Serving: Upstate, Hudson Valley, and Western New York.
Enrollment in this Plan is limited; see page 6 for requirements.
This Plan has Excellent accreditation from
the NCQA. See the 2001
Guide for
more information on NCQA.
Enrollment codes:
Region I includes the Capital Area of New York.
SG1 Self Only SG2 Self and Family
Region II includes the Hudson Valley of New York.
QB1 Self Only QB2
Self and Family
Region III includes the North and Central New York area.
PW1 Self Only
PW2 Self and Family
Authorized for distribution by the:
RI 73-549
For changes in benefits
see page 7. 1
1
Page 2 3
Table of
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . 4
Plain Language . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . 4
Section 1. Facts about this
HMO plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . 5
How we pay providers . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . 5
Who provides my health care? . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . 5
Patients' Bill of Rights . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . 5
Service Area . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . 6
Section 2. How we change for 2001 . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . 7
Program-wide changes . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 7
Changes to this Plan . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 7
Section 3. How you get care . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 8
Identification cards . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 8
Where you get covered care . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 8
° Plan providers . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
° Plan facilities . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
What you must do to get covered care . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
°
Primary care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
°
Specialty care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
°
Hospital care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Circumstances beyond our control . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Services
requiring our prior approval . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . 10
Section 4. Your costs
for covered services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . 11
° Copayments . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . 11
° Deductible . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . 11
° Coinsurance . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . 11
Your out-of-pocket maximum . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . 11
Section 5. Benefits . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . 12
Overview . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . 12
(a) Medical services and
supplies provided by physicians and other health care professionals . . . . . .
. 13
(b) Surgical and anesthesia services provided by physicians and other
health care professionals . . . . . . 21
(c) Services provided by a hospital
or other facility, and ambulance services . . . . . . . . . . . . . . . . . . .
. 24
(d) Emergency services/ accidents . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
(e)
Mental health and substance abuse benefits . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . .28
(f) Prescription drug
benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . 31
(g) Special features . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . 34
(h) Dental benefits . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . 35
(i) Non-FEHB benefits available to Plan
members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 36
2001 CDPHP 2 Table of Contents 2
2
Page 3 4
Table of
Contents continued
Section 6. General exclusionsÑ things
we don't cover . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . 37
Section 7. Filing a claim for covered
services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . 38
Section 8. The disputed claims
process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . 39
Section 9. Coordinating
benefits with other coverage . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . 41
When you haveÉ
° Other health coverage . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
° Original Medicare . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
° Medicare+ Choice . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
TRICARE/ Workers' Compensation/ Medicaid . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Other Government
agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . 44
When others are responsible
for injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . 44
Section 10. Definitions of terms we use in
this brochure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . 45
Section 11. FEHB facts . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . 46
Coverage information . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . 46
° No pre-existing condition
limitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . 46
° Where you get information about enrolling
in the FEHB Program . . . . . . . . . . . . . . . . . . . . . . . . . 46
° Types of coverage available for you and your family . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . 46
° When benefits
and premiums start . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . 47
° Your medical and claims records
are confidential . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 47
° When you retire . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 47
When you lose benefits . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
47
° When FEHB coverage ends . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
°
Spouse equity coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
° Temporary
Continuation of Coverage (TCC) . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . 47
° Enrolling in TCC . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . 47
° Converting to individual coverage . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 48
° Getting a Certificate of Group Health Plan Coverage .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Inspector General advisory: Stop health care fraud! . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . 50
Summary of benefits . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . 51
Rates . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . Back cover
2001 CDPHP 3 Table of Contents 3
3
Page 4 5
Introduction
Capital District Physicians' Health Plan, Inc.
17 Columbia Circle
Albany, NY 12203
This brochure describes the benefits of Capital District Physicians' Health
Plan, Inc. under our contract (CS 2612) 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 51. 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 under-standable
to the public by requiring agencies to use plain language. In response, a
team of health plan representatives and
OPM staff worked cooperatively to
make this brochure clearer. Except for necessary technical terms, we use common
words.
"You" means the enrollee or family member; "we"
means Capital District Physicians' Health Plan, Inc.
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.
2001 CDPHP 4 Introduction/ Plain Language 4
4 Page 5 6
Section 1. Facts about this HMO plan
This
Plan is a health maintenance organization (HMO). We require you to see specific
physicians, hospitals, and other
providers that contract with us. These Plan
providers coordinate your health care services.
HMOs emphasize preventive care such as routine office visits, physical exams,
well-baby care, and immunizations, in
addition to treatment for illness and
injury. Our providers follow generally accepted medical practice when
prescribing
any course of treatment.
When you receive services from Plan providers, you will not have to submit
claim forms or pay bills. You only pay the
copayments, coinsurance, and
deductibles described in this brochure. When you receive emergency services from
non-Plan
providers, you may have to submit claim forms.
You should join an HMO because you prefer the plan's benefits, not because
a particular provider is available. You cannot change plans because a provider
leaves our Plan. We cannot guarantee that any one physician, hospital,
or
other provider will be available and/ or remain under contract with us.
How we pay providers
We contract with individual physicians,
medical groups, and hospitals to provide the benefits in this brochure. These
Plan
providers accept a negotiated payment from us, and you will only be
responsible for your copayments or coinsurance.
Who provides my health care?
The Capital District Physicians'
Health Plan, Inc. (CDPHP) provides medical care through participating providers
in their
private offices, area hospitals, and other health care facilities.
The first and most important decision each member must make is the selection
of a primary care doctor. The decision is
important since it is through this
doctor that all other health services, particularly those of specialists, are
obtained. When
you enroll, you will be asked to let the Plan know which
primary care doctor( s) you have selected for you and each of your
family
members. In addition, female members may also select an obstetrician/
gynecologist. The Plan's provider directory
lists primary care doctors,
(general practitioners, family practitioners, pediatricians, and internists),
with their locations and
phone numbers, and notes whether or not the doctor
is accepting new patients. Directories are updated on a regular basis and
are available at the time of enrollment or by calling the Member Services
Department at 518/ 862-3747 or 1-800-777-2273.
If you need help choosing a
doctor, call the Plan. You may change your doctor selection by notifying the
Plan thirty (30)
days in advance.
Patients' Bill of Rights
OPM requires that all FEHB Plans comply
with the Patients' Bill of Rights, recommended by the President's Advisory
Commission on Consumer Protection and Quality in the Health Care Industry.
You may get information about us, our
networks, providers, and facilities.
OPM's FEHB website (www. opm. gov/ insure) lists the specific types of
information
that we must make available to you. Some of the required
information is listed below.
° CDPHP is licensed in New York State.
° CDPHP has been in
existence for more than 16 years.
° CDPHP is a not-for-profit health
maintenance organization.
If you want more information about us, call 1-800-777-2273, or write to
Member Services, CDPHP, 17 Columbia Circle,
Albany, NY 12203. You may also
contact us by fax at 518/ 456-0679 or visit our website at www. cdphp. com.
2001 CDPHP 5 Section 1 5
5 Page 6 7
Section 1. Facts
about this HMO plan continued
Service Area
To enroll
with us, you must live or work in our service area. This is where our providers
practice. Our New York State
service area is:
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
care or services that have received prior approval from the Plan. We will not
pay for any
other health care services.
If you or a covered family member move outside of our service area, you can
enroll in another plan. If your dependents
live out of the area, you should
consider enrolling in a fee-for-service plan or an HMO that has agreements with
affiliates in other areas. If you or a family member move, you do not have
to wait until Open Season to change plans.
Contact your employing or
retirement office.
2001 CDPHP 6 Section 1
Region IÑ Code SG Region IIÑ Code QB Region IIIÑ Code PW
Albany County Dutchess County Broome County
Columbia County Orange
County Chenango County
Fulton County Ulster County Delaware County
Greene County Essex County
Montgomery County Hamilton County
Rensselaer County Herkimer County
Saratoga County Madison County
Schenectady County Oneida County
Schoharie County Otsego County
Warren County Tioga County
Washington County 6
6 Page 7 8
Section 2. How we change for 2001
Program-wide
changes
° The plain language team reorganized the brochure and the
way we describe our benefits. We hope this will make it
easier for you to
compare plans.
° This year, the Federal Employees Health Benefits Program is
implementing network mental health and substance abuse
parity. This means
that your coverage for mental health, substance abuse, medical, surgical, and
hospital services from
providers in our plan network will be the same with
regard to deductibles, coinsurance, copays, and day and visit
limitations
when you follow a treatment plan that we approve. Previously, we placed shorter
day or visit limitations on
mental health and substance abuse services than
we did on services to treat physical illness, injury, or disease.
° Many health care organizations have turned their attention this past
year to improving health care quality and patient
safety. OPM asked all FEHB
plans to join them in this effort. You can find specific information on our
patient safety
activities by calling Member Services Department at 518/
862-3747 or 1-800-777-2273, or checking our website
www. cdphp. com.
You can find out more about patient safety on the OPM website, www. opm. gov/
insure. To improve
your health care, take these five steps:
°° 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 25.2% for Self Only or 32.6% for Self and Family.
°
You pay $5.00 per prescription unit or refill for generic drugs and $20.00
per prescription unit or refill for name brand drugs.
°
Self-administered injectable drugs; you pay $5 for covered generic, $20 for
covered brand name.
° Infertility drugs; you pay $5 for covered
generic, $20 for covered brand name.
