Blue Cross-HMO 2001 http:// www.
bluecrossca. com
A Health Maintenance Organization
Enrollment in this Plan is limited; see page 6 for requirements.
This
Plan has full accreditation from the NCQA. See the
2001 Guide
for more information on NCQA
RI 73-517
For
changes in
benefits,
see page 7
Enrollment Code: M51 Self Only
M52 Self and Family 1
1 Page 2 3
2001 Blue Cross-HMO Plan 2 Table of Contents
Table of
Contents
Introduction
..........................................................................................................................................................
4
Plain Language
......................................................................................................................................................
4
Section 1. Facts about this HMO plan
....................................................................................................................
5
Who provides my health care
................................................................................................................
5
How we pay provider
............................................................................................................................
5
Patients' Bill of Rights
..........................................................................................................................
6
Service Area
.........................................................................................................................................
6
Section 2. How we change for 2001
......................................................................................................................
7
Program-wide changes
..........................................................................................................................
7
Changes to this Plan
..............................................................................................................................
7
Section 3. How you get care
..................................................................................................................................
8
Identification cards
...............................................................................................................................
8
Where you get covered care
..................................................................................................................
8
· Plan providers
.................................................................................................................................
8
· Plan facilities
..................................................................................................................................
8
What you must do to get care
................................................................................................................
8
· Primary care
...................................................................................................................................
8
· Specialty care
.................................................................................................................................
9
· Hospital care
.................................................................................................................................
11
Circumstances beyond our control
.......................................................................................................
11
Section 4. Your costs for covered services
...........................................................................................................
12
· Copayments
..................................................................................................................................
12
· Deductible
....................................................................................................................................
12
· Coinsurance
..................................................................................................................................
12
Your out-of-pocket maximum for coinsurance and copayments
........................................................... 12
Section 5. Benefits
..............................................................................................................................................
13
Overview
............................................................................................................................................
13
(a) Medical services and supplies provided by
physicians and other health care professionals........... 14
(b) Surgical and anesthesia services provided by physicians and
other health care professionals ....... 22
(c)
Services provided by a hospital or other facility, and ambulance
services.................................... 25
(d)
Emergency services
..................................................................................................................
29
(e) Mental health and substance abuse benefits
................................................................................
31
(f) Prescription drug benefits
.........................................................................................................
35
(g) Special features
........................................................................................................................
39
(h) Dental benefits
..........................................................................................................................
40
(i) Non-FEHB benefits available to Plan members
......................................................................... 41
Section 6. General exclusions --things we don't cover
........................................................................................
42 2
2 Page 3 4
2001 Blue Cross-HMO Plan 3 Table of Contents
Section 7. Filing a claim for covered services
......................................................................................................
43
Section 8. The disputed claims process
...............................................................................................................
44
Section 9. Coordinating benefits with other
coverage
..........................................................................................
47
When you have other health coverage
.................................................................................................
47
·What is Medicare
..........................................................................................................................
47
·The Original Medicare Plan
..........................................................................................................
47
·Medicare managed care plan
.........................................................................................................
50
·Private contract
.............................................................................................................................
50
·Enrollment in Medicare Part B
......................................................................................................
50
TRICARE
..........................................................................................................................................
51
Workers' Compensation
.....................................................................................................................
51
Medicaid
............................................................................................................................................
51
When other Government agencies are responsible for your care
.......................................................... 51
When others
are responsible for injuries
.............................................................................................
51
Section 10. Definitions of terms we use in this
brochure.......................................................................................
52
Section 11. FEHB facts
......................................................................................................................................
54
No pre-existing condition limitation
..................................................................................................
54
Where you get information about enrolling in the FEHB Program
..................................................... 54
Types of coverage
available for you and your family
......................................................................... 54
When benefits and premiums start
...................................................................................................
.55
Your medical and claims records are confidential
..............................................................................
55
When you retire
................................................................................................................................
55
When you lose benefits
.....................................................................................................................
55
· When FEHB coverage ends
......................................................................................................
55
· Spouse equity coverage
............................................................................................................
55
· (TCC) Temporary Continuation of Coverage
............................................................................ 55
· Converting to individual coverage
............................................................................................
56
Getting a Certificate of Group Health Plan Coverage
......................................................................... 56
Inspector General Advisory
..............................................................................................................
56
Department of Defense/ FEHB Demonstration Project
..........................................................................................
57
Index………..
.....................................................................................................................................................
59
Summary of benefits
...........................................................................................................................................
60
Rates
.....................................................................................................................................................
Back cover 3
3 Page
4 5
2001 Blue Cross-HMO Plan 4
Introduction/ Plain Language
Introduction
Blue Cross of
California, P. O. Box 4089, Woodland Hills, Ca. 91365
This brochure
describes the benefits of the Blue Cross – HMO under our contract (CS
2514) with the Office of
Personnel Management (OPM), as authorized by the
Federal Employees Health Benefits law. This brochure is the
official
statement of benefits. No oral statement can modify or otherwise affect the
benefits, limitations, and
exclusions of this brochure.
If you are enrolled in this Plan, you are entitled to the benefits described
in this brochure. If you are enrolled for Self
and Family coverage, each
eligible family member is also entitled to these benefits. You do not have a
right to
benefits that were available before January 1, 2001, unless those
benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes
are effective January 1, 2001, and are
summarized on page 7. 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
Blue Cross.
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 Blue Cross-HMO Plan 5 Section 1
Section 1. Facts about this HMO plan
This Plan is a health
maintenance organization (HMO). We require you to see specific physicians,
hospitals, and
other providers that contract with us. These Plan providers
coordinate your health care services.
HMOs emphasize preventive care such as routine office visits, physical exams,
well-baby care, and immunizations, in
addition to treatment for illness and
injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit
claim forms or pay bills. You only pay
the copayments and coinsurance
described in this brochure. When you receive emergency services from non-Plan
providers, you may have to submit claim forms.
You should join an HMO because you prefer the plan's benefits, not because
a particular provider is available. You cannot change plans because a provider
leaves our Plan. We cannot guarantee that any one physician,
hospital, or
other provider will be available and/ or remain under contract with us.
Who provides my health care
When you enroll you should choose a
primary care physician. Your primary care physician will be the first doctor
you see for all your health care needs. If you need special kinds of care,
this physician will refer you to other kinds of
health care providers.
Your primary care physician will be part of a Blue Cross HMO contracting
medical group. There are two types of
Blue Cross HMO medical groups.
· A primary medical group (PMG) is a group practice staffed by a team
of doctors, nurses, and other health care providers.
· An independent practice association (IPA) is a group of doctors in
private offices who usually have ties to the same hospital.
You and your
family members can enroll in whatever medical group is best for you.
· You must live or work within 30 miles of the medical group.
You and your family members do not have to enroll in the same medical
group.
How we pay providers
Your medical group is paid a set amount for
each member per month. Your medical group may also get added money
for some
types of special care or for overall efficiency, and for managing services and
referrals. Hospitals and other
health care facilities are paid a set amount
for the kind of service they provide to you or an amount based on a
negotiated discount from their standard rates. If you want more information,
please call us at 800-235-8631, or you
may call your medical group.
You do not have to pay any Blue Cross HMO provider for what we owe them, even
if we don't pay them. But you
may have to pay a non-Plan provider any
amounts not paid to them by us. 5
5 Page 6 7
2001 Blue Cross-HMO
Plan 6 Section 1
Patients' Bill of Rights
OPM requires
that all FEHB Plans comply with the Patients' Bill of Rights, recommended by the
President's
Advisory Committee on Consumer Protection and Quality in the
Health Care Industry. You may get information
about your health plan, its
networks, providers, and facilities. You can also find out about care
management, which
includes medical practice guidelines, disease management
programs and how we determine if procedures are
experimental or
investigational. OPM's FEHB website (www. opm. gov/ insure) lists the specific
types of information
that we must make available to you.
If you want specific information about us, call 800-235-8631, or write to P.
O. Box 4089, Woodland Hills, CA 91365.
You may also contact us by fax at
818-234-6401, or visit our website at www. bluecrossca. com.
