, the calendar year begins on the
effective date of their enrollment and ends on
December 31 of the same year.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services. See page 10.
Covered services Care we provide benefits for, as described in this
brochure.
Custodial care Care primarily for the purpose of helping
you with daily living or meeting personal needs and could be provided by person
without
professional skills or training. Much of the care provided in
nursing
homes to people with chronic, long-term illness or disabilities is
considered custodial care.
Experimental or The Plan uses peer-reviewed medical literature, FDA
regulations, and investigational services review by any Institutional
Review board to determine experimental,
investigative, or unproved services
such as medical, surgical, diagnostic,
psychiatric, substance abuse or other
health care technologies, supplies,
treatments, diagnostic procedures, drug
therapies and devices.
Medical necessity Only benefits that are medically necessary (or are
preventive services) are covered under CHPO. Medically necessary means health
care
services that: are appropriate and consistent with the diagnosis in
accordance with generally accepted standards of medical practice
recognized by the Plan; are not considered Experimental or Investigative;
could not have been omitted without adversely affecting the member's
condition or quality of care; are not primarily for the convenience of the
member, the provider or the caregiver; necessary to meet the basic health
needs of the member; rendered in the most cost-efficient manner and type
of setting appropriate for the delivery of the health service; and
consistent
type, frequency and duration of treatment with scientifically
based
guidelines of national medical, research or health care coverage
organizations or governmental agencies that are accepted by the Plan.
Us/ We Us and we refer to Community Health Plan of Ohio
You
You refers to the member and each covered family member. 41
41 Page 42 43
2001 Community Health Plan of Ohio 42
Section 11
Section 11. FEHB facts
No pre-existing condition
We will not refuse to cover the treatment of a condition that you had
limitation before you enrolled in this Plan solely because you had
the condition before you enrolled.
Where you can get information See www. opm. gov/ insure. Also, your
employing or retirement office
about enrolling in the can answer your
questions, and give you a Guide to Federal Employees
FEHB Program
Health Benefits Plans, brochures for other plans, and other materials
you need to make an informed decision about:
When you may change your enrollment;
How you can cover your family
members;
What happens when you transfer to another Federal agency, go on
leave without pay, enter military service, or retire;
When your enrollment ends; and
When the next open season for enrollment
begins.
We don't determine who is eligible for coverage and, in most cases,
cannot change your enrollment status without information from your
employing or retirement office.
Types of coverage available Self Only coverage is for you alone. Self
and Family coverage is for
for you and your family you, your spouse,
and your unmarried dependent children under age 22, including any foster
children or stepchildren your employing or
retirement office authorizes coverage for. Under certain circumstances,
you may also continue coverage for a disabled child 22 years of age or
older who is incapable of self-support.
If you have a Self Only enrollment, you may change to a Self and Family
enrollment if you marry, give birth, or add a child to your family. You
may change your enrollment 31 days before to 60 days after that event.
The Self and Family enrollment begins on the first day of the pay period
in which the child is born or becomes an eligible family member. When
you change to Self and Family because you marry, the change is effective
on the first day of the pay period that begins after your employing office
receives your enrollment form; benefits will not be available to your
spouse until you marry.
Your employing or retirement office will not notify you when a family
member is no longer eligible to receive health benefits, nor will we.
Please tell us immediately when you add or remove family members
from
your coverage for any reason, including divorce, or when your child
under
age 22 marries or turns 22.
If you or one of your family members is enrolled in one FEHB plan, that
person may not be enrolled in or covered as a family member by another
FEHB plan. 42
42 Page
43 44
2001 Community Health Plan of
Ohio 43 Section 11
When benefits and The benefits in this
brochure are effective on January 1. If you are new
premiums start to
this Plan, your coverage and premiums begin on the first day of your first pay
period that starts on or after January 1. Annuitants' premiums begin on January
1.
Your medical and claims We will keep your medical and claims
information confidential. Only
records are confidential the following
will have access to it:
OPM, this Plan, and subcontractors when they administer this contract;
This Plan, and appropriate third parties, such as other insurance plans and
the Office of Workers' Compensation Programs (OWCP), when
coordinating benefit payments and subrogating claims;
Law enforcement
officials when investigating and/ or prosecuting alleged civil or criminal
actions;
OPM and the General Accounting Office when conducting audits;
Individuals
involved in bona fide medical research or education that does not disclose your
identity; or
OPM, when reviewing a disputed claim or defending litigation about a claim.
When you retire When you retire, you can usually stay in the FEHB
Program. Generally, you must have been enrolled in the FEHB Program for the last
five years of your
Federal service. If you do not meet this requirement, you
may be eligible for
other forms of coverage, such as Temporary Continuation
(TCC).