° Intravenous fluids and
medication for home use, implantable drugs, and some injectable drugs are
covered under Medical and Surgical Benefits; you pay $5 generic, $20 name brand.
° Implanted time-release medications, you pay one-time copay of $5.00 per
generic or $20.00 per name brand drug.
2001 CDPHP 7 Section 2 7
7 Page 8 9
Section 3. How you
get care
Identification cards We will send you an identification (ID)
card when you enroll. You should carry your ID card with you at all times. You
must show it whenever you receive
services from a Plan provider, or fill a
prescription at a Plan pharmacy. Until
you receive your ID card, use your
copy of the Health Benefits Election Form,
SF-2809, your health benefits
enrollment confirmation (for annuitants), or
your Employee Express
confirmation letter.
If you do not receive your ID card within 30 days after the effective date of
your enrollment, or if you need replacement cards, call us at 1-800-777-2273
or 518/ 862-3747.
Where you get covered care You get care from "Plan
providers" and "Plan facilities." You will only pay copayments or
coinsurance, and you will not have to file claims.
° Plan providers
Plan providers are physicians and other health care professionals in our
service area that we contract with to provide covered services to our members.
We
credential Plan providers according to NCQA national standards.
We
list Plan providers in the provider directory, which we update periodically.
The list is also on our Web site.
° 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 Web site.
What you must do It depends on the type of care you need. First, you
and each family member must choose a primary care physician. This decision is
important since your
primary care physician provides or arranges for most of
your health care.
The Plan provider directory lists primary care doctors,
with their locations
and phone numbers, and notes whether or not the doctor
is accepting new
patients. If you need help choosing a doctor, call the
Plan. You may change
your doctor selection by notifying the Plan thirty (30)
days in advance.
° Primary care Your primary care physician can be a family
practitioner, internist, general practitioner, or pediatrician. Your primary
care physician will provide most
of your health care, or give you a referral
to see a specialist. Women may
also select an OB/ GYN in addition to their
primary care physician.
If you want to change primary care physicians or if your primary care
physician leaves the Plan, call us. We will help you select a new one.
° Specialty care Your primary care physician will refer you to a
specialist for needed care. However, you may see your obstetrician/ gynecologist
of record, seek coverage
for emergency care, or obtain a routine eye exam
once every 24 months
without a referral.
2001 CDPHP 8 Section 3 8
8 Page 9 10
Section 3. How
you get care continued
Here are other things you should know
about specialty care:
° If you need to see a specialist frequently
because of a chronic, complex,
or serious medical condition, your primary
care physician will work with
the specialist, the Plan, and the member or
member's designee to develop
a treatment plan that allows you to see your
specialist for a certain number
of visits without additional referrals. Your
primary care physician will use
our criteria when creating your treatment
plan (the physician may have to
get an authorization or approval
beforehand). The treatment plan must be
approved by CDPHP.
° 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 Your Plan primary care physician or specialist
will make necessary hospital arrangements and supervise your care. This includes
admission to a skilled
nursing or other type of facility.
If you are in
the hospital when your enrollment in our Plan begins, call our
member
service department immediately, or as soon as possible, at 518/ 862-3747
or
1-800-777-2273. If you are new to the FEHB Program, we will arrange for
you
to receive care.
2001 CDPHP 9 Section 3 9
9 Page 10 11
Section 3. How
you get care continued
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
92nd day after you become a member of this Plan, whichever
happens first.
These provisions apply only to the hospital benefits of the hospitalized
person.
Circumstances beyond our control Under certain extraordinary
circumstances, such as natural disasters, we may have to delay your services or
we may be unable to provide them. In that case,
we will make all reasonable
efforts to provide you with the necessary care.
Services requiring our Your primary care physician has authority to
refer you for most services. For prior approval certain services,
however, your physician must obtain approval from us. The
approval is based
on whether the service is covered, medically necessary, and
follows
generally accepted medical practice.
We call this review and approval process prior approval. Your physician or
specialist must obtain prior approval for the following services:
hospitalization
or skilled nursing facility care, home health care,
inpatient rehabilitation unit
or facility services, prosthetic devices, some
identified medications, durable
medical equipment, home dialysis, and
hospice care. Prior approval is also
required for physical therapy,
occupational therapy, speech therapy, mental
health/ substance abuse, GHT,
and other services such as off-plan referrals.
Your primary care physician and/ or specialist contacts CDPHP's Resource
Coordination Management Department with a description of the medical
necessity of the request.
A nurse reviewer reviews the request. Clinical information is obtained to
support the medical necessity of the request. Clinical information is
reviewed
against established criteria. Decisions are based on the
appropriateness of care.
Ultimate determinations are made by the Plan's
Medical Director. Upon approval
you and your provider are notified via
telephone and mail. Services that do
not receive prior approval will not be
covered by the Plan.
2001 CDPHP 10 Section 3 10
10
Page 11 12
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 and when you go in the hospital, you pay nothing per
admission.
° Deductible We do 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 20% of our allowance for durable medical
equipment.
Your out-of-pocket maximum We do not have an out-of-pocket maximum.
2001 CDPHP 11 Section 4 11
11
Page 12 13
Section 5. BenefitsÑ OVERVIEW (See page 7 for how our
benefits changed this year and page 51 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 518/ 862-3747
or
1-800-777-2273 or at our Web site at www. cdphp. com.
(a) Medical services and supplies provided by physicians and other health
care professional . . . . . . . . . . . . . . . . 13Ð 20
°
Diagnostic and treatment services ° Hearing services (testing, treatment,
and supplies)
° Lab, X-ray, and other diagnostic tests ° Vision
services (testing, treatment, and supplies)
° Preventive care, adult
° Foot care
° Preventive care, children ° Orthopedic and
prosthetic devices
° Maternity care ° Durable medical equipment
(DME)
° Family planning ° Home health services
° Infertility
services ° Alternative treatments
° Allergy care ° Educational
classes and programs
° Treatment therapies
° Rehabilitative
therapies
(b) Surgical and anesthesia services provided by physicians and other health
care professionals . . . . . . . . . . . . . . 21Ð 23
° Surgical
procedures ° Oral and maxillofacial surgery
° Reconstructive surgery
° Organ/ tissue transplants
° Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services
. . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Ð 25
°
Inpatient hospital ° Extended care benefits/ skilled nursing care
°
Outpatient hospital or ambulatory surgical center ° facility benefits
° Hospice care
° Ambulance
(d) Emergency services/ accidents . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
26Ð 27
° Medical emergency ° Ambulance
(e) Mental health and substance abuse benefits . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Ð 30
(f) Prescription drug benefits . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 31Ð 33
(g) Special features . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . 34
° Non-emergency routine care for full-time °
Childbirth Education Reimbursement Program
° students out-of-area °
Centers of Excellence for transplants, surgery, etc.
° Services for deaf
and hearing impaired
(h) Dental benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 35
(i) Non-FEHB benefits available to Plan members . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Summary of benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 51
2001 CDPHP 12 Section 5 12
12
Page 13 14
I M
P O
R T
A N
T
I M
P O
R T
A N
T
Section 5 (a) Medical services and supplies provided by physicians and
other health care professionals
Here are some important things to keep in
mind about these benefits: ° Please remember that all benefits are
subject to the definitions, limitations, and
exclusions in this brochure and
are payable only when we determine they are
medically necessary.
°
Plan physicians must provide or arrange your care.
° Be sure to read
Section 4, Your costs for covered services for valuable information
about how cost sharing works. Also read Section 9 about coordinating
benefits
with other coverage, including with Medicare.
Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
° In physician's office $10
per office visit
° Preventive annual adult routine physical Nothing
° Well-child
visits are covered in full for the following visits: 1 month,
2 months, 4
months, 6 months, 9 months, 12 months, 15 months,
and 18 months, ages 2-22,
an annual exam.
Professional services of physicians
° In an urgent care center $25
per visit
° During a hospital stay Nothing
° In a skilled nursing facility
up to 90 days with prior approval
° Initial examination of a newborn
child covered under a family enrollment
° Office medical consultations $10 per visit
° Second surgical
opinion
At home $10 per visit
Not covered All charges
° Surgery
primarily for cosmetic purposes
° Homemaker services
° Storage of blood and blood derivatives, except in the case of
autologous blood donations required for a scheduled surgical procedure.
2001 CDPHP 13 Section 5( a) 13
13
Page 14 15
Lab,
X-ray and other diagnostic tests You pay
Tests, such as: Nothing if you
receive these
° Blood tests services at a preferred facility;
° Urinalysis otherwise, $10 per office visit
°
Pathology
° X-rays
° Non-routine mammograms
° CAT scans/ MRI
° Ultrasound
°
Electrocardiogram and EEG
° Non-routine pap tests $10 per office visit
Preventive
care, adult
Routine screenings, such as: Nothing
° Blood lead
levelÑ One annually
° Total blood cholesterolÑ once every
three years, ages 19 through 64
° Colorectal cancer screening, including
°° Fecal occult blood test every 5 years starting at age 50
°° Sigmoidoscopy, screeningÑ every five years starting at age
50
Prostate Specific Antigen (PSA test)Ñ one annually for men age 40 and
older $10 per office visit
Routine Pap test
Routine mammogramÐ covered for women age 35 and older, as follows:
Nothing
° From age 35 through 39, one baseline during this five year
period
° From age 40 through 64, one every calendar year
° At
age 65 and older, one every two consecutive calendar years
Routine Immunizations, limited to: Nothing
° Tetanus-diphtheria (Td)
boosterÑ once every 10 years, ages 19 and over
(except as provided
for under childhood immunizations)
° Influenza/ Pneumococcal vaccines, annually, age 65 and over
Not covered: Physical exams required for obtaining or continuing All
charges
employment or insurance, attending schools or camp, or travel.