Service Area
To enroll in this Plan, you must live in or work in
our Service Area. Our service area is:
Northern California --Amador
--Fresno --Marin --Placer --San Joaquin --Stanislaus
--Alameda --Humboldt --Mendocino --Plumas --San Mateo --Tehama
--Butte
--Kings --Merced --Sacramento --Santa Cruz --Tulare
--Contra Costa --Lake
--Modoc --San Benito --Shasta --Tuolumne
--Del Norte --Lassen --Napa --Santa
Clara --Solano --Yolo
--El Dorado --Madera --Nevada --San Francisco --Sonoma
Southern California --Imperial --Los Angeles --Orange --San Diego
--San Louis Obispo
--Santa Barbara --Ventura
You may also enroll with us
if you live in or work in the Zip Codes of the following counties:
KERN:
93203, 93205-06, 93215-17, 93220, 93222, 93224-26, 93238, 93240-41, 93243,
93249-52, 93255, 93263,
93276, 93280, 93283, 93285, 93287, 93300-09,
93311-13, 93380-89, 93399, 93504-05, 93516, 93518-19, 93523-24,
93528,
93531, 93554, 93555, 93556, 93560-61, 93570, 93581-82, 93596
RIVERSIDE: 91718-20, 91752, 91753, 91760, 92201-03, 92210, 92211, 92220,
92223, 92230, 92234-36, 92240,
92241, 92253-55, 92258, 92260-64, 92270,
92276, 92282, 92292, 92303, 92320, 92330-31, 92343-44, 92348, 92353,
92355,
92360-62, 92367, 92370, 92379-81, 92383, 92387-88, 92390, 92395-96, 92500-09,
92513-19, 92521-23,
92530-32, 92542-46, 92548, 92550, 92552-57, 92562-64,
92567, 92570-72, 92581-87, 92589-93, 92595-96, 92599
SAN BERNARDINO: 91701, 91708-10, 91729-30, 91737, 91739, 91743, 91758,
91761-64, 91784-86, 91798,
92337, 92252, 92256, 92268, 92277-78, 92284-86,
92301, 92305, 92307-08, 92311-13, 92314-18, 92321-22,
92324-27, 92329,
92333-37, 92339-42, 92345-47, 92350, 92352, 92354, 92356-59, 92365, 92368-69,
92371-78,
92382, 92385-86, 92391-94, 92397, 92398, 92399, 92400-18, 92420,
92423-24, 92427
Ordinarily, you must get your care from providers who contract with us. If
you receive care outside our service area,
we will pay only for emergency or
urgent care services.
If you or a covered family member move outside of our service area, you can
enroll in another plan. If you or a family
member move, you do not have to
wait until Open Season to change plans. Contact your employing or retirement
office. 6
6 Page
7 8
2001 Blue Cross-HMO Plan 7
Section 2
Section 2. How we change for 2001
Program-wide
changes
· The plain language team reorganized the brochure and
the way we describe our benefits. We hope this will make it easier for you to
compare plans.
· This year, the Federal Employees Health Benefits Program is
implementing network mental health and substance abuse parity. This means that
your coverage for mental health, substance abuse, medical, surgical, and
hospital
services from providers in our Blue Cross HMO network will be the
same with regard to coinsurance,
copayments, and day and visit limitations
when you follow a treatment plan that we approve. Previously, we
placed
higher patient cost sharing and shorter day or visit limitations on mental
health and substance abuse
services than we did on services to treat
physical illness, injury, or disease.
· Many healthcare organizations have turned their attention this past
year to improving healthcare quality and patient safety. OPM asked all FEHB
plans to join them in this effort. You can find out more about patient safety
on the OPM website, www. opm. gov/ insure. To improve your healthcare, take
these five steps:
--Speak up if you have questions or concerns.
--Keep a
list of all the medicines you take.
--Make sure you get the results of any
test or procedure.
--Talk with your doctor and health care team about your
options if you need hospital care.
--Make sure you understand what will
happen if you need surgery.
· We clarified the language to show that anyone who needs a mastectomy
may choose to have the procedure performed on an inpatient basis and remain in
the hospital up to 48 hours after the procedure. Previously, the
language
referenced only women.
Changes to this Plan
· Your share of the non-Postal premium
will increase by 4.2 percent for Self Only and 4.2 percent for Self and Family.
· Diabetes education programs are now covered as described on page 21.
Also covered are therapeutic shoes and inserts designed to prevent foot
complications due to diabetes.
· Coverage will be provided for
formulas and food products (approved by the FDA) for the treatment of
phenylketonuria when prescribed by a Plan physician. 7
7 Page 8 9
2001 Blue Cross-HMO Plan 8 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 a prescription at a
participating pharmacy. Until you
receive your ID card, use your copy of
the Health Benefits Election Form,
SF-2809, your health benefits
enrollment confirmation (for annuitants), or
your Employee Express
confirmation letter.
If you do not receive your ID card within 30 days after the effective date
of your enrollment, or if you need replacement cards, call us at 800/
235-
8631.
Where you get covered care You get care from "Plan
providers" and "Plan facilities." You will only pay copayments
and/ or coinsurance, and you will not have to file claims.
For treatment of
a mental health or substance abuse condition you may
request an authorized
referral to a non-Plan provider. See Mental Health
and Substance Abuse
Benefits (Section 5e) for details.
· · Plan providers Plan providers are physicians and
other health care professionals in our service area that we contract with to
provide covered services to our
members. We credential Plan providers
according to national standards.
We list Plan providers in the provider
directory, which we update
periodically. The list is also on our website.
· ·Plan facilities Plan facilities are hospitals and
other facilities in our service area that we contract with to provide covered
services to our members. We list these
in the provider directory, which we
update periodically. The list is also
on our website.
What you must do to get care It depends on the type of care you need.
First, you and each family member must choose a primary care physician. Your
primary care
physician will be the first doctor you see for all your health
care needs.
If you need special kinds of care, this doctor will refer you to
other kinds
of health care providers. This decision is important since your
primary
care physician provides or arranges for most of your health care.
Your
primary care physician will be part of a Blue Cross HMO contracting
medical group. There are two types of Blue Cross HMO medical groups:
· A primary medical group (PMG) is a group practice staffed by a team
of doctors, nurses, and other health care providers.
· An independent practice association (IPA) is a group of doctors in
private offices who usually have ties to the same hospital.
You and your family members can enroll in whatever medical group is
best
for you.
· You must live or work within 30 miles of the medical
group.
· You and your family members do not have to enroll in the
same medical group.
· ·Primary care Your primary care physician can be a
general or family practitioner, internist or pediatrician. Certain specialists
as we may approve may also
be designated primary care physician. 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. 8
8 Page 9 10
2001 Blue Cross-HMO Plan 9 Section 3
· · Specialty care Your doctor may refer you to
another physician if you need special care. Your primary care physician must
approve all the care you get except
when you have an emergency or need
urgent care.
Your doctor's medical group has to agree that the service or
care you will
be getting from the other health care provider is medically
necessary.
Otherwise it won't be covered.
· You will need to make the appointment at the other doctor's office.
· Your primary care physician will give you a referral form to take with
you to your appointment. This form gives you the approval to get this
care. If you don't get this form, ask for it or talk to your Blue Cross
HMO coordinator.
· You may have to pay a copayment. You shouldn't
get a bill, unless it is for a copayment, for this service. If you do, send it
to your Blue
Cross HMO coordinator at your primary medical group right away.
The
medical group will see that the bill is paid. If you need additional
help
you can call our customer service department.
Standing Referrals. If you have a condition or disease that:
· Requires continuing care from a specialist; or is
·
Life-threatening;
· Degenerative; or
· Disabling; your
primary care physician may give you a standing referral to a
specialist or specialty care center. The referral will be made if your
primary care physician, in consultation with you, and a specialist or
specialty care center, if any, determine that continuing specialized care is
medically necessary for your condition or disease.
If it is determined that you need a standing referral for your condition or
disease, a treatment plan will be set up for you. The treatment plan:
· Will describe the specialized care you will receive;
·
May limit the number of visits to the specialist; or
· May limit the
period of time that visits may be made to the specialist.
If a standing referral is authorized, your primary care physician will
determine which specialist or specialty care center to send you to in the
following order:
· First, a Blue Cross HMO contracting specialist or specialty care
center which is associated with your medical group;
· Second, any Blue Cross HMO contracting specialist or specialty care
center; and
· Last, any specialist or specialty care center;
that
has the expertise to provide the care you need for your condition or
disease.
After the referral is made, the specialist or specialty care center will be
authorized to provide you health care services that are within the
specialist's area of expertise and training in the same manner as your
primary care physician, subject to the terms of the treatment plan.
Remember: We only pay for the number of visits and the type of special
care that your primary care physician approves. Call your
physician if you need more care. If your care isn't approved ahead of
time, you will have to pay for it (except for emergencies or urgent
care.) 9
9 Page
10 11
2001 Blue Cross-HMO Plan 10
Section 3
Ready Access. There are two ways you may get special
care without getting an approval from you medical group. These two ways are the
"Direct Access" and "Speedy Referral" programs. Not all
medical
groups take part in the Ready Access program. See your Blue Cross
HMO Directory for those that do.
Direct Access. You may be able to get some special care without an
approval from your primary care physician. We have a program called
"Direct Access", which lets you get special care, without an
approval
from your primary care physician for:
· Allergy
· Dermatology
· Ear/ Nose/ Throat
· OB-GYN
Ask your Blue Cross HMO coordinator if your medical group takes part
in
the "Direct Access" program. If your medical group participates in the
Direct Access program, you must still get your care from a physician
who
works with your medical group. The Blue Cross HMO coordinator
will give you
a list of those doctors.
Speedy Referral. If you need special care, your primary care physician
may be able to refer you for it without getting an approval from your
medical group first. The types of special care you can get through
Speedy
Referral depend on your medical group.
If You Are A Woman You can get OB-GYN services from a doctor who
specializes in caring
for women (OB-GYN) or family practice doctor who does OB-GYN and
works
with your medical group.
· You can get these services without an approval from your primary
care physician.
· Ask your Blue Cross HMO coordinator for the list of OB-GYN health
care providers you must choose from.