When you lose benefits
When FEHB coverage ends You will
receive an additional 31 days of coverage, for no additional premium, when:
Your enrollment ends, unless you cancel your enrollment, or
You are a
family member no longer eligible for coverage.
You may be eligible for
spouse equity coverage or Temporary
Continuation of Coverage.
Spouse equity If you are divorced from a Federal employee or
annuitant, you may not coverage continue to get benefits under your
former spouse's enrollment. But, you
may be eligible for your own FEHB coverage under the spouse equity
law.
If you are recently divorced or are anticipating a divorce, contact
your
ex-spouse's employing or retirement office to get RI 70-5, the
Guide to
Federal Employees Health Benefits Plans for Temporary
Continuation of
Coverage and Former Spouse Enrollees, or other
information about your
coverage choices.
TCC If you leave Federal service, or if you lose coverage because you
no longer qualify as a family member, you may be eligible for Temporary
Continuation of Coverage (TCC). For example, you can receive TCC if
you
are not able to continue your FEHB enrollment after you retire.
You may not elect TCC if you are fired from your Federal job due to
gross
misconduct.
Get the RI 79-27, which describes TCC, and the RI 70-5, the Guide to
Federal Employees Health Benefits Plans for Temporary Continuation of
Coverage and Former Spouse Enrollees, from your employing or
retirement
office or from www. opm. gov/ insure. 43
43 Page 44 45
2001 Community
Health Plan of Ohio 44 Section 11
Converting to You may
convert to an individual policy if: individual coverage Your coverage
under TCC or the spouse equity law ends. If you
canceled your coverage or
did not pay your premium, you cannot
convert;
You decided not to receive coverage under TCC or the spouse equity law; or
You are not eligible for coverage under TCC or the spouse equity law.
If
you leave Federal service, your employing office will notify you of
your
right to convert. You must apply in writing to us within 31 days
after you
receive this notice. However, if you are a family member who
is losing
coverage, the employing or retirement office will not notify
you. You
must apply in writing to us within 31 days after you are no
longer eligible
for coverage.
Your benefits and rates will differ from those under the FEHB Program;
however, you will not have to answer questions about your health, and
we
will not impose a waiting period or limit your coverage due to pre-existing
conditions.
Getting a Certificate of If you leave the FEHB Program, we will give
you a Certificate of Group Group Health Plan Coverage Health Plan
Coverage that indicates how long you have been enrolled
with us. You can use
this certificate when getting health insurance or
other health care
coverage. Your new plan must reduce or eliminate
waiting periods,
limitations, or exclusions for health related conditions
based on the
information in the certificate, as long as you enroll within
63 days of
losing coverage under this Plan.
If you have been enrolled with us for less than 12 months, but were
previously enrolled in other FEHB plans, you may also request a
certificate from those plans.
Inspector General Advisory Stop health care fraud! Fraud increases the
cost of health care for everyone. If you suspect that a physician, pharmacy, or
hospital has
charged you for services you did not receive, billed you twice
for the
same service, or misrepresented any information, do the following:
Call the provider and ask for an explanation. There may be an error. If the
provider does not resolve the matter, call us at 740-348-1400
and explain
the situation.
If we do not resolve the issue, call THE HEALTH CARE FRAUD
HOTLINE— 202-418-3300 or write to: The United States Office of
Personnel Management, Office of the Inspector General Fraud
Hotline, 1900
E Street, NW, Room 6400, Washington, DC 20415.
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB
Program benefits can be
prosecuted for fraud. Also, the Inspector General
may investigate
anyone who uses an ID card if the person tries to obtain
services for
someone who is not an eligible family member, or is no longer
enrolled
in the Plan and tries to obtain benefits. Your agency may also take
administrative action against you. 44
44
Page 45 46
2001
Community Health Plan of Ohio 45 Index
Index
Do not
rely on this page; it is for your convenience and does not explain your benefit
coverage.