2001 CDPHP 14 Section 5( a) 14
14
Page 15 16
Preventive care, children You pay
° Childhood immunizations
recommended by the American Academy Nothing.
of Pediatrics
° Examinations, such as: $10 per office visit.
°° Eye exams
through age 17 to determine the need for vision correction.
Limited to one
every 24 months.
°° Ear exams through age 17 to determine the need for hearing
correction
°° Examinations done on the day of immunizations (through
age 22)
° Well-child care charges for routine examinations, immunizations and
Nothing.
care through age 22. Well-child care for the following visits: 1
month,
2 months, 4 months, 6 months, 9 months, 12 months, 15 months, and
18 months, ages 2-22 an annual exam
Maternity care
Complete maternity (obstetrical) care, such as: $10
office visit for the initial
° Prenatal care diagnosis. You pay nothing
thereafter.
° Delivery
° Postnatal care
Note: Here are some
things to keep in mind:
° You do not need to precertify your normal
delivery; see page 10 for
other circumstances, such as extended stays for
you or your baby.
° You may remain in the hospital up to 48 hours after a regular delivery
and 96 hours after a cesarean delivery. We will extend your inpatient
stay if medically necessary.
° We cover routine nursery care of the newborn child during the covered
portion of the mother's maternity stay. We will cover other care of an
infant who requires non-routine treatment only if we cover the infant
under a Self and Family enrollment.
° We pay hospitalization and surgeon services (delivery) the same as
for illness and injury. See Hospital benefits (Section 5c) and Surgery
benefits (Section 5b).
Not covered: Elective sonograms to determine fetal sex All charges
2001 CDPHP 15 Section 5( a) 15
15
Page 16 17
Family planning You pay
Voluntary sterilization $10 per office
visit
° Surgically implanted contraceptives $5 for a covered generic,
° Injectable contraceptive drugs $20 for a covered brand name
° Intrauterine devices (IUDs) $10 per office visit
° Genetic
counseling when approved
Not covered: reversal of voluntary surgical sterilization All charges
Infertility services
Diagnosis and treatment of infertility,
such as: $10 per office visit
° Artificial insemination:
°°
intravaginal insemination (IVI)
°° intracervical
insemination (ICI)
°° intrauterine insemination (IUI)
° Fertility drugs
Note: We cover fertility drugs under the
prescription drug benefit
for up to six cycles per lifetime.
Not covered: All charges
° 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
° Leuprolide Acetate when used for cessation of ovulation.
° Items such as ovulation predictor kits and home pregnancy
testing kits.
° IVIG when utilized for infertility or pregnancy
loss.
Allergy care
Testing and treatment $10 per office visit
Allergy injection
Allergy serum Nothing
Not covered: provocative food testing and
sublingual allergy desensitization All charges
2001 CDPHP 16 Section 5( a) 16
16
Page 17 18
Treatment therapies You pay
° Chemotherapy and radiation
therapy $10 per office visit
Note: High dose chemotherapy in association
with autologous bone
marrow transplants are limited to those transplants
listed under
Organ/ Tissue Transplants on page 23.
° Respiratory and inhalation therapy
° DialysisÑ
Hemodialysis and peritoneal dialysis
° Intravenous (IV)/ Infusion TherapyÑ Home IV and antibiotic
therapy $10 per office visit if received as an
outpatient. Covered in full
if part of
home health care.
° Growth hormone therapy (GHT) $10 per office visit
Note: We will
only cover GHT when we preauthorize the treatment.
Your physician will call
for preauthorization. We will ask you to submit
information that establishes
that the GHT is medically necessary. If you
do not ask or if we determine
GHT is not medically necessary, we will
not cover the GHT or related
services and supplies. See Services requiring
our prior approval in
Section 3.
Rehabilitative therapies
Physical therapy, occupational therapy
and speech therapyÑ $10 per office visit
° Up to 120 calendar
days per condition for the service of a participating
physical therapists;
° Up to 60 calendar days per condition for the services of each of the
following:
°° speech therapists; and
°° occupational therapists.
Note: We only cover therapy to restore bodily function or speech when
there has been a total or partial loss of bodily function or functional
speech due to illness or injury.
Cardiac rehabilitation following a heart transplant, bypass surgery, or a
myocardial infarction is provided for up to 36 sessions.
Not covered: All charges
° Long-term rehabilitative therapy
° Exercise programs
° Continuous ECG Monitoring
and Thallium stress tests.
° Services for chronic or maintenance
phase of cardiac rehabilitation.
2001 CDPHP 17 Section 5( a) 17
17
Page 18 19
Hearing services (testing, treatment, and supplies) You pay
°
First hearing aid and testing only when necessitated by accidental injury $10
per office visit
° Hearing testing for children through age 18 (see
Preventive care, children)
Not covered: All charges
° All other hearing testing
° Hearing aids, testing, and examinations for them
Vision services (testing, treatment, and supplies)
° One pair
of eyeglasses or contact lenses to correct an impairment $10 per office visit
directly caused by accidental ocular injury or intraocular surgery
(such
as for cataracts)
° Eye exam to determine the need for vision correction for children $10
per office visit
through age 17 (see preventive care)
° Eye refractions once every 24 months
° Eye exercises and
orthoptics when approved
Not covered: All charges
° Eyeglasses or contact lenses
° Radial keratotomy and other refractive surgery
Foot care
Routine foot care when you are under active treatment
for a metabolic or $10 per office visit
peripheral vascular disease, such as
diabetes.
See orthopedic and prosthetic devices for information on podiatric
shoe inserts.
Not covered: All charges
° Cutting, trimming or removal of
corns, calluses, or the free edge of
toenails, and similar routine treatment
of conditions of the foot,
except as stated above
° Treatment of weak, strained or flat feet or bunions or spurs; and of
any instability, imbalance or subluxation of the foot (unless the
treatment is by open cutting surgery)
2001 CDPHP 18 Section 5( a) 18
18
Page 19 20
Orthopedic and prosthetic devices You pay
° Artificial limbs
and eyes 20 percent of charges
° Externally worn breast prostheses and
surgical bras, including necessary
replacements, following a mastectomy
° Internal prosthetic devices, such as artificial joints, pacemakers,
cochlear Nothing
implants, and surgically implanted breast implant following
mastectomy.
Note: We pay internal prosthetic devices as hospital benefits;
see
Section 5 (c) for payment information. See 5( b) for coverage of the
surgery to insert the device.
° Corrective orthopedic appliances for non-dental treatment of 20 percent
of charges
temporomandibular joint (TMJ) pain dysfunction syndrome.
° Approved lumbosacral supports
Not covered: All charges
° Orthopedic and corrective shoes
° Arch supports
° Foot orthotics
°
Heel pads and heel cups
° Corsets, trusses, elastic stockings,
support hose, and other
supportive devices
° Prosthetic replacements provided less than 3 years after the last
one
we covered unless medically indicated
° Stump hose
Durable medical equipment (DME)
Rental or purchase, at our option,
including repair and adjustment, of 20 percent of charges
durable medical
equipment prescribed by your Plan physician, such as
oxygen and dialysis
equipment. Under this benefit, we also cover:
° hospital beds
° wheelchairs
° crutches
°
walkers
° blood glucose monitors $10 per item
° insulin pumps
Note:
Your provider will call our office for authorization. We will arrange
with a
health care provider to rent or sell you durable medical equipment.
Not covered: All charges
° Motorized wheel chairs
2001 CDPHP 19 Section 5( a) 19
19
Page 20 21
Home
health services You pay
° Home health care ordered by a Plan
physician and provided by a Nothing registered nurse (R. N.), licensed practical
nurse (L. P. N.), licensed
vocational nurse (L. V. N.), or home health aide
° Services include oxygen therapy, intravenous therapy and
medically 20 percent of charges necessary medications.
Not covered: All charges
° Nursing care requested by, or
for the convenience of, the patient or
the patient's family;
° Nursing care primarily for hygiene, feeding, exercising, moving the
patient, homemaking, companionship or giving oral medication.
° Rest cures
Alternative treatments
Chiropractic servicesÑ medically
necessary care for spinal manipulation. $10 per office visit
Not covered:
All charges
° Acupuncture
° Naturopathic services
° Hypnotherapy
° Biofeedback
Educational classes and programs
Coverage is limited to: Nothing
° Smoking CessationÑ Up 12 weeks, including all related expenses
such as drugs, per member per lifetime. You must attend a smoking
cessation program that CDPHP provides at no cost to you.
° Peak Asthma PerformanceÑ Members receive invitation to free
class and
a quarterly newsletter about asthma. Members who attend the class
receive
a peak flow meter, a video on asthma, a daily diary, and medication
spacer.
° PressureWiseÑ An interactive program for members identified as
hypertensive. Members attending program receive a blood pressure
monitor
and information on taking their blood pressure at home.
2001 CDPHP 20 Section 5( a) 20
20
Page 21 22
I M
P O
R T
A N
T
I M
P O
R T
A N
T
Section 5 (b). Surgical and anesthesia services provided by physicians and
other health care professionals
Here are some important things to keep in
mind about these benefits: ° Please remember that all benefits are
subject to the definitions, limitations, and
exclusions in this brochure and
are payable only when we determine they are
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).