When You Want a Second Opinion There may be times when you want a
second opinion. Perhaps you have
a question about your condition or your
primary care physician or a
specialist you have been referred to thinks you
should have a treatment or
surgery you are not sure about. You can ask that
another primary care
physician or specialist advise you about what you
should do. If care is
being provided by a specialist, the second opinion
will be provided by a
doctor in the same specialty.
· If you want a second opinion, ask the Blue Cross HMO coordinator at
your medical group. For additional assistance, call us at
800/ 235-8631.
· The second opinion will consist of a consultation
only. No other services, such as x-rays and laboratory tests or other procedures
are
included.
· In most cases, the doctor or specialist providing the
second opinion will be part of your medical group or will be another doctor who
has
an agreement with us.
· A decision will be made promptly. If you
have a serious condition, a decision will be made within 72 hours when possible.
· If your request is denied, and you are unsatisfied, see Section 8:
The disputed claims process. You can request that we review the denial. 10
10 Page 11 12
2001 Blue Cross-HMO Plan 11 Section 3
Here are other things you should know about specialty care:
·
If you are seeing a specialist when you enroll in our Plan, talk to your primary
care physician. Your primary care physician will decide
what treatment you
need. If he or she decides to refer you to a
specialist, ask if you can see
your current specialist. If your current
specialist does not participate
with us, you must receive treatment
from a specialist who does. Generally,
we will not pay for you to see
a specialist who does not participate with
our Plan.
· If you are seeing a specialist and your specialist leaves the Plan,
call your primary care physician, who will arrange for you to see another
specialist. You may receive services from your current specialist
until
we can make arrangements for you to see someone else.
· If you have a chronic or disabling condition and lose access to your
specialist because we:
·· terminate our contract with your specialist for other than
cause; or
·· drop out of the Federal Employees Health Benefits
(FEHB) Program and you enroll in another FEHB Plan; or
·· reduce our service area and you enroll in another FEHB Plan,
you may be able to continue seeing your specialist for up to 90 days
after you receive notice of the change. Contact us.
If you are in the second or third trimester of pregnancy and you lose
access to your specialist based on the above circumstances, you can
continue to see your specialist until the end of your postpartum care, even
if it is beyond the 90 days.
· · Hospital care There may be a time when your primary
care physician says you need to go to the hospital. If it is not an emergency,
the medical group will look
into whether or not it is medically necessary.
If the medical group
approves your hospital stay, you will need to go to a
hospital that works
with your medical group. The same is true for admissions
to a skilled
nursing or other type of facility.
If you are in the hospital when your enrollment in our Plan begins, call
our customer service department immediately at 800/ 235-8631. 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. 11
11 Page 12 13
2001 Blue Cross-HMO Plan 12 Section 4
Section 4. Your costs for covered services
You must share the
cost of some services. You are responsible for:
· ·
Copayments A copayment is a fixed amount of money you pay to the provider
when you receive services.
Example: When you see your primary care physician you pay a
copayment of
$10 per office visit.
· · Deductible This Plan does not have a deductible.
· ·Coinsurance Coinsurance is the percentage of our negotiated
fee that you must pay for your care.
Example: In our Plan, you pay 50% of our allowance for infertility
services.
Your out-of-pocket maximum for After your copayments total $1,000 for
one family member or $3,000 for
coinsurance and copayments three or
more family members in any calendar year, you do not have to pay any more for
covered services. However, copayments or
coinsurance for the following services do not count toward your out-of-pocket
maximum, and you must continue to pay copayments or
coinsurance for
these services:
· Prescription drug benefits
· Infertility
services
Be sure to keep accurate records of your copayments since you
are
responsible for informing us when you reach the maximum. 12
12 Page 13 14
2001 Blue Cross-HMO Plan 13 Section 5
Section 5. Benefits – OVERVIEW
(See page 7 for
how our benefits changed this year and page 60 for a benefits summary.)
NOTE: This benefits section is divided into subsections. Please read
the important things you should keep in mind at the beginning of each
subsection. Also read the General Exclusions in Section 6; they apply to the
benefits in the
following subsections. To obtain claims forms, claims filing
advice, or more information about our benefits, contact us
at 800/ 235-8631
or at our website at www. bluecrossca. com.
(a) Medical services and supplies provided by physicians and other health
care professionals .................................... 14-21
·Diagnostic and treatment services
·Lab, X-ray, and other
diagnostic tests
·Preventive care, adult
·Preventive care,
children
·Maternity care
·Family planning
·Infertility services
·Allergy care
·Treatment
therapies
·Rehabilitative therapies
·Hearing services (testing, treatment, and supplies)
·Vision services (testing, treatment, and supplies)
·Foot
care
·Orthopedic and prosthetic devices
·Durable medical
equipment (DME)
·Home health services
·Alternative
treatments
·Educational classes and programs
(b) Surgical and anesthesia services provided by physicians and other health
care professionals...................... 22-24
·Surgical procedures
·Reconstructive surgery
·Oral and maxillofacial surgery
·Organ/ tissue transplants
·Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services
.................................................. 25-28
·Inpatient hospital
·Outpatient hospital or ambulatory
surgical center
·Extended care benefits/ skilled nursing care
facility benefits
·Hospice care
·Ambulance
(d) Emergency services
..................................................................................................................................
29-30
·Emergency inside or outside of our service area
(e) Mental health and substance abuse
benefits...............................................................................................
31-34
(f) Prescription drug benefits
.........................................................................................................................
35-38
(g) Special Features
............................................................................................................................................
39
(h) Dental benefits
..............................................................................................................................................
40
(i) Non-FEHB benefits available to Plan
members..............................................................................................
41
Summary of benefits
............................................................................................................................................
60 13
13 Page 14
15
2001 Blue Cross-HMO Plan 14 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.
· Be
sure to read Section 4, Your costs for covered services for valuable
information about how cost sharing works. Also read Section 9 about coordinating
benefits with other
coverage, including with Medicare.
I M
P O
R T
A N
T
Benefit Description You pay
Diagnostic and treatment services
Professional services of
physicians
· In physician's
office……………………………………………………
$10 per office visit
Professional services of physicians
· In an urgent care
center………………………………………………
· During a hospital
stay………………………………………………..
· In a skilled nursing
facility…………………………………………...
· Office medical
consultations…………………………………………
· Second surgical
opinion……………………………………………...
· Initial examination of a newborn child covered under a family
enrollment
…………………………………………………………...
Nothing
Nothing
Nothing
$10 per office visit
$10 per office visit
Nothing in hospital
($ 10 per office visit if exam is
done in the
doctors office)
Professional services of physicians
· At home $10 per visit 14
14 Page 15 16
2001 Blue Cross-HMO Plan 15 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
Preventive care, adult You pay
· Full physical exams and
periodic check-ups ordered by your primary care
physician……………………………….
· Eye exams to determine the need for vision correction. Vision exams
include a vision check by your primary care physician to see
if it is
medically necessary for you to have a complete vision exam
by a vision
specialist. If approved by your primary care physician,
this may include an
exam with diagnosis, a treatment program and
refractions……………………….…………………………………………
· Ear exams to determine the need for hearing correction. Hearing
exams include tests to diagnose and correct
hearing…………………
· Health screenings as prescribed by your primary care physician, such
as mammograms, Pap tests,
prostate cancer screenings, sigmoidoscopies,
etc……………………
·
Immunizations prescribed by your primary care
physician…………...
$10 per office visit
Nothing
Nothing
Nothing
Nothing
Not covered: Physical exams required for obtaining or continuing
employment or insurance, attending schools or camp, or travel.
All
charges. 15
15 Page
16 17
2001 Blue Cross-HMO Plan 16
Section 5 (a)
Preventive care, (all enrolled children regardless
of age) You pay
· Childhood immunizations recommended by the
American Academy of Pediatrics Nothing
· Well-child care for routine examinations and care, such as:
·· Full physical exams and periodic check-ups ordered by your
primary care physician
…………………………………………
··Eye exams to determine the need for vision correction. Vision
exams include a vision check by your primary care physician to
see if it is
medically necessary for you to have a complete vision
exam by a vision
specialist. If approved by your primary care
physician, this may include an
exam with diagnosis, a treatment
program and
refractions…………………………………………
··Ear exams to determine the need for hearing correction.
Hearing exams include tests to diagnose and correct
hearing……………
Nothing
Nothing
Nothing
Maternity care You pay
Complete maternity (obstetrical) care, such
as:
· Prenatal
care………………………………………………………….
·
Delivery………………………………………………………………
· Postnatal
care………………………………………………………...
Note: Here are some things to keep in mind:
· You do not need to
precertify your normal delivery.
· 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).
$10 per office visit
Nothing
$10 per office visit 16
16 Page 17 18
2001 Blue Cross-HMO Plan 17 Section 5 (a)
Family planning You pay
· Voluntary sterilization for
females (tubal
ligation)…………………..
·
Voluntary sterilization for males
(vasectomy)……………………….
· Family planning visits
……………………………………………….
· Shots and implants for birth
control………………………………….
· Intrauterine contraceptive devices (IUDs) and diaphragms, dispensed
by a
doctor………………………………………………...