Accidental injury 26 Allergy tests 15
Alternative treatment 19
Ambulance 27
Anesthesia 22 Autologous bone marrow
transplant 22
Biopsies 20
Blood and blood plasma 23, 24 Breast cancer screening 13
Casts 20 Catastrophic protection 10, 47
Changes for 2001 6
Chemotherapy 16
Childbirth 14 Cholesterol tests 13
Claims 34 Colorectal
cancer screening 13
Congenital anomalies 20 Contraceptive devices and drugs
14, 30
Coordination of benefits 37 Covered charges 10
Covered providers
7
Crutches 18
Definitions 4 Dental care 33
Diagnostic services 12 Disputed claims review 35
Donor expenses
(transplants) 22 Dressings 23, 24, 31
Durable medical equipment (DME) 18
Educational classes and programs 19 Effective date of enrollment 43
Emergency 26 Experimental or investigational 34
Eyeglasses 17 Family
planning 14
Fecal occult blood test 13 General Exclusions 34
Hearing services 16
Home health services 19 Hospice care 24
Home nursing care 19 Hospital 23
Immunizations 13, 14 Infertility 15
Inhospital physician care 12
Inpatient Hospital Benefits 23
Insulin 30 Laboratory and pathological
services 13 Machine diagnostic tests 13
Magnetic Resonance
Imagings (MRIs) 13
Mammograms 13 Maternity Benefits 14
Medicaid 40
Medically necessary 41
Medicare 37 Members 41, 42
Mental Conditions/
Substance Abuse Benefits 28
Newborn care 12 Nurse
Licensed
Practical Nurse 19 Nurse Anesthetist 23
Registered Nurse 19 Nursery charges
14
Obstetrical care 14 Occupational therapy 16
Office visits 12
Oral and maxillofacial surgery 21
Orthopedic devices 17, 18 Out-of-pocket
expenses 10
Outpatient facility care 24 Oxygen 18,23, 24
Pap test
13 Physical examination 13
Physical therapy 16 Physician 7
Pre-admission
testing 24
Precertification 9 Preventive care, adult 13
Preventive care, children
13, 14
Prescription drugs 30 Preventive services 13, 14
Prior
Authorization 9 Prostate cancer screening 13
Prosthetic devices 17, 18
Psychologist 28
Psychotherapy 28 Radiation therapy 16
Rehabilitation therapies 16
Renal dialysis 16, 18 Room and board 23
Second surgical opinion 12 Skilled nursing facility care 24
Smoking cessation 31 Speech therapy 16
Splints 23 Sterilization
procedures
14, 20 Subrogation 40
Substance abuse 28 Surgery 20
Anesthesia 22 Oral 21
Outpatient 24 Reconstructive 21
Syringes 30
Temporary continuation of
coverage 43 Transplants 22
Treatment
therapies 16
Vision services 17 Well child care 13, 14
Wheelchairs 18 Workers' compensation 40
X-rays 13 45
45 Page 46 47
2001 Community Health Plan of Ohio 46
NOTES: 46
46 Page
47 48
2001 Community Health Plan of
Ohio 47
Summary of benefits for the Community Health Plan of Ohio
-2001
Do not rely on this chart alone. All benefits are provided
in full unless indicated and are subject to the
definitions, limitations,
and exclusions in this brochure. On this page we summarize specific expenses we
cover;
for more detail, look inside.
If you want to enroll or change your enrollment in this Plan, be sure to put
the correct enrollment code from the
cover on your enrollment form.
We only cover services provided or arranged by Plan physicians, except in
emergencies.
Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office.................
Office visit copay: $10 primary care; $20 specialist 12
Services provided by a hospital:
Inpatient............................................................................................
Outpatient
.........................................................................................
$50 copay per day maximum/
$250 copay per admission
23
24
Emergency benefits:
In-area
.............................................................................................
Out-of-area
......................................................................................
$30 per urgent care visit, waived
if admitted
$50 per hospital visit,
waived if
admitted
$30 per urgent care visit, waived
if admitted
$50 per hospital visit , waived if
admitted
26
27
Mental health and substance abuse treatment
..................................... Regular cost sharing 28
Prescription
drugs
.................................................................................
$10 copay generic
$15 copay brand
30
Dental
Care.......................................................................................
No benefit. 33
Vision
Care.......................................................................................
Office visit copay: $10 primary
care; $20 specialist 17
Special features
Flexible benefits
option…………………………………………
24 hour nurse
line……………………………………………….
Services for deaf and hearing
impaired…………………………
Centers of excellence for transplants/ heart/ surgery/ etc
………..
Travel benefit/ services
overseas…………………………………
32
Protection against catastrophic costs
(your out-of-pocket maximum)
........................................................
Nothing after $500/ Self Only or
$1,000/ Family enrollment per year
Some costs do not count toward
this protection
10 47
47 Page
48
2001 Community Health Plan of Ohio 48
2001
Rate Information for
Community Health Plan of Ohio
Non-Postal rates apply to most non-Postal enrollees. If you are in a
special enrollment category,
refer to the FEHB Guide for that category or
contact the agency that maintains your health benefits
enrollment.
Postal rates apply to career Postal Service employees. Most employees
should refer to the FEHB
Guide for United States Postal Service Employees,
RI 70-2. Different postal rates apply and
special FEHB guides are published
for Postal Service Nurses and Tool & Die employees (see RI
70-2B); and
for Postal Service Inspectors and Office of Inspector General (OIG) employees
(see
RI 70-2IN).
Postal rates do not apply to non-career postal employees, postal retirees, or
associate members of
any postal employee organization. Refer to the
applicable FEHB Guide .
Type of
Enrollment Code
Non-Postal Premium
Biweekly Monthly
Gov't Your Gov't Your
Share Share Share Share
Postal Premium
Biweekl