Benefit Description You pay
Surgical procedures
°
Treatment of fractures, including casting $10 per office visit;
° Normal
pre-and post-operative care by the surgeon nothing for hospital visit
°
Correction of amblyopia and strabismus
° Endoscopy procedure
°
Biopsy procedure
° Removal of tumors and cysts
° Correction of
congenital anomalies (see reconstructive surgery)
° Surgical treatment
of morbid obesity, a condition in which an
individual's body mass index is
greater than 40 and there is
documented failure of a non-surgical attempt.
° Insertion of internal prosthetic devices. See 5( a)Ñ orthopedic
braces
and prosthetic devices for device coverage information.
° Voluntary sterilization $10 per office visit
° Norplant (a
surgically implanted contraceptive) and intrauterine devices
(IUDs). Note:
Devices are covered under 5( a) Prescription drug coverage.
° Treatment of burns
Note: Generally, we pay for internal prostheses
(devices) according to
where the procedure is done.
Not covered: All charges
° Reversal of voluntary
sterilization
° Routine treatment of conditions of the foot; see
Foot care.
2001 CDPHP 21 Section 5( b) 21
21
Page 22 23
Reconstructive surgery You pay
° Surgery to correct a
functional defect $10 per office visit;
° Surgery to correct a condition
caused by injury or illness if: nothing for hospital visits
°° the
condition produced a major effect on the member's functional
defect and
°° the condition can reasonably be expected to be corrected by such
surgery
° Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form or norm. Examples of
congenital anomalies are: protruding ear deformities; cleft lip;
cleft
palate; birth marks; webbed fingers; and webbed toes.
° All stages of breast reconstruction surgery following a mastectomy,
such as: $10 per office visit;
°° surgery to produce a symmetrical
appearance on the other breast; nothing for hospital visit
°°
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.
Not covered: All charges
° Cosmetic surgeryÑ any
surgical procedure (or any portion of a
procedure) performed primarily to
improve physical appearance
through change in bodily form, except repair of
accidental injury
° Surgeries related to sex transformation
Oral and maxillofacial surgery
Oral surgical procedures, limited
to: $10 per office visit;
° Reduction of fractures of the jaws or facial
bones; nothing for hospital visit
° Surgical correction of cleft lip,
cleft palate, or severe functional
malocclusion;
° Removal of stones from salivary ducts;
° Excision of
leukoplakia or malignancies;
° Excision of cysts and incision of
abscesses when done as independent
procedures; and
° Other surgical procedures that do not involve the teeth or their
supporting structures.
Not covered: All charges
° Oral implants and transplants
° Procedures that involve the teeth or their supporting
structures
(such as the periodontal membrane, gingiva, and alveolar bone)
° Dental work related to TMJ.
2001 CDPHP 22 Section 5( b) 22
22
Page 23 24
Organ/ tissue transplants You pay
Limited to: $10 per office
visit;
° Cornea nothing at hospital visit.
° Heart
°
Heart/ lung
° Kidney
° Kidney/ Pancreas
°Liver
°
Lung: Single ÐDouble
° Pancreas
° Allogeneic (donor) bone
marrow transplants
° Autologous bone marrow transplants (autologous stem
cell and peripheral
stem cell support) for the following conditions: acute
lymphocytic or
non-lymphocytic leukemia; advanced Hodgkin's lymphoma;
advanced
non-Hodgkin's lymphoma; advanced neuroblastoma; breast cancer;
multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal,
retroperitoneal, and ovarian germ cell tumors
° National Transplant Program (NTP)Ñ CDPHP facilitates organ
transplants at a CDPHP approved transplant center.
Limited BenefitsÑ Treatment for breast cancer, multiple myeloma, and
epithelial ovarian cancer may be provided in an NCI-or NIH-approved
clinical trial at a Plan-designated center of excellence and if approved
by the Plan's Medical Director in accordance with the Plan's protocols.
Note: We cover related medical and hospital expenses of the donor when
we
cover the recipient.
Not covered: All charges
° Donor screening tests and donor
search expenses, except those
performed for the actual donor
° Implants of artificial organs
° Transplants not
listed as covered
Anesthesia
Professional services provided inÑ Nothing
° Hospital (inpatient)
° Skilled nursing facility
°
Ambulatory surgical center
° Office $10 per office visit
2001 CDPHP 23 Section 5( b) 23
23
Page 24 25
I M
P O
R T
A N
T
Section 5 (c). Services provided by a hospital or other facility, and
ambulance services
Here are some important things to remember about these
benefits: ° Please remember that all benefits are subject to the
definitions, limitations, and
exclusions in this brochure and are payable
only when we determine they are
medically necessary.
° Plan
physicians must provide or arrange your care and you must be hospitalized
in
a Plan facility.
° Be sure to read Section 4, Your costs for covered
services for valuable information
about how cost sharing works. Also
read Section 9 about coordinating benefits with
other coverage, including
with Medicare.
° The amounts listed below are for the charges billed by
the facility (i. e., hospital or
surgical center) or ambulance service for
your surgery or care. Any costs associated
with the professional charge (i.
e., physicians, etc.) are covered in Section 5( a) or (b).
Benefit Description You pay
Inpatient hospital
Room and board,
such as Nothing
° ward, semiprivate, or intensive care accommodations;
° general nursing care; and
° meals and special diets.
NOTE:
If you want a private room when it is not medically necessary,
you pay the
additional charge above the semiprivate room rate.
Other hospital services and supplies, such as: Nothing
° Operating,
recovery, maternity, and other treatment rooms
° Prescribed drugs and
medicines
° Diagnostic laboratory tests and X-rays
°
Administration of blood and blood products
° Blood or blood plasma, if
not donated or replaced
° Dressings, splints, casts, and sterile tray
services
° Medical supplies and equipment, including oxygen
°
Anesthetics, including nurse anesthetist services
° Take-home items
° Medical supplies, appliances, medical equipment, and any covered items
billed by a hospital for use at home.
Not covered: All charges
° Custodial care
°
Non-covered facilities, such as nursing homes, extended care facilities,
schools
° Personal comfort items, such as telephone, television, barber
services,
guest meals and beds
° Private nursing care
2001 CDPHP 24 Section 5( c)
I M
P O
R T
A N
T 24
24
Page 25 26
Outpatient hospital or ambulatory surgical center You pay
°
Operating, recovery, and other treatment rooms $10 per day
° 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 20 percent of charges
°
Anesthetics and anesthesia service $10 per day
Note: We cover hospital
services and supplies related to dental procedures
when necessitated by a
non-dental physical impairment. We do not cover
the dental procedures.
Not covered: Blood and blood derivatives not replaced by the member All
charges
Extended care benefits/ skilled nursing care facility
benefits
Skilled nursing facility up to 90 days in lieu of
hospitalization. Nothing
Not covered: Custodial and rest care All charges
Hospice care
Up to 210 days combined inpatient and outpatient
Nothing
Not covered: Independent nursing, homemaker services All charges
Ambulance
° Local professional ambulance service when
medically appropriate Nothing
Not covered: Transportation for
convenience. All charges
2001 CDPHP 25 Section 5( c) 25
25
Page 26 27
I M
P O
R T
A N
T
I M
P O
R T
A N
T
Section 5 (d). Emergency services/ accidents
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.
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 emergenciesÑ what they all have in
common is the need for quick action.
What to do in case of emergency: You should go directly to the
emergency room, call 911 or the appropriate emergency response number, or call
an
ambulance if the situation is a medical emergency as defined above.
Emergencies within our service area: If you are unsure whether your
condition is an emergency, contact your primary care physician for assistance
and guidance. However, if you believe you need immediate medical attention,
follow the emergency procedures.
Emergencies outside our service
area: If you have an emergency outside of CDPHP's service area, simply go to
the nearest hospital emergency room. If you are required to pay for services at
the time of treatment, please request an
itemized bill. Send the bill along
with your name and member ID number to CDPHP's Member Services Department, 17
Columbia Circle, Albany, NY 12203.
If you are not admitted to the hospital for further services or care, you
will be responsible for a $50 copayment. If you
are admitted immediately,
the emergency room copayment is waived and the hospital services will cost you
nothing.
After receiving emergency medical care, be sure your primary care physician
is notified within forty-eight (48) hours,
unless it is not reasonably
possible to do so. He or she will need to know what services were provided
before scheduling
any of your follow-up care. All follow-up care must be
provided or directed by your primary care physician. Examples of
follow-up
care are removal of stitches, cast removal, and X-rays.
Benefit Description You pay
Emergency within our service area
Emergency care at a doctor's office $10 per visit
Emergency care at
an urgent care center $25 per visit
Emergency care as an outpatient or
inpatient at a hospital, including $50 per visit. Nothing if admitted.
doctors' services
Not covered: Elective care or non-emergency care All charges
2001 CDPHP 26 Section 5( d) 26
26
Page 27 28
Emergency outside our service area You pay
° Emergency care
at a doctor's office $10 per visit
° Emergency care at an urgent care
center $25 per visit
° Emergency care as an outpatient or inpatient at a hospital, including
$50 per visit. Nothing if admitted.
doctors' services
Not covered: All charges
° 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
Ambulance
Professional ambulance service when medically
appropriate. Nothing
° Air ambulance if medically appropriate.