· Doctor's services to prescribe, fit and insert an IUD or
diaphragm……………………………………………….……………
· Genetic testing, when medically
necessary…………………………..
$150
$50
$10 per office visit
Nothing
Nothing
$10 per office visit
Nothing
Not covered: reversal of voluntary surgical sterilization All charges
Infertility services You pay
Diagnosis and treatment of
infertility, such as:
· Artificial insemination:
··intravaginal insemination (IVI)
··intracervical insemination (ICI)
··intrauterine insemination (IUI)
Note: We
cover fertility drugs under the prescription drug benefit.
50% for all care
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
All charges
Allergy care You pay
Testing and
treatment…………………………………………………….
Allergy
serum……………………………………………………………
$10 per office visit
Nothing
Treatment therapies You pay
· Chemotherapy and radiation
therapy………………………………
· Respiratory and inhalation
therapy…………………………………
· Dialysis – Hemodialysis and peritoneal
dialysis……………………
· Intravenous (IV)/ Infusion Therapy – Home IV and antibiotic
therapy……………………………………………………………….
· Growth hormone therapy when approved by your primary care
physician……………………………………………………………..
Nothing
Nothing
Nothing
Nothing
Nothing 17
17 Page 18 19
2001 Blue
Cross-HMO Plan 18 Section 5 (a)
Rehabilitative therapies You
pay
· Visits for rehabilitation, such as physical therapy,
occupational therapy or speech therapy when prescribed by your physician for the
services of each of the following:
··qualified licensed
physical therapists;
·· licensed speech therapists; and
·· licensed occupational therapists.
· Cardiac
rehabilitation following a heart transplant, bypass surgery or a myocardial
infarction, is provided for up to 60 days.
Nothing
Nothing
Not covered:
· long-term rehabilitative
therapy
· exercise programs
All charges
Hearing services (testing, treatment, and supplies) You pay
· Hearing testing which includes screenings to diagnose and
correct hearing Nothing
Not covered:
· Hearing aids or services for fitting or
making a hearing aid All charges
Vision services (testing, treatment, and supplies) You pay
· Vision screening includes a vision check by your primary care
physician to see if it is medically necessary for you to have a
complete vision exam by a vision specialist. If approved by your
primary
care physician, this may include an exam with diagnosis, a
treatment program
and refractions.
Nothing
Not covered:
· Eyeglasses or contact lenses
· Eye exercises and orthoptics
· Radial
keratotomy and other refractive surgery
All charges
Foot care You pay
We cover medically necessary care for the
diagnosis and treatment of
conditions of the foot, when prescribed by your
physician.
See durable medical equipment for information on podiatric shoe
inserts.
$10 per office visit
Not covered:
· Routine foot care All charges 18
18 Page 19 20
2001 Blue Cross-HMO Plan 19 Section 5 (a)
Orthopedic and prosthetic devices You pay
· Surgical
implants.........................................................................................
· Artificial limbs or eyes
................................................................................
· The first pair of contact lenses or eye glasses when needed after a
covered and
medically necessary eye surgery
..................................................................
·
Breast prostheses following a mastectomy
...................................................
· Prosthetic
devices to restore a method of speaking when required as a result
of a
laryngectomy........................................................................................
· Colostomy supplies
.....................................................................................
· Supplies needed to take care of these devices
...............................................
Nothing
Nothing
Nothing
Nothing
Nothing
Nothing
Nothing
Not covered:
· Orthopedic shoes (except when joined to
braces) or shoe inserts (except custom molded orthotics). This does not apply to
shoes and
inserts designed to prevent or treat foot complications due to
diabetes.
All charges
Durable medical equipment (DME) You pay
· You can rent or
buy up to $2,000 (a calendar year) of long-lasting medical equipment
(called durable medical equipment) and supplies if
they are:
--Ordered by your Plan physician.
--Used only for the
health problem.
--Used only by the person who needs the equipment or
supplies.
--Made only for medical use. We cover items such as:
·
Hospital beds
· Wheelchairs
· Insulin pumps
·
Surgical bras
Note: Covered medical supplies include therapeutic shoes and inserts
designed to prevent foot complications due to diabetes.
Nothing
Durable Medical Equipment is Not covered if:
--It is needed only
for your comfort or hygiene.
--It is for exercise.
--It is needed for
making the room or home comfortable, such as air
conditioning or air
filters.
All charges 19
19 Page 20 21
2001 Blue
Cross-HMO Plan 20 Section 5 (a)
Home health services You pay
You can get up to three 2-hour visits a day for the following home
health care,
furnished by a home health agency (HHA) or visiting nurse
association (VNA):
· Care from a registered nurse
·
Physical therapy, occupational therapy, speech therapy, or respiratory therapy
· Visits with a medical social service worker
· Care from
of a health aide who works under a registered nurse with the HHA or VNA
· 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 charge
Alternative treatments You pay
Acupuncture – Medically
necessary acupuncture if referred by your primary care physician and approved by
the medical group, for the
treatment of chronic pain.
$10 per office visit
Not covered:
· Acupressure, or massage to help pain, treat
illness or promote health by putting pressure to one or more areas of the body
All charge
Chiropractic Care – Covered up to 20 visits in a year when you
see
a chiropractor in the American Specialty Health Plans (ASHP) network.
Also up to $50 per calendar year in rental or purchase charges are
covered for medical equipment and supplies ordered by an ASHP
chiropractor, and approved as medically necessary by ASHP. Such
medical
equipment includes: (1) elbow, back, thoracic, lumbar, rib or
wrist
supports; (2) cervical collars or pillows; (3) ankle, knee, lumbar,
or wrist
braces; (4) heel lifts; (5) hot or cold packs; (6) lumbar cushions;
(7)
orthotics; and (8) home traction units for treatment of the cervical or
lumbar regions.
Note: The ASHP chiropractor is responsible for obtaining the
necessary approval from the Plan.
$10 per office visit
Not covered:
· Any services provided by ASHP that are
not approved by us, except for the first visit;
· The services of a non-ASHP chiropractor.
All charges 20
20 Page 21 22
2001 Blue
Cross-HMO Plan 21 Section 5 (a)
Educational classes and
programs You pay
Coverage is limited to:
· Diabetes self-management programs supervised by a doctor to teach
you and your family members about the disease and how to
take care of it.
This includes training, education and nutrition
therapy to enable you to use
the equipment, supplies and medicines
needed to manage the disease.
· Other health education programs given by your primary care physician
or the medical group. Ask about our many programs to:
--Educate you about living a healthy life
--Get a health screening
--Learn about your health problem
Usually Nothing-Separate
copayments may apply to some
programs. Call
us for more
information. 21
21 Page 22 23
2001 Blue
Cross-HMO Plan 22 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).
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
· Any medically necessary eye surgery
· Endoscopy
procedure · Biopsy procedure
· Removal of tumors and cysts
· Treatment of burns
· Correction of congenital anomalies (see reconstructive surgery)
· Surgical treatment of morbid obesity as determined by your medical
group, when the treatment is approved in advance
· Insertion of internal prostethic devices. See 5( a) –
Orthopedic braces and prosthetic devices for device coverage information.
Note: Generally, we pay for internal prostheses (devices) according
to where the procedure is done. For example, we pay Hospital benefits or
a
pacemaker and Surgery benefits for insertion of the pacemaker.
Nothing
· Voluntary sterilization for female (tubal
ligation)………………….
·
Voluntary sterilization for male
(vasectomy)………………………
· Norplant (a surgically implanted contraceptive) and intrauterine
devices (IUDs) Note: Devices are covered under 5(
a)………………
$150
$50
$10 per office visit
Not covered:
· Reversal of voluntary sterilization;
· Radial keratotomy and other refractive surgeries.
All charges 22
22 Page 23 24
2001 Blue
Cross-HMO Plan 23 Section 5( b)
Reconstructive surgery You pay
· Reconstructive surgery performed to correct deformities caused
by congenital or developmental
abnormalities, illness, or injury for the purpose of improving bodily
function, reducing symptoms or creating a normal appearance.
Nothing
· 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 this procedure
performed on an inpatient basis and remain in the hospital
up to 48 hours
after the procedure.
Nothing
Not covered:
· Cosmetic surgery – any surgical
procedure (or any portion of a procedure) performed primarily to improve
physical appearance
through change in bodily form. This does not apply to surgery you
might need to:
--give you back the use of a body part
--have a
breast reconstruction after a mastectomy
--Correct or repair a deformity
caused by birth defects, abnormal
development, injury or illness in order to
improve function,
symptomatology or create a normal appearance.
Cosmetic
surgery does not become reconstructive because of
psychological or
psychiatric reasons.
· 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;
· Splint therapy or surgical treatment for disorders of the joints
linking the jawbones and the skull (the temporomandibular joints);
including
the complex of muscles, nerves and other tissues related to
those joints;
and
· Other surgical procedures that do not involve the teeth or
their supporting structures.
Nothing
Not covered:
· Oral implants and transplants
· Procedures that involve the teeth or their supporting
structures (such as the periodontal membrane, gingiva, and alveolar bone)
All charges 23
23 Page 24 25
2001 Blue
Cross-HMO Plan 24 Section 5( b)
Organ/ tissue transplants You
pay
Limited to:
· Cornea
· Heart
·
Kidney
· 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, when approved by the Plan
medical director
Note: We cover related medical and hospital expenses of the donor
when we
cover the recipient.
Nothing
Not covered:
· Donor screening tests and donor search
expenses, except those performed for the actual donor
· 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
Dental Care–
General anesthesia and facility services when dental
care must be provided
in a hospital or ambulatory surgery center when you
are:
· Less than seven years old;
· Developmentally
disabled; or
· Your health is compromised and general anesthesia is
medically necessary.
Note: No benefits are provided for the dental procedure itself or for
the professional services of a dentist to do the dental procedure.
Nothing
Nothing 24
24 Page 25 26
2001 Blue
Cross-HMO Plan 25 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).
I M
P O
R T
A N
T
Benefit Description You pay
Inpatient hospital
Room and board,
such as
· ward, semiprivate, or intensive care accommodations;
·
general nursing care; and
· meals and special diets.
NOTE: If you want a private room when it is not medically necessary,
you
pay the additional charge above the semiprivate room rate.
Nothing
Inpatient hospital continued on next page. 25
25 Page 26 27
2001 Blue Cross-HMO Plan 26 Section 5( c)
Inpatient hospital (Continued) You pay
Other
hospital services and supplies, such as:
· Operating, recovery,
maternity, and other treatment rooms
· Prescribed drugs and medicines
· Diagnostic laboratory tests and X-rays
· Blood
transfusions. This includes the cost of blood, blood products or blood
processing
· Dressings, splints, casts, and sterile tray services
·
Medical supplies and equipment, including oxygen
· Anesthetics,
including nurse anesthetist services
Note: Inpatient hospital services are covered for dental care only
when the Stay is:
--Needed for dental care because of other medical problems
you may
have;
--Ordered by a doctor (M. D.) or a dentist (D. D. S.); and
--Approved by the medical group.
Nothing
Not covered:
· Custodial care
·
Non-covered facilities, such as nursing homes, extended care facilities,
schools
· Personal comfort items, such as telephone, television, barber
services, guest meals and beds
· Private nursing care
All charges
Outpatient hospital or ambulatory surgical center 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
Dental Care–
Facility services when dental care must be provided in
a hospital or
ambulatory surgery center when you are:
· Less than
seven years old;
· Developmentally disabled; or
· Your
health is compromised and general anesthesia is medically necessary.
Note: No benefits are provided for the dental procedure itself or for
the
professional services of a dentist to do the dental procedure.
Nothing
Nothing 26
26 Page 27 28
2001 Blue
Cross-HMO Plan 27 Section 5( c)
Skilled nursing care facility
benefits You pay
We cover the following care in a skilled nursing
facility for up to 100 days in a
calendar year.
· A room
with two or more beds
· Special treatment rooms
· Regular
nursing services
· Laboratory tests · Physical therapy,
occupational therapy, speech therapy, or respiratory
therapy
· Drugs and medicines given during your stay.
This includes oxygen.
· Blood transfusions
· Needed
medical supplies and appliances
Nothing
Not covered: custodial care All charges
Hospice care You pay
We cover hospice care if you have an illness that may lead to death
within 6
months. Your primary care physician will work with the hospice and
help
develop your care plan. The hospice must send a written care plan to
your
medical group every 30 days. You can get 180 days during your
lifetime for
the following hospice care.
· Room and board charges in a hospice unit
· Care from a
registered nurse, licensed practical nurse and licensed vocational nurse
· Physical therapy, occupational therapy, speech therapy and
respiratory therapy
· Medical social services
· Care from
a home health aide
· Diet and nutrition advice; nutrition help such
as intravenous feeding or hyperalimentation
· Drugs and medicines prescribed by a doctor
· Medical
supplies, oxygen and respiratory therapy supplies respiratory therapy supplies
· Care which controls pain and relieves symptoms
Nothing
Not covered: Independent nursing, homemaker services All charges 27
27 Page 28 29
2001 Blue Cross-HMO Plan 28 Section 5( c)
Ambulance You pay
You can get these services from a licensed
ambulance in an emergency or
when ordered by your primary care physician.
(We will provide benefits for
these services if you receive them as a result
of a 9-1-1 emergency response
system call for help if you think you have an
emergency.) Air ambulance is
also covered, but, only if ground ambulance
service can't provide the service
needed. Air ambulance service, if
medically necessary, is provided only to the
nearest hospital that can give
you the care you need.
· Base charge and mileage · Disposable supplies
· Monitoring, EKG's or ECG's, cardiac defibrillation, CPR, oxygen, and
IV Solutions
IN SOME AREAS, THERE IS A 9-1-1 EMERGENCY RESPONSE
SYSTEM. THIS SYSTEM IS
TO BE USED ONLY WHEN THERE IS AN
EMERGENCY.
Nothing 28
28 Page
29 30
2001 Blue Cross-HMO Plan 29
Section 5( d)
Section 5 (d). Emergency services
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.
· 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 is urgent care?
We provide coverage for medically necessary
care by non-Plan providers to prevent serious deterioration of
your health
resulting from an unforeseen illness or injury when you are more than 20 miles
from your medical
group (or your medical group's enrollment area hospital if
you are enrolled in an independent practice
association), and seeking health
services cannot wait until you return.
If you need urgent care you should seek medical attention immediately. If you
are admitted to a hospital for
urgently needed care, you should contact your
primary care physician or Medical Group within 48 hours,
unless
extraordinary circumstances prevent such notification. Follow-up care will be
covered when the care
required continues to meet our definition of
"Urgent Care". Urgent care is defined as services received for a
sudden, serious, or unexpected illness, injury or condition, which is not an
emergency, but which requires
immediate care for the relief of pain or
diagnosis and treatment of such condition.
What to do in case of emergency:
If you need emergency services,
get the medical care you need right away. In some areas, there is a 9-1-1
emergency response system that you may call for emergency services (this
system is to be used only when there is
an emergency that requires an
emergency response).
Once you are stabilized, your primary care physician must approve any care
you need after that.
· Ask the hospital or emergency room doctor to
call your primary care physician.
· Your primary care physician will
approve any other medically necessary care or will take over your care. You may
need to pay a copayment for emergency room services. We cover the rest.
If You Are In-Area. You are in-area if you are 20 miles or less from
your medical group (or 20 miles or less from your medical group's hospital, if
your medical group is an independent practice association).
If you need
emergency services, get the medical care you need right away. If you want, you
may also call your
primary care physician and follow his or her
instructions.
Your primary care physician or medical group may:
· Ask you to
come into their office;
· Give you the name of a hospital or
emergency room and tell you to go there;
· Order an ambulance for
you;
· Give you the name of another doctor or medical group and tell
you to go there; or
· Tell you to call the 9-1-1 emergency response
system. 29
29 Page
30 31
2001 Blue Cross-HMO Plan 30
Section 5( d)
If You're Out of Area. You can still get
emergency services if you are more than 20 miles away from your medical group.
If you need emergency services, get the medical care you need right away
(follow the instructions above for What
to do in case of emergency). In some
areas, there is a 9-1-1 emergency response system that you may call for
emergency services (this system is to be used only when there is an
emergency that requires an emergency
response). You must call us within 48
hours if you are admitted to a hospital.
Remember:
· We won't cover services that do not fit the
description of medical emergency on page 29.
· Your primary care
physician must approve care you get once you are stabilized, unless Blue Cross
HMO approves it.
· Once your medical group or Blue Cross HMO gives an approval for
emergency services, they cannot withdraw it.
Benefit Description You pay
Emergency inside or outside of our service
area
· Emergency care at a doctor's office
………………………………
· Emergency care at an urgent care
center……………………………
· Emergency care on an outpatient basis at a hospital (if care
results in admission to a hospital, the copayment will not
apply)…………
· Emergency care at a hospital on an inpatient
basis…………………
$10 per office visit
$25 per visit
$25 per visit
Nothing
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 30
30 Page 31 32
2001 Blue
Cross-HMO Plan 31 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.
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:
· Please remember that all benefits are subject to the
definitions, limitations, and exclusions in this brochure.
· Be sure to read Section 4, Your costs for covered services
for valuable information about how cost sharing works. Also read Section 9
about coordinating benefits with other
coverage, including with Medicare.
· You can get care for outpatient professional treatment of mental
health and substance abuse conditions by a Plan provider without getting prior
approval from your medical group. In order for care to be covered, you
must go to a Plan provider. You can get a directory of Plan providers from
us by calling 800/ 235-8631. You must get prior approval for all inpatient
facility based care and any visits to a non-Plan provider. Please see Medical
Management Programs on page 32 for more information.
I M
P O
R T
A N
T
Benefit Description You pay
Mental health and substance abuse benefits
We will cover services for the treatment of mental health
and substance
abuse conditions provided by a Plan provider.
We will also cover services of
a non-Plan provider if an
authorized referral is obtained.