See
5( c) for non-emergency service.
Not covered: Non-emergency or routine transport. All charges
2001 CDPHP 27 Section 5( d) 27
27
Page 28 29
I M
P O
R T
A N
T
I M
P O
R T
A N
T
Section 5 (e). Mental health and substance abuse benefits
Parity
Beginning in 2001, all FEHB plans' mental health and substance abuse
benefits will
achieve "parity" with other benefits. This means
that we will provide mental health
and substance abuse benefits differently
than in the past.
When you get our approval for services and follow a
treatment plan we approve, cost-sharing
and limitations for Plan mental
health and substance abuse benefits will be
no greater than for similar
benefits for other illnesses and conditions.
Here are some important
things to keep in mind about these benefits: ° All benefits are subject
to the definitions, limitations, and exclusions in this
brochure.
° Be sure to read Section 4, Your costs for covered
services for valuable information
about how cost sharing works. Also
read Section 9 about coordinating benefits
with other coverage, including
with Medicare.
° YOU MUST GET PREAUTHORIZATION OF THESE SERVICES.
See the
instructions after the benefits description below.
Benefit Description You pay
Mental health and substance abuse benefits
Diagnostic and treatment services recommended by a Plan provider and
Your cost sharing responsibilities
contained in a treatment plan that we
approve. The treatment plan may are no greater than for other illness
include services, drugs, and supplies described elsewhere in this brochure.
or conditions.
Note: Plan benefits are payable only when we determine the care is
clinically appropriate to treat your condition and only when you receive
the care as part of a treatment plan that we approve.
° Professional services, including individual or group therapy by
providers $10 per visit
such as psychiatrists, psychologists, or clinical
social workers
° Medication management
Mental health and substance abuse benefitsÑ Continued on next page
2001 CDPHP 28 Section 5( e) 28
28
Page 29 30
Mental Health and substance abuse benefits (continued) You
Pay
° Diagnostic tests $10 per visit
° Services
provided by a hospital or other facility Nothing for inpatient; $10 per visit
° Services in approved alternative care settings such as: partial for
outpatient services
hospitalization, full-day hospitalization, facility
based intensive
outpatient treatment
Not covered in the network: Services we have not approved All charges.
Preauthorization To be eligible to receive these enhanced mental
health and substance abuse benefits, you must follow your treatment plan and all
of our network authorization processes.
These include:
° Mental
Health Care You have direct access to mental health care without the need for a
referral from
your primary care physician, except in the case of psychiatric
(M. D.) care where
a referral still will be needed from your primary care
physician.
A direct access toll-free telephone number, 1-800-700-4824, to the Capital
District
Behavioral Alliance will connect you to a qualified mental health
clinician who
will assist and arrange for treatment. For your convenience,
the telephone number
for mental health services is also included on your
CDPHP ID card.
° Alcohol/ Substance Abuse Benefits You have access to alcohol and
substance abuse care with a referral from your
primary care physician. These
benefits are coordinated by St. Peter's Addiction
Recovery Center (SPARC).
CDPHP members can also contact SPARC directly at
1-800-427-9025.
Mental health and substance abuse benefitsÑ Continued on next page
2001 CDPHP 29 Section 5( e) 29
29
Page 30 31
Special transitional benefit If a mental health or substance abuse
professional provider is treating you under our plan as of January 1, 2001, you
will be eligible for continued coverage with
your provider for up to 90 days
under the following condition:
° If your mental health or substance
abuse professional provider with whom you
are currently in treatment leaves
the Plan at our request for other than cause.
If this condition applies to you, we will allow you reasonable time to
transfer
your care to a network mental health or substance abuse
professional provider.
During the transitional period, you may continue to
see your treating provider and
will not pay any more out-of-pocket than you
did in the year 2000 for services.
This transitional period will begin with
our notice to you of the change in coverage.
The transitional period will
last for up to 90 days from the date you receive notice
of the change. You
may receive this notice prior to January 1, 2001, and the 90 day
period
begins with receipt of the notice.
Limitation We may limit your benefits if you do not follow your
treatment plan.
2001 CDPHP 30 Section 5( e) 30
30
Page 31 32
I M
P O
R T
A N
T
I M
P O
R T
A N
T
Section 5 (f). Prescription drug benefits
Here are some important
things to keep in mind about these benefits: ° We cover prescribed drugs
and medications, as described in the chart beginning on
the next page.
° All benefits are subject to 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.
There are important features you should be aware of. These include:
° Who can write your prescription. A Plan physician must write
the prescription
° Where you can obtain them.
° You must
fill the prescription at a Plan pharmacy, or by mail for a maintenance
medication.
° Approved maintenance prescriptions can be filled through
the mail at two copayments for a 90-day supply.
° We use a formulary.
A formulary is a list of prescription drugs covered by CDPHP based on their
efficacy and cost
in providing effective patient care. Coverage is available
for all formulary drugs.
You may have a medical necessity for an excluded drug. You will receive a
non-covered prescription under the
following conditions:
1. Documented allergic/ adverse reaction to a formulary drug;
2.
Documented failure on a formulary drug; or
3. Documented patient stability/
control issues for a patient where a formulary drug is contraindicated or a
change in
therapy is not advisable.
Your provider who is prescribing the medication must supply appropriate
information and complete a medical exception
request. A determination
regarding the medical exception request will be forwarded to you and your
physician.
° These are the dispensing limitations. Prescriptions filled at a
participating pharmacy are limited to a 30-day supply.
Maintenance
prescriptions are filled up to a 90-day supply by mail order. Only certain
maintenance prescriptions are
available via mail order to insure quality,
proper dosage, and medical appropriateness. Prescription refills received
prior to the next scheduled refill date will not be filled.
There are different copayments for generic and brand name prescriptions. If
there is no generic equivalent available,
you will still be responsible for
the brand name copayment.
° When you have to file a claim. You do not have to submit claims.
Prescription drug benefits begin on the next page.
2001 CDPHP 31 Section 5( f) 31
31
Page 32 33
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan
physician $5 per generic
and obtained from a Plan pharmacy or through our
mail order program: $20 per brand name
° Self-administered injectable drugs. 90-day mail order supply available
for
° Implanted time-release medications. There will be no refund of any
portion
$10 per generic, $40 per brand name.
of the copay if the medication is removed before the end of its expected
life.
Note: If there is no generic equivalent
available, you will still
have to pay
the brand name copay.
° Durable medical equipment for insulin-dependent persons with $10 per
item
pre-authorization.
° Nutritional supplements for the therapeutic treatment of
phenylketonuria (PKU). $5 per generic
$20 per brand name ° Infertility
drugs.
90-day mail order supply available for
° Intravenous fluids
and medication for home use. $10 per generic, $40 per brand name.
Note: If
there is no generic equivalent ° Prescription drugs for certain inherited
disease of amino acid and organic
available, you will still have to pay acid
metabolism shall include modified sold food products that are low
the brand
name copay. protein or which contain modified protein which are medically
necessary
for up to 12 months. Benefit limit of $2,500.
° Drugs and medicines
that by Federal law of the United States require a
physician's prescription
for their purchase, except as excluded below.
° Disposable needles and syringes for the administration of covered 20%
medications (non-diabetic)
° Insulin, oral agents to control blood sugar, needles, test strips,
lancets, and $10 or 20 percent, whichever is less.
visual reading and urine
test strips.
° Drugs for sexual dysfunction $5 per generic
$20 per brand name
° Contraceptive drugs and devices
90-day mail order supply available for
° Smoking Cessation prescriptions up to a 12-week supply. $10 per
generic, $40 per brand name.
Note: Members must complete a smoking cessation class. Note: If there is no
generic equivalent
Classes are provided free to members. available, you will
still have to pay the brand name copay.
Covered medications and suppliesÑ Continued on next page
2001 CDPHP 32 Section 5( f) 32
32
Page 33 34
Covered medications and supplies (continued) You pay
Here are some things to keep in mind about our prescription drug
program:
° A generic equivalent will be dispensed if it is available,
unless your physician specifically requires a name brand.
° We have an open formulary. If your physician believes a name brand
product is necessary or there is no generic available, your physician may
prescribe a name brand drug from a formulary list. This list of name brand
drugs is a preferred list of drugs that we selected to meet patient needs at
a lower cost. To order a prescription drug brochure, call 1-800-777-2273
or 518/ 862-3747.
Not covered: All charges
° Drugs and supplies for cosmetic
purposes
° Vitamins, nutrients, and food supplements that can be
purchased without
a prescription
° Nonprescription medicines
2001 CDPHP 33 Section 5( f) 33
33
Page 34 35
Section 5 (g). Special Features
Feature Description
Non-emergency
routine care If you are away at school and need medical care
(non-preventive) for an for full-time students illness or injury,
coverage is available. When a medical situation develops,
out-of-the area call 1-800-274-2332 prior to seeking care and CDPHP
will arrange for medical services and payment with a practitioner in the area.
Childbirth Education CDPHP will reimburse expectant mothers 50 percent
of the cost, up to $30 Reimbursement Program per year, for participating
in and completing childbirth education classes.
Once you complete the class,
send the receipt and certificate of completion
to CDPHP, 17 Columbia Circle,
Albany, NY 12203, for reimbursement.
Services for deaf and The telephone system also includes a TDD system.
Members may call hearing impaired 1-877-261-1164 for services.
Centers of excellence for CDPHP facilitates care at approved
transplant centers for medically necessary, transplants/ heart surgery/ etc.
non-experimental treatment.