Cost sharing and limitations for benefits that we
cover (for example,
visit/ day limits, coinsurance,
copayments, and out-of-pocket maximums) for
mental health and substance abuse are based on the
cost sharing and
limits for similar benefits under
our network medical, hospital,
prescription drug,
diagnostic testing, and surgical benefits.
· Professional services, including individual or group therapy by
providers such as psychiatrists,
psychologists, or clinical social workers………...
· Medication
management….……………………..
· Diagnostic laboratory or x-ray
tests……….……
· Facility-based care
(care provided in a hospital, psychiatric health facility, or residential
treatment
center)…………………………………………….
Note: If facility based care is not approved by us
before you get
care, we will not provide benefits.
Please see Medical
Management Programs on page
32 for more information.
$10 per office visit
$10 per office visit
Nothing
Nothing
Not covered:
· Services we have not approved.
Note: OPM's review of disputes about network
treatment
plans will be based on the treatment plan's
clinical appropriateness. OPM
will generally not
order one clinically appropriate treatment plan in
favor of another.
All charges 31
31 Page 32 33
2001 Blue
Cross-HMO Plan 32 Section 5( e)
Mental health and substance
abuse benefits – CONTINUED
Medical Management Programs for Mental
Health and Substance Abuse Conditions
Medical Management Programs apply
only to the treatment of mental health and substance abuse conditions for the
following services:
¨ facility based care (facility based care is care provided in a
hospital, psychiatric health facility, or residential treatment center) and
¨ authorized referrals to non-Plan providers.
The medical management
programs are set up to work together with you and your physician to be sure that
you get
appropriate medical care and avoid costs you weren't expecting.
You don't have to get a referral from your primary care physician when you go
to a Plan provider for professional
services, such as counseling, for the
treatment of mental health and substance abuse conditions. You can get a
directory
of Plan providers who specialize in the treatment of mental health
and substance abuse conditions from us by calling
800/ 235-8631.
Your primary care physician must provide or coordinate all other care and
your medical group must approve it.
We have two medical management
programs for treatment of mental health and substance abuse conditions:
¨ The Utilization Review Program applies to facility-based care for the
treatment of mental health and substance abuse conditions.
¨ The Authorization Program applies to referrals to non-Plan providers.
We will pay benefits only if you are covered at the time you get
services, and our payment will follow the terms and requirements of this Plan.
Utilization Review Program
The utilization review program looks at
whether care is medically necessary and appropriate, and the setting in which
care is provided. We will let you and your physician know if we have
determined that services can be safely provided
in an outpatient setting, or
if we recommend an inpatient stay. We certify and monitor services so that you
know when
it is no longer medically necessary and appropriate to continue
those services.
You need to make sure that your physician contacts us before scheduling
you for any service that requires utilization review. If you get any such
service without following the directions under "How to Get Utilization
Reviews," no benefits will be provided for that service.
Utilization review has three parts:
¨ Pre-service review.
We look at non-emergency facility-based care for the treatment of mental
health and substance abuse conditions and decide if the proposed facility-based
care is medically necessary and appropriate.
¨ Concurrent review. We look at and decide whether services are
medically necessary and appropriate when pre-service review is not required or
we are notified while service is being provided, such as with an emergency
admission to a hospital.
¨ Retrospective review. We look at
services that have already been provided:
· When a pre-authorization,
pre-service or concurrent review was not completed; or
· To examine
and audit medical information after services were provided.
Retrospective
review may also be done for services that continued longer than originally
certified. 32
32 Page
33 34
2001 Blue Cross-HMO Plan 33
Section 5( e)
Mental health and substance abuse benefits –
CONTINUED
Effect on Benefits
¨ When you don't get the required
pre-service review before you get facility-based care for the treatment of
mental health and substance abuse conditions, we will not provide benefits
for those services.
¨ Facility-based care for the treatment of mental health and substance
abuse conditions will be provided only when the type and level of care requested
is medically necessary and appropriate for your condition. If you go ahead
with any services that have been determined to be not medically necessary
and appropriate at any stage of the
utilization review process, we will
not provide benefits for those services.
¨ When services are not reviewed before or during the time you receive
the services, we will review those services when we receive the bill for benefit
payment. If that review determines that part or all of the services were not
medically necessary and appropriate, we will not provide benefits for
those services.
How to Get Utilization Reviews
Remember, you must
make sure that the review has been done.
Pre-Service Reviews
No
benefits will be provided if you do not get pre-service review before receiving
scheduled (non-emergency) services,
as follows:
¨ You must tell your physician that this Plan requires pre-service
review. Physicians who are Plan providers will ask for the review for you. The
toll-free number to call for pre-service review is 800/ 274-7767.
¨ For all scheduled services that require utilization review, you or your
physician must ask for the pre-service review at least three working days before
you are to get services.
¨ We will certify services that are medically
necessary and appropriate. For facility-based care for the treatment of mental
health and substance abuse conditions we will, if appropriate, certify the type
and level of services, as well
as a specific length of stay. You, your
physician and the provider of the service will get a written notice showing
this information.
¨ If you do not get the certified service within 60 days of the
certification, or if the type of the service changes, you must get a new
pre-service review.
Concurrent Reviews
¨ If pre-service review was not done, you, your
physician or the provider of the service must contact us for concurrent review.
If you have an emergency admission or procedure, you need to let us know within
one working
day of the admission or procedure, unless your condition prevented you from
telling us or a member of your family
was not available to tell us for you
within that time period.
¨ When you tell Plan providers that you must have utilization review,
they will call us for you. You may ask a non-Plan provider to call the toll free
number on your Member ID card or you may call directly.
¨ When we decide that the service is medically necessary and appropriate,
we will, depending upon the type of treatment or procedure, certify the service
for a period of time that is medically appropriate. We will also decide on
the medically appropriate setting.
¨ If we decide that the service
is not medically necessary and appropriate, we will tell your physician by
telephone no later than 24 hours after the decision. You and your physician will
receive written notice no later than one business
day after the decision. 33
33 Page 34 35
2001 Blue
Cross-HMO Plan 34 Section 5( e)
Mental health and substance
abuse benefits – CONTINUED
Retrospective Reviews
¨ We will
do a retrospective review:
· If we were not told of the service you received, and were not able
to do the appropriate review before your discharge from the hospital or
residential treatment center.
· If pre-service or concurrent review was done, but services continued
longer than originally certified.
· For the evaluation and audit of
medical documentation after you got the services, whether or not pre-service or
concurrent review was performed.
¨ If such services are determined to not have been medically necessary
and appropriate, we will deny certification.
Authorization Program
The authorization program provides prior approval for medical care or
service by a non-Plan provider. The service you
receive must be a covered
benefit of this Plan.
You must get approval before you get any non-emergency or non-urgent
service from a non-Plan provider for the treatment of mental health and
substance abuse conditions. The toll-free number to call for prior approval is
on your member ID card.
If you get any such service, and do not follow
the procedures set forth in this section, no benefits will be provided for that
service.
Authorized Referrals. In order for the benefits of this Plan to be
provided, you must get approval before you get services from non-Plan
providers. When you get proper approvals, these services are called authorized
referral services.
Effect on Benefits. If you receive authorized
referral services from a non-Plan provider, the Plan provider copayment
will
apply. When you do not get a referral, no benefits are provided for
services received from a non-Plan provider.
How to Get an Authorized Referral. You or your physician must call the
toll-free telephone number on your member ID card before scheduling an
admission to, or before you get the services of, a non-Plan provider.
When an Authorized Referral Will be Provided. Referrals to non-Plan
providers will be approved only when all of the following conditions are met:
¨ There is no Plan provider who practices the specialty you need,
provides the required services or has the necessary facilities within 50-miles
of your home; AND
¨ You are referred to the non-Plan provider by a
physician who is a Plan provider; AND
¨ The services are authorized as
medically necessary before you get the services.
Disagreements with Medical Management Program Decisions
¨ If
you or your physician don't agree with a Medical Management Program decision, or
question how it was reached, either of you may ask for a review of the decision.
To request a review, call the number or write to the
address included on
your written notice of determination. If you send a written request it must
include medical
information to support that services are medically
necessary.
¨ If you, your representative, or your physician acting for you, are
still not satisfied with the reviewed decision, a written appeal may be sent to
us.
¨ If you are not satisfied with the appeal decision, you may follow the
procedures under Section 8: The disputed claims process. 34
34 Page 35 36
2001 Blue Cross-HMO Plan 35 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 page 37.
· 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. Drugs must be prescribed by a health care provider licensed to
prescribe such medication, and must be given to you within one year of being
prescribed.
· Where you can obtain them. You may fill the prescription at
any licensed retail pharmacy or by our mail service program.
·
Using Participating Pharmacies. To get medicine your physician has
prescribed: --Go to a participating pharmacy.
--For help finding a
participating pharmacy, call us at 1-800-700-2541.
--Show your Member ID
card.
--Pay your copayment when you get the medicine. You must also pay for
any medicine or supplies
that are not covered under the Plan.
--When
your prescription is for a brand name drug, the pharmacist will substitute it
with a generic drug
unless your physician writes "dispense as
written".
· Using Non-Participating Pharmacies. It will cost you more if you
go to a non-participating pharmacy:
--Take a claim form with you to the non-participating pharmacy. If you need a
claim form or if you
have questions, call 1-800-700-2541.
--Have the
pharmacist fill out the form and sign it.
--Then send the claim form (within
90 days) to:
Prescription Drug Program
P. O. Box 4165
Woodland Hills, CA
91365-4165
When we first get your claim, we take out:
--Costs for medicine or
supplies not covered under the Plan,
--Then any cost more than the limited
fee schedule we use for non-participating pharmacies, and
--Then your
copayment.
The rest of the cost is covered.
· If you are out of state, and you need medicine, --Call
1-800-700-2541 to find out where there is a participating pharmacy.
--If there is no participating pharmacy, pay for the drug and send us a claim
form. 35
35 Page
36 37
2001 Blue Cross-HMO Plan 36
Section 5( f)
Prescription drug benefits – CONTINUED
· Getting your medicine through the mail. When you order
medicines through the mail, here's what to do:
--Get your
prescription from your health care provider. He or she should be sure to sign
it. It must have the drug name, hhow much and how often to take it, how to use
it, the provider's name and address and
telephone number along with your
name and address.
--Fill out the order form. The first time you use
the mail service program, you must also send a filled out Patient Profille
questionnaire about yourself. Call 1-888-888-DRUG (3784) for order forms and
the Patient Profile questionnaire.
--Be sure to send the copayment along
with the prescription and the order form and the Patient Profile.
You can
pay by check, money order, or credit card.
--Send your order to:
Prescription Drug Program – Mail Service
P. O. Box 550
Pittsburgh, PA 15230-9424
1-888-888-DRUG
--There may be some
medicines you cannot order through this program. Call 1-888-888-DRUG to
find
out if you can order your medicine through the mail service program.
· We use a formulary. A preferred drug list, sometimes called a
formulary, is used to help your physician make prescribing decisions. This list
of drugs is updated quarterly by a committee of
doctors and pharmacists so that the list includes drugs that are safe and
effective in the treatment of
disease. Under the terms of your Plan, only
preferred drugs are covered at participating pharmacies
and through the mail
order program unless the prescriber has specified dispense as written. If you
are prescribed a non-preferred drug without "dispense as written",
you will pay the participating
pharmacy's, or mail order program's full cost
of the drug.
You can get drugs not listed as preferred drugs if the physician writes
"do not substitute" or "dispense as
written" on the
prescription. Some drugs need to be approved -the physician or pharmacy will
know
which drugs they are.
You cannot order non-preferred drugs through the mail service program.
If
you have questions about whether a drug is on the preferred drug list or needs
to be approved, please
call us at 1-800-700-2541.
If we don't approve a request for a drug that is not part of our preferred
drug list, you or your
physician can appeal the decision by calling us at
1-800-700-2541. If you are not satisfied with the
result, please see Section
8: The disputed claims process.
· These are the dispensing limitations. You can get a 30-day or
100 unit supply, whichever is less, if you get the drug at a retail pharmacy.
You can get a 60-day supply of drugs at a retail pharmacy for
treating
attention deficit disorder if they:
--Are FDA approved for treating
attention deficit disorder;
--Are federally classified as Schedule II drugs;
and
--Require a triplicate prescription form.
You can get a 90-day supply if you get the drug from our mail service
program.
Drugs for the treatment of impotence and/ or sexual dysfunction
are:
--Limited to six tablets (or treatments) for a 30-day period; and
--Available at retail pharmacies only. You must give us proof that a medical
condition has caused the
problem.
Prescription drugs benefits begin on the next page. 36
36 Page 37 38
2001 Blue Cross-HMO Plan 37 Section 5( f)
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan
physician and obtained from a retail pharmacy or through our mail
order
program:
· Outpatient Drugs and medicines which require a
prescription by law. Formulas prescribed by a physician for the treatment of
phenylketonuria. These formulas are subject to the brand name
copayment.
· Oral and injectable contraceptive drugs-up to a three-cycle supply
may be obtained for a single copayment charge
· Prescribed contraceptive drugs and devices which are approved by the
Food and Drug Administration.
· Insulin, with a copayment charge
applied to each vial
· Diabetic supplies including insulin syringes,
needles, glucose test tablets and test tape. Benedict's solution or equivalent
and acetone
test tablets.
· Disposable needles and syringes needed for
injecting covered prescribed medication
· Drugs used primarily for the purpose of treating infertility
· Smoking cessation drugs and medications, only if a prescription is
required by law
· Drugs that have FDA labeling to be injected under the skin by you or
a family member
· Drugs for sexual dysfunction (see limits on page
36)
Here are some things to keep in mind about our prescription drug
program:
· At participating pharmacies, a generic equivalent will be dispensed
if it is available, unless your physician specifically requires a brand
name
drug.
· If you receive brand name drugs when there is no generic
equivalent, you will still have to pay the brand name drug
copayment.
· We have an open formulary. If your physician believes a brand name
product is necessary or there is no generic available, your
physician may
prescribe a name brand drug from the preferred drug
list.
For Blue Cross Participating Pharmacies:
Preferred generic drugs:
$5 copay per prescription or refill
Brand name drugs and generic,
non-preferred drugs if the
physician
writes "dispense as
written":
$10 copay per
prescription or refill
For Non-participating Pharmacies:
Generic drugs:
$5 plus
50% of the drug limited fee schedule
Brand name drugs:
$10 plus 50% of the drug limited fee schedule
For drugs through the Mail Service Program:
Preferred generic
drugs:
$5 copay per prescription or refill
Brand name drugs and generic,
non-preferred drugs if the
physician
writes "dispense as
written":
$20 copay per
prescription or refill 37
37 Page 38 39
2001 Blue
Cross-HMO Plan 38 Section 5( f)
Covered medications and
supplies (continued) You pay
Not covered:
· Immunizing agents, biological sera, blood, blood products or
blood plasma.
· Drugs and medicines you can get without a physician's
prescription, except insulin or niacin for cholesterol lowering.
· Drugs labeled "Caution, Limited by Federal Law to
Investigational Use," experimental drugs. Drugs and medicines prescribed
for
experimental indications.
· Any cost for a drug or
medicine that is higher than what we cover.
· Cosmetics,
health and beauty aids.
· Drugs used mainly for cosmetic
purposes. · Drugs for losing weight, except when needed to treat
morbid obesity
(for example, diet pills and appetite suppressants).
·
Drugs you get outside the United States.
· Infusion drugs,
except drugs you inject under the skin yourself.
· Some kinds
of drugs which have not been shown to work better or have fewer side effects
than those listed on our list of preferred
drugs. We will still cover the drug if the physician writes "dispense
as written" or "do not substitute."
·
Herbal, nutritional and diet supplements.
· Drugs to
enhance athletic performance.
All charges 38
38 Page 39 40
2001 Blue
Cross-HMO Plan 39 Section 5( g)
Section 5 (g). Special
Features
Feature Description
MedCall (24-hour nurse assessment
service) Your Plan includes MedCall, a 24-hour nurse assessment service to help
you make decisions about your medical care. When you call MedCall toll free at
800-977-0037, be prepared to provide your name, the patient's name
(if you're not calling for yourself), the employee's social security number, and
the patient's phone number.
The nurse will ask you some questions to help
determine your health care
needs. Based on the information you provide, the
advice may be:
· Home self-care. A follow-up phone call may be made to determine how
well home self-care is working.
· Schedule a routine appointment within the next two weeks, or an
appointment at the earliest time available (within 64 hours), with your
primary care physician.
· Call your primary care physician for
further discussion and assessment.
· To go to an urgent care center
used by your primary care physician.
· To go to an emergency room
used by your primary care physician.
· Instructions to immediately
call 911.
In addition to providing a nurse to help you make decisions about
your health
care, MedCall gives you free unlimited access to its Audio
Health Library
featuring recorded information on more than 100 health care
topics. To
access the Audio Health Library, call toll free 800-977-0037 and
follow the
instructions given.
We have made arrangements with an independent company to make MedCall
available to you as a special service. It may be discontinued without
notice.
Note: MedCall is an optional service. Remember, the best place to go for
medical care is your primary care physician. 39
39
Page 40 41
2001
Blue Cross-HMO Plan 40 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.
· Your medical group must provide or arrange for your care.
· We cover hospitalization for dental procedures only when a
non-dental physical impairment exists which makes hospitalization necessary to
safeguard the health of the patient; we do not
cover the dental procedure unless it is described below. See Hospital
benefits (Section
5c).
· 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
We cover restorative services and
supplies necessary for the initial repair (but not replacement) of sound natural
teeth. The need for these services must result from an accidental injury.
You pay nothing. Care is not covered if
you damage or injure your
teeth while chewing or biting.
Dental benefits
We have no other dental benefits. 40
40 Page 41 42
2001 Blue Cross-HMO Plan 41 Section 5( i)
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium,
and you cannot file an FEHB
disputed claim about them. Fees you pay
for these services do not count toward FEHB deductibles or out-of-pocket
maximums.
Optional Dental Benefits – These are separate benefit packages
that require additional premiums.