2001 CDPHP 34 Section 5( g) 34
34
Page 35 36
I M
P O
R T
A N
T
I M
P O
R T
A N
T
Section 5 (h). Dental benefits
Here are some important things to keep
in mind about these benefits: ° Please remember that all benefits are
subject to the definitions, limitations, and
exclusions in this brochure and
are payable only when we determine they are
medically necessary.
°
Plan dentists must provide or arrange your care.
° Be sure to
read Section 4, Your costs for covered services for valuable information
about how cost sharing works. Also read Section 9 about coordinating benefits
with other coverage, including with Medicare.
Accidental injury benefit You pay
We cover restorative services
and supplies necessary to promptly repair $10 per visit
(but not replace)
sound natural teeth. The need for these services must
result from an
accidental injury
Dental benefits
We have no other dental benefits.
2001 CDPHP 35 Section 5( h) 35
35
Page 36 37
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.
2001 CDPHP 36 Section 5( i)
"The Road to Good
Health" Wellness Workshops Through a series of wellness workshops, you will
learn
how the combined power of good nutrition, regular
exercise and
stress management can help you move toward
optimal health and well-being. A
schedule of wellness
programs appears on our web site, www. cdphp. com and
in SmartMoves, CDPHP's quarterly member newsletter.
All wellness
programs are free to members.
Wellness Discount Program The Wellness Discount Program allows you to receive
discounts at a variety of health and wellness facilities.
Disease Management Programs ° Smoking CessationÑ Up 12 weeks,
including all related
expenses such as drugs, per member per lifetime. You
must attend a smoking cessation program that CDPHP
provides at no cost
to you.
° Peak Asthma PerformanceÑ Members receive invitation
to free
class and a quarterly newsletter about asthma.
Members who attend the class
receive a peak flow meter,
a video on asthma, a daily diary and medication
spacer.
° PressureWiseÑ An interactive program for members
identified
as hypertensive. Members attending program
receive a blood pressure monitor
and information on
taking their blood pressure at home. 36
36 Page 37 38
Section 6. General exclusionsÑ things we
don't cover
The exclusions in this section apply to all benefits.
Although we may list a specific service as a benefit, we will not cover
it unless your Plan doctor determines it is medically necessary to prevent,
diagnose, or treat your illness, disease, injury, or condition and we agree, as
discussed under What Services Require Our Prior Approval on
page 10.
We do not cover the following:
° Care by non-Plan providers except
for authorized referrals or emergencies (see Emergency Benefits);
°
Services, drugs, or supplies you receive while you are not enrolled in this
Plan;
° Services, drugs, or supplies that are not medically necessary;
° Services, drugs, or supplies not required according to accepted
standards of medical, dental, or psychiatric practice;
° Experimental or
investigational procedures, treatments, drugs or devices;
° Services,
drugs, or supplies related to abortions, except when the life of the mother
would be endangered if the fetus
were carried to term or when the pregnancy
is the result of an act of rape or incest;
° Services, drugs, or supplies related to sex transformations; or
° Services, drugs, or supplies you receive from a provider or facility
barred from the FEHB Program.
2001 CDPHP 37 Section 6 37
37
Page 38 39
Section 7. Filing a claim for covered services
When you see Plan
physicians, receive services at Plan hospitals and facilities, or obtain your
prescription drugs at Plan
pharmacies, you will not have to file claims.
Just present your identification card and pay your copayment, coinsurance,
or deductible.
You will only need to file a claim when you receive emergency services from
non-plan providers. Sometimes these
providers bill us directly. Check with
the provider. If you need to file the claim, here is the process:
Medical, hospital and drug In most cases, providers and facilities
file claims for you. Physicians must Benefits file on the form HCFA-1500,
Health Insurance Claim Form. Facilities will
file on the UB-92 form. For
claims questions and assistance, call us at
1-800-777-2273 or 518/ 862-3747.
When you must file a claimÑ such as for out-of-area careÑ
submit it on the
HCFA-1500 or a claim form that includes the information
shown below.
Bills and receipts should be itemized and show:
° Covered member's name and ID number;
° Name and address
physician or facility that provided the service or supply;
° Dates you
received the services or supplies;
° Diagnosis;
° Type of each
service or supply;
° The charge for each service or supply;
° A
copy of the explanation of benefits, payments, or denial from any
primary
payerÑ such as the Medicare Summary Notice (MSN); and
° Receipts, if you paid for your services.
Submit your claims to:
Capital District Physicians' Health Plan, Inc., Member Services Department
17 Columbia Circle, Albany, NY 12203.
When we need more information Please reply promptly when we ask for
additional information. We may delay processing or deny your claim if you do not
respond.
2001 CDPHP 38 Section 7 38
38
Page 39 40
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
suppliesÑ including a request for preauthorization:
Step Description
1 Ask us in writing to reconsider our initial
decision. You must: (a) Write to us within 6 months from the date of our
decision; and
Send your request to us at: Capital District Physicians' Health Plan, Inc.,
17 Columbia Circle, Albany, NY 12203 and
(b) Include a statement about why you believe our initial decision was wrong,
based on specific benefit
provisions in this brochure; and
(c) Include copies of documents that support your claim, such as physicians'
letters, operative reports, bills,
medical records, and explanation of
benefits (EOB) forms.
2 We have 30 days from the date we receive your request to: (a) Pay
the claim (or, if applicable, arrange for the health care provider to give you
the care); or
(b) Write to you and maintain our denialÑ 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
requestÑ 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 usÑ if we did not answer that
request in some way within 30 days; or
° 120 days after we asked for
additional information.
Write to OPM at: Office of Personnel Management,
Office of Insurance Programs, Contracts Division xx,
P. O. Box 436,
Washington, D. C. 20044-0436.
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.
2001 CDPHP 39 Section 8 39
39
Page 40 41
Section 8. The disputed claims process continued
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 preauthorization/ prior approval, then call us
at 1-800-777-2273 or 518/
862-3747 and we will expedite our review; or
(b) We denied your initial request for care or preauthorization/ prior
approval, then:
°° If we expedite our review and maintain our
denial, we will inform OPM so that they can give your
claim expedited
treatment too, or
°° You can call OPM's Health Benefits Contracts Division III at 202/
606-0755 between 8 a. m. and 5 p. m.
eastern time.
2001 CDPHP 40 Section 8 40
40
Page 41 42
Section 9. Coordinating benefits with other coverage
When you have
other You must tell us if you are covered or a family member is covered
under health coverage another group health plan or have automobile
insurance that pays health care
expenses without regard to fault. This is
called "double coverage."
When you have double coverage, one plan
normally pays its benefits in full as
the primary payer and the other plan
pays a reduced benefit as the secondary
payer. We, like other insurers,
determine which coverage is primary according
to the National Association of
Insurance Commissioners' guidelines.
When we are the primary payer, we will pay the benefits described in this
brochure.
When we are the secondary payer, we will determine our allowance. After
the primary plan pays, we will pay what is left of our allowance, up to our
regular benefit. We will not pay more than our allowance.
° What is Medicare? Medicare is a Health Insurance Program for:
°° People 65 years of age and older.
°° Some people with
disabilities, under 65 years of age.
°° People with End-Stage Renal
Disease (permanent kidney failure
requiring dialysis or a transplant).
Medicare has two parts:
°° Part A (Hospital Insurance). Most
people do not have to pay for Part A.
°° Part B (Medical Insurance).
Most people pay monthly for Part B.
If you are eligible for Medicare, you may have choices in how you get your
health care. Medicare + Choice is the term used to describe the various
health plan choices available to Medicare beneficiaries. The information in
the next few pages shows how we coordinate benefits with Medicare,
depending on the type of Medicare managed care plan you have.
° The Original Medicare Plan The Original Medicare Plan is
available everywhere in the United States. It is the way most people get their
Medicare Part A and Part B benefits. You may
go to any doctor, specialist,
or hospital that accepts Medicare. Medicare pays
its share and you pay your
share. Some things are not covered under Original
Medicare, like
prescription drugs.
When you are enrolled in this Plan and Original Medicare, you still need to
follow the rules in this brochure for us to cover your care. Your care must
continue to be authorized by your Plan PCP or precertified as required.
We will not waive any of our copayments, coinsurance, and deductibles.
(Primary payer chart begins on next page.)
2001 CDPHP 41 Section 9 41
41
Page 42 43
Section 9. Coordinating benefits with other coverage continued
The following chart illustrates whether Original Medicare or this Plan
should be the primary payer for you according to
your employment status and
other factors determined by Medicare. It is critical that you tell us if you or
a covered family
member has Medicare coverage so we can administer these
requirements correctly.
Typically, your participating Plan provider will submit claims on your
behalf. If your physician does not participate in
Medicare, you will have to
file a claim with Medicare.
2001 CDPHP 42 Section 9
Primary Payer Chart
A. When either youÑ or your covered
spouseÑ are age 65 or over andÉ Then the primary payer isÉ
Original Medicare This Plan
1) Are an active employee with the
Federal government (including when you
or a family member are eligible for
Medicare solely because of a disability),
2) Are an annuitant,
3) Are a reemployed annuitant with the Federal
government whenÉ
a) The position is excluded from FEHB, or
b) The position is not excluded from FEHB
Ask your employing office which
of these applies to you.
4) Are a Federal judge who retired under title 28, U. S. C., or a Tax Court
judge
who retired under Section 7447 of title 26, U. S. C. (or if your
covered
spouse is this type of judge),
5) Are enrolled in Part B only, regardless of your employment status,
(for Part B (for other
services) services)
6) Are a former Federal employee receiving Workers' Compensation and the
Office of Workers' Compensation Programs has determined that you are (except
for claims
unable to return to duty, related to Workers'
Compensation.)
B. When youÑ or a covered family memberÑ have Medicare based
on end stage renal disease (ESRD) andÉ
1) Are within the first 30 months of eligibility to receive Part A
benefits solely because of ESRD,
2) Have completed the 30-month ESRD
coordination period and are still
eligible for Medicare due to ESRD,
3) Become eligible for Medicare due to ESRD after Medicare became
primary
for you under another provision,
C. When you or a covered family member have FEHB andÉ
1)
Are eligible for Medicare based on disability, and
a) Are an annuitant; or
b) Are an active employee 42
42 Page 43 44
Section 9.
Coordinating benefits with other coverage continued
°
Medicare managed care plan If you are eligible for Medicare, you may choose
to enroll in and get your Medicare benefits from a Medicare managed care plan.
These are health care
choices (like HMOs) in some areas of the country. In
most Medicare managed
care plans, you can only go to doctors, specialists,
or hospitals that are part of
the plan. Medicare managed care plans cover
all Medicare Part A and B benefits.
Some cover extras, like prescription
drugs. To learn more about enrolling in
a Medicare managed care plan,
contact Medicare at 1-800-MEDICARE
(1-800-633-4227) or at www. medicare.
gov. If you enroll in a Medicare
managed care plan, the following options
are available to you:
This Plan and our Medicare managed care plan: You may enroll in our
Medicare managed care plan and also remain enrolled in our FEHB plan. In
this case, we do not waive any of our copayments, coinsurance, or
deductibles for your FEHB coverage.
This Plan and another Plan's Medicare managed care plan: You may
enroll in another plan's Medicare+ Choice plan and also remain enrolled in our
FEHB
plan. We will still provide benefits when your Medicare+ Choice plan is
primary,
even out of the managed care plan's network and/ or service area
(if you use our
Plan providers), but we will not waive any of our
copayments, coinsurance,
or deductibles.
Suspended FEHB coverage and a Medicare managed care plan: If you are
an annuitant or former spouse, you can suspend your FEHB coverage to
enroll
in a Medicare managed care plan, eliminating your FEHB premium.
(OPM does
not contribute to your Medicare managed care plan premium.)
For information
on suspending your FEHB enrollment, contact your retirement
office. If you
later want to re-enroll in the FEHB Program, generally you may
do so only at
the next open season unless you involuntarily lose coverage or
move out of
the Medicare managed care plan service area.
° Enrollment in Note: If you choose not to enroll in Medicare Part
B, you can still be covered ° Medicare Part B under the FEHB Program.
We cannot require you to enroll in Medicare.
TRICARE TRICARE is the health care program for members, eligible
dependents of military persons and retirees of the military. TRICARE includes
the CHAMPUS
program. If both TRICARE and this Plan cover you, we pay first.
See your
TRICARE Health Benefits Advisor if you have questions about TRICARE
coverage.
Workers' Compensation We do not cover services that:
° you
need because of a workplace-related disease or injury that the Office
of
Workers' Compensation Programs (OWCP) or a similar Federal or State
agency
determines they must provide; or
° OWCP or a similar agency pays for through a third party injury
settlement
or other similar proceeding that is based on a claim you filed
under OWCP
or similar laws.
Once OWCP or similar agency pays its maximum benefits for your treatment,
we will cover your benefits. You must use our providers.
2001 CDPHP 43 Section 9 43
43
Page 44 45
Section 9. Coordinating benefits with other coverage continued
Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies We do not cover services and supplies
when a local, State, or Federal are responsible for your care Government
agency directly or indirectly pays for them.
When others are responsible When you receive money to compensate you
for medical or hospital care for injuries for injuries or illness caused
by another person, you must reimburse us for
any expenses we paid. However,
we will cover the cost of treatment that
exceeds the amount you received in
the settlement.
If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our subrogation
procedures.
2001 CDPHP 44 Section 9 44
44
Page 45 46
Section 10. Definitions of terms we use in this brochure
Calendar
year January 1 through December 31 of the same year. For new enrollees, the
calendar year begins on the effective date of their enrollment and ends on
December 31 of the same year.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services. See page 11.
Coinsurance Coinsurance is the percentage of our allowance that you
must pay for your care. See page 11.
Covered services Care we provide
benefits for, as described in this brochure.
Custodial care Custodial
care is care that does not have a direct medical benefit such as house cleaning,
preparing meals, personal hygiene.
Deductible A deductible is a fixed amount of covered expenses you must
incur for certain covered services and supplies before we start paying benefits
for those services.
We do not have deductibles. See page 11.
Experimental or A procedure that is not approved by the Federal Food
and Drug Administration investigational services and/ or the National
Institute of Health Technology Assessment.
Group health coverage Medical benefits such as hospital, surgical, and
preventive that are purchased on an employer sponsored basis.
Medical
necessity A service or treatment which is appropriate and consistent with
the diagnosis and accepted standards in the medical community.
Plan
allowance Plan allowance is the amount we use to determine our payment and
your coinsurance for covered services. Fee-for-service plans determine their
allowances in different ways. We determine our allowance by the average
community charges. Our providers accept the allowances as payment in full.
Us/ We Us and we refer to Capital District Physicians' Health Plan,
Inc.
Yo u You refers to the enrollee and each covered family member.
2001 CDPHP 45 Section 10 45
45
Page 46 47
Section 11. FEHB facts
No pre-existing condition We will not
refuse to cover the treatment of a condition that you had limitation
before you enrolled in this Plan solely because you had the condition before
you enrolled.
Where you can get information See www. opm. gov/ insure. Also, your
employing or retirement office can about enrolling in the answer your
questions, and give you a Guide to Federal Employees Health
FEHB
Program Benefits Plans, brochures for other plans, and other
materials you need to make an informed decision about:
° When you may change your enrollment;
° How you can cover your
family members;
° What happens when you transfer to another Federal
agency, go on leave
without pay, enter military service, or retire;
° When your enrollment ends; and
° When the next open season for
enrollment begins.
We don't determine who is eligible for coverage and, in
most cases, cannot
change your enrollment status without information from
your employing or
retirement office.
Types of coverage available Self Only coverage is for you alone. Self
and Family coverage is for you, for you and your family your spouse, and
your unmarried dependent children under age 22, including
any foster
children or stepchildren your employing or retirement office
authorizes
coverage for. Under certain circumstances, you may also continue
coverage
for a disabled child 22 years of age or older who is incapable of
self-support.
If you have a Self Only enrollment, you may change to a Self and Family
enrollment if you marry, give birth, or add a child to your family. You may
change your enrollment 31 days before to 60 days after that event. The Self
and Family enrollment begins on the first day of the pay period in which the
child is born or becomes an eligible family member. When you change to Self
and Family because you marry, the change is effective on the first day of
the
pay period that begins after your employing office receives your
enrollment
form; benefits will not be available to your spouse until you
marry.
Your employing or retirement office will not notify you when a family
member
is no longer eligible to receive health benefits, nor will we. Please
tell us
immediately when you add or remove family members from your coverage
for any reason, including divorce, or when your child under age 22 marries
or turns 22.
If you or one of your family members is enrolled in one FEHB plan, that
person may not be enrolled in or covered as a family member by another
FEHB plan.
2001 CDPHP 46 Section 11 46
46
Page 47 48
Section 11. FEHB facts continued
When benefits and
The benefits in this brochure are effective on January 1. If you are new to
this premiums start Plan, your coverage and premiums begin on the first
day of your first pay period
that starts on or after January 1. Annuitants'
premiums begin on January 1.
Your medical and claims We will keep your medical and claims
information confidential. Only records are confidential the following
will have access to it:
° OPM, this Plan, and subcontractors when they
administer this contract;
° This Plan, and appropriate third parties,
such as other insurance plans and the
Office of Workers' Compensation
Programs (OWCP), when coordinating
benefit payments and subrogating claims;
° Law enforcement officials when investigating and/ or prosecuting
alleged
civil or criminal actions;
° OPM and the General Accounting Office when conducting audits;
°
Individuals involved in bona fide medical research or education that does
not disclose your identity; or
° OPM, when reviewing a disputed claim or defending litigation about a
claim.
When you retire When you retire, you can usually stay in the FEHB
Program. Generally, you must have been enrolled in the FEHB Program for the last
five years of your
Federal service. If you do not meet this requirement, you
may be eligible for
other forms of coverage, such as temporary continuation
of coverage (TCC).
When you lose benefits ° When FEHB coverage ends You will receive
an additional 31 days of coverage, for no additional
premium, when:
°° Your enrollment ends, unless you cancel your enrollment, or
°° You are a family member no longer eligible for coverage.
You
may be eligible for spouse equity coverage or Temporary Continuation
of
Coverage.
° Spouse equity coverage If you are divorced from a Federal
employee or annuitant, you may not continue to get benefits under your former
spouse's enrollment. But, you may be eligible
for your own FEHB coverage
under the spouse equity law. If you are recently
divorced or are
anticipating a divorce, contact your ex-spouse's employing or
retirement
office to get RI 70-5, the Guide to Federal Employees Health
Benefits
Plans for Temporary Continuation of Coverage and Former Spouse
Enrollees,
or other information about your coverage choices.