HERE'S AN OPPORTUNITY TO ENHANCE YOUR
TOTAL HEALTH CARE PACKAGE BY ADDING COMPREHENSIVE DENTAL BENEFITS
Dental SelectHMO & Dental Net -Dental Maintenance Organization
Options: These are plans that offer members broad ranges of dental coverage
at a lower cost. Under either plan, members choose their own dentist
from a
network of providers, and may change their dentist at any time. Once you have
enrolled in Dental
SelectHMO or Dental Net, your provider will perform
preventive and diagnostic services and other dental services
free of charge
or at a greatly reduced rate.
Key Dental SelectHMO & Dental Net Advantages
· Diagnostic and
Preventive Services are FREE
· No Deductibles and No Claim Forms
· Benefits include Orthodontic Coverage
Eyewear Savings Program for Blue Cross-HMO Members at no extra premium
· Instant savings on eyewear As a Federal Employee and a member
of the Blue Cross-HMO you are now entitled to special savings on
frames,
lenses (including contact lenses), as well as other important eye care
accessories. These savings are
available through optical departments located
in selected Sears, Montgomery Ward and J. C. Penney stores.
· No
Claim Forms There are currently more than 135 participating optical departments
located throughout California. To receive
your eyewear discount, just present your Blue Cross-HMO ID card to the
optical department of the stores listed
above.
Blue Cross Senior Secure -Medicare prepaid plan (HMO) provides
complete coverage for medically necessary hospital and doctor services with no
monthly premium, no deductibles and a prescription drug benefit.
Coverage
includes:
°Prescription Drug °Chiropractic Care
°Vision
°Hearing
°Dental °Podiatry
Blue Cross Senior Secure features all of the health coverage services offered
by Medicare plus some extra services
Medicare does not offer. Contact
Customer Service, toll free 1-888-230-7338 to obtain detailed benefits and a
list of
providers in your area. As indicated on page 50, you may remain
enrolled in FEHBP when you enroll in a Medicare
Prepaid Plan.
Benefits on this page are not part of the FEHB contract 41
41 Page 42 43
2001 Blue Cross –HMO Plan 42 Section 6
Section 6. General exclusions – things we don't cover
The exclusions in this section apply to all benefits. Although we may
list a specific service as a benefit, we
will not cover it unless we
determine it is medically necessary to prevent, diagnose, or treat your illness,
disease, injury or condition.
We do not cover the following:
· 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;
· Services, drugs, or supplies you receive from a provider or
facility barred from the FEHB Program; or
· Services provided by
non-Plan providers unless you receive a referral or the services are for
emergency or urgent care. 42
42 Page 43 44
2001 Blue
Cross-HMO Plan 43 Section 7
Section 7. Filing a claim for
covered services
How to claim benefits You normally won't have to submit
claims to us unless you receive emergency or urgent case services from a
provider who doesn't
contract with us. If you file a claim, please send us
all of the
documents for your claim as soon as possible. To obtain claim
forms or
other claims filing advice or answers about our benefits, contact
us at
800-235-8631, or at our website at www. bluecrossca. com.
Deadline for filing your claim Most claims will be submitted for you.
However, there is a deadline for filing claims yourself. You must submit claims
by December 31 of the
year after the year you received the service. OPM can
extend this
deadline if you show that circumstances beyond your control
prevented
you from filing on time.
When we need more information Please reply promptly when we ask for
additional information. We may delay processing or deny your claims if you do
not respond. 43
43 Page
44 45
2001 Blue Cross-HMO Plan 44
Section 8
Section 8. The disputed claims process
Follow
this Federal Employees Health Benefits Program disputed claims process if you
disagree with our decision
on your claim or request for services, drugs, or
supplies – including a request for prior approval:
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: Blue Cross of California, P. O. Box 4089, Woodland Hills, Ca.
91365;
and
(c) Include a statement about why you believe our initial decision was wrong,
based on specific
benefit provisions in this brochure; and
(d) Include copies of documents that support your claim, such as physicians'
letters, operative reports,
bills, medical records, and explanation of
benefits (EOB) forms.
For additional review information regarding denials of experimental or
investigative treatment-go to page
46.
2 We have 30 days from the date we receive your request to: (a) Pay
the claim (or, if applicable, arrange for the health care provider to give you
the care); or
(b) Write to you and maintain our denial --go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider,
we will send you a copy
of our request— go to step 3.
3 You or your provider must send the information so that we receive it
within 60 days of our request. We will then decide within 30 more days. If we do
not receive the information within 60 days, we will decide within 30 days of the
date the
information was due. We will base our decision on the information
we already have.
We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
· 90 days after the date of our letter
upholding our initial decision; or
· 120 days after you first wrote
to us --if we did not answer that request in some way within 30 days; or
· 120 days after we asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance
Programs, Contracts Division II,
P. O. Box 436, Washington, D. C.
20044-0436. 44
44 Page
45 46
2001 Blue Cross-HMO Plan 45
Section 8
Send OPM the following information:
· A
statement about why you believe our decision was wrong, based on specific
benefit provisions in this brochure;
· Copies of documents that support your claim, such as physicians'
letters, operative reports, bills, medical records, and explanation of benefits
(EOB) forms;
· Copies of all letters you sent to us about the claim;
· Copies of all letters we sent to you about the claim; and
· Your daytime phone number and the best time to call.
Note: If you want OPM to review different claims, you must clearly identify
which documents apply to
which claim.
Note: You are the only person who has a right to file a disputed claim with
OPM. Parties acting as your
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, drugs, or supplies. This is the only deadline that may not be
extended.
OPM may disclose the information it collects during the review
process to support their disputed claim
decision. This information will
become part of the court record.
You may not sue until you have completed the disputed claims process.
Further, Federal law governs your
lawsuit, benefits, and payment of
benefits. The Federal court will base its review on the record that was
before OPM when OPM decided to uphold or overturn our decision. You may
recover only the amount of
benefits in dispute.
NOTE: If you have a serious or life threatening condition (one that
may cause permanent loss of bodily functions or death if not treated as soon as
possible), and
(a) We haven't responded yet to your initial request for care
or prior approval, then call us at 800/ 235-8671 and
we will expedite our
review; or
(b) We denied your initial request for care or prior approval, then:
·· If we expedite our review and maintain our denial, we will
inform OPM so that they can give your claim expedited treatment too, or
·· You can call OPM's Health Benefits Contracts Division at
202/ 606-3818 between 8 a. m. and 5 p. m. eastern time. 45
45 Page 46 47
2001 Blue Cross-HMO Plan 46 Section 8
Review of Denials of Experimental or Investigative Treatment. If
coverage for a proposed treatment is denied because we or your medical group
determine that the treatment is experimental or investigative, you may ask that
the denial be reviewed by an external independent medical review
organization which has a contract with the
California Department of Managed
Health Care. To request this review, please call us at the telephone number
listed on your identification card or write to us at Blue Cross of
California, 21555 Oxnard Street, Woodland Hills,
CA 91367. To qualify for
this review, all of the following conditions must be met:
· You have a life threatening or seriously debilitating condition. The
condition meets either or both of the following descriptions:
-A life threatening condition or a disease is one where the likelihood of
death is high unless the course of the disease is interrupted. A life
threatening condition or disease can also be one with a potentially
fatal
outcome where the end point of clinical intervention is the patient's survival.
-A seriously debilitating condition or disease is one that causes major
irreversible morbidity.
· The proposed treatment must be recommended
by either (a) a Plan provider or (b) a board certified or board eligible
physician qualified to treat you who certifies in writing that the proposed
treatment is more
likely to be beneficial than standard treatment. This certification must
include a statement of the evidence
relied upon.
· If this review is requested either by you or by a qualified
provider, other than a Blue Cross HMO provider, as described above, the
requester must supply two items of acceptable medical and scientific evidence.
This evidence consists of the following sources:
-Peer-reviewed
scientific studies published in medical journals with nationally recognized
standards;
-Medical literature meeting the criteria of the National
Institute of Health's National Library of Medicine for indexing in Index
Medicus, Excerpta Medicus, Medline, and MEDLARS database Health
Services Technology Assessment Research;
-Medical journals recognized by
the Secretary of Health and Human Services, under Section 1861( t)( 2) of the
Social Security Act;
-The American Hospital Formulary Service-Drug Information, the American
Medical Association Drug Evaluation, the American Dental Association Accepted
Dental Therapeutics, and the United States
Pharmacopoeia-Drug Information;
-Findings, studies or research conducted by or under the auspices of federal
governmental agencies and nationally recognized federal research institutes; and
-Peer reviewed abstracts accepted for presentation at major medical
association meetings.
Within five days of receiving your request for review
we will send the reviewing panel all relevant medical
records and documents
in our possession, as well as any additional information submitted by you or
your
physician. Information we receive subsequently will be sent to the
review panel within five business days. The
external independent review
organization will complete its review and render its opinion within 30 days of
its
receipt of request for review (or within seven days in the case of an
expedited review). This timeframe may be
extended by up to three days for
any delay in receiving necessary records. 46
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2001
Blue Cross-HMO Plan 47 Section 9
Section 9. Coordinating
ben