° TCC If you leave Federal service, or if you lose coverage
because you no longer qualify as a family member, you may be eligible for
Temporary Continuation
of Coverage (TCC). For example, you can receive TCC
if you are not able to
continue your FEHB enrollment after you retire.
You may not elect TCC if you are fired from your Federal job due to gross
misconduct.
2001 CDPHP 47 Section 11 47
47
Page 48 49
Section 11. FEHB facts continued
Get the RI 79-27, which
describes TCC, and the RI 70-5, the Guide to Federal
Employees Health
Benefits Plans for Temporary Continuation of Coverage
and Former Spouse
Enrollees, from your employing or retirement office or
from www. opm.
gov/ insure.
° Converting to You may convert to a non-FEHB individual policy
if: ° individual coverage
°° Your coverage under TCC or
the spouse equity law ends. If you canceled
your coverage or did not pay
your premium, you cannot convert;
°° You decided not to receive coverage under TCC or the spouse equity
law;
or
°° You are not eligible for coverage under TCC or the spouse equity
law.
If you leave Federal service, your employing office will notify you of
your
right to convert. You must apply in writing to us within 31 days after
you
receive this notice. However, if you are a family member who is losing
coverage,
the employing or retirement office will not notify you. You
must apply in
writing to us within 31 days after you are no longer eligible
for coverage.
Your benefits and rates will differ from those under the FEHB Program;
however, you will not have to answer questions about your health, and we
will not impose a waiting period or limit your coverage due to pre-existing
conditions.
Getting a Certificate of If you leave the FEHB Program, we will give
you a Certificate of Group Group Health Plan Coverage Health Plan
Coverage that indicates how long you have been enrolled with us.
You can use
this certificate when getting health insurance or other health care
coverage. Your new plan must reduce or eliminate waiting periods,
limitations,
or exclusions for health related conditions based on the
information in the
certificate, as long as you enroll within 63 days of
losing coverage under
this Plan.
If you have been enrolled with us for less than 12 months, but were
previously
enrolled in other FEHB plans, you may also request a certificate
from those plans.
2001 CDPHP 48 Section 11 48
48
Page 49 50
Section 12. Inspector General Advisory
Inspector General Advisory
Stop health care fraud! Fraud increases the cost of health care for
everyone. If you suspect that a physician, pharmacy, or hospital has charged you
for
services you did not receive, billed you twice for the same service, or
misrepresented any information, do the following:
° Call the provider and ask for an explanation. There may be an error.
° If the provider does not resolve the matter, call us at 1-800-280-6885
and
explain the situation.
° If we do not resolve the issue, call THE HEALTH CARE FRAUD
HOTLINEÑ 202/ 418-3300 or write to: The United States Office of
Personnel Management, Office of the Inspector General Fraud Hotline,
1900 E Street, NW, Room 6400, Washington, DC 20415.
Penalties for
Fraud Anyone who falsifies a claim to obtain FEHB Program benefits can be
prosecuted for fraud. Also, the Inspector General may investigate anyone
who
uses an ID card if the person tries to obtain services for someone who
is
not an eligible family member, or is no longer enrolled in the Plan and
tries to obtain benefits. Your agency may also take administrative action
against you.
2001 CDPHP 49 Section 12 49
49
Page 50 51
Index
Do not rely on this page; it is for your convenience and
does not explain your benefit coverage.
2001 CDPHP 50 Index
Allergy tests 16
Alternative
treatment 20
Ambulance 25
Anesthesia 23
Autologous bone marrow
transplant 23
Biopsies 21
Birthing centers 15
Blood and blood
plasma 24
Breast cancer screening 14
Casts 21
Cat Scans 14
Changes for 2001 7
Chemotherapy 17
Childbirth 15
Childbirth
Education 34
Chiropractic Care 20
Cholesterol tests 14
Claims 39
Coinsurance 11
Colorectal cancer screening 14
Congenital anomalies
21
Contraceptive devices and drugs 32
Coordination of benefits 41
Copayment 11
Covered providers 8
Crutches 19
Deductible
45
Definitions 45
Dental care 35
Diagnostic services 14
Dialysis 17
Disputed claims review 39
Donor expenses (transplants)
23
Dressings 21
Durable medical equipment (DME) 19
Educational
classes and programs 20
Effective date of enrollment 47
Emergency 26
Experimental or investigational 45
Extended care 25
Eye exam 18
Eyeglasses 18
Family planning 16
Fecal occult blood test 14
Foot care 18
Formulary 31
Fraud and abuse 49
General Exclusions 37
Hearing services 18
Home health services 20
Hospice care 25
Home nursing care 20
Hospital 24
Immunizations, adult 14
Immunizations, child 15
Infertility 16
In hospital physician care 24
Inpatient Hospital Benefits 24
Insulin 32
Laboratory and
pathological services 14
Machine diagnostic tests 14
Magnetic
Resonance Imagings
(MRIs) 14
Mail Order Prescription Drugs 32
Mammograms 14
Maternity Benefits 15
Medicaid 44
Medically
necessary 45
Medicare 41
Medicare +Choice 43
Mental Conditions/
Substance Abuse
Benefits 28
Newborn care 15
Non-FEHB Benefits
36
Nurse
Licensed Practical Nurse 20
Registered Nurse 20
Nursery
charges 15
Obstetrical care 15
Occupational therapy 17
Ocular
injury 18
Office visits 13
Oral and maxillofacial surgery 22
Orthopedic devices 19
Out-of-pocket expenses 11
Outpatient facility
care 25
Oxygen 19
Pap test 14
Physical examination 13
Physical therapy 17
Physician 13
Pre-existing Conditions 46
Pre-certification 10
Prenatal 15
Preventive care, adult 14
Preventive care, children 15
Prescription drugs 31
Preventive services 13
Primary Payor Chart 42
Prior approval 10
Prostate cancer screening 14
Prosthetic devices 19
Psychologist 28
Psychotherapy 28
Radiation therapy 17
Rehabilitation therapies 17
Renal dialysis 17
Room and board 24
Second surgical opinion 13
Service Area 6
Skilled nursing
facility care 25
Smoking cessation 20
Speech therapy 17
Splints 21
Sterilization procedures 16
Students out-of-area 34
Subrogation 44
Substance abuse 28
Surgery 21
° Anesthesia 23
° Oral 22
° Outpatient 25
° Reconstructive 22
Syringes 32
Temporary continuation of coverage 47
Transplants 23
Treatment therapies 17
Ultrasounds 14
Vision services
18
Well child care 15
Wheelchairs 19
Workers' compensation 43
X-rays 14 50
50 Page
51 52
Summary of benefits for the
Capital District Physicians' Health Plan, Inc. 2001
° Do not rely
on this chart alone. All benefits are provided in full unless indicated and
are subject to the definitions,
limitations, and exclusions in this
brochure. On this page we summarize specific expenses we cover; for more detail,
look inside.
° If you want to enroll or change your enrollment in this Plan, be sure
to put the correct enrollment code from the cover
on your enrollment form.
° Note: We only cover services that are provided or arranged by Plan
physicians, except in emergencies.
51 Summary
Benefits You Pay Page
Medical services provided
by physicians:
° Diagnostic and treatment services provided in the
office Office visit copay: $10 13
Services provided by a hospital:
° Inpatient Nothing 24
° Outpatient $10 per day for ambulatory surgical 25
center or
outpatient department
Emergency benefits
° In-area $50 per visit to hospital for
emergency 26
room visit; $25 per visit per urgent
care center
° Out-of-area $50 per visit for emergency services 27
Mental health and substance abuse treatment Regular cost sharing 28
Prescription drugs $5 copay per prescription for generic 31 drugs;
$20 copay per prescription for
name brand drugs, injectable drugs and
implanted time-release medications.
Dental care $10 per visit for accidental injury benefit 35
Vision Care $10 per visit for one refraction every 18 twenty-four
(24) months
Special features 34
Non-emergency medical care (non-preventive for
full-time students attending school out-of CDPHP's
service area
Childbirth Education Reimbursement Program
Services for deaf and hearing
impaired
Centers of excellence for transplants/ heart surgery
Protection against catastrophic costs Your out-of-pocket expenses for
services 11 (your out-of-pocket maximum) covered under the Plan are
limited to
the stated copayments and coinsurance,
which are required for
a few benefits.
2001 CDPHP 51
51 Page
52
2001 Rate Information for Capital District Physicians'
Health Plan
Non-Postal rates apply to most non-Postal enrollees. If you
are in a special enrollment category, refer to the FEHB Guide for that category
or contact the agency that maintains your health benefits
enrollment.
Postal rates apply to career U. S. Postal Service employees. Most
employees should refer to the FEHB Guide for United States Postal Service
Employees, RI 70-2. Different postal rates apply and special
FEHB guides are
published for Postal Service Nurses and Tool & Die employees (see RI 70-2B);
and for Postal Service Inspectors and Office of Inspector General (OIG)
employees (see RI 70-2IN).
Postal rates do not apply to non-career postal employees, postal retirees, or
associate members of any postal employee organization. Refer to the applicable
FEHB Guide.
52
Type of Enrollment Code Gov't Share Your Share Gov't Share Your
Share USPS Share Your Share
Non-Postal Premium
Biweekly Monthly Biweekly
Postal Premium
Self Only
Self and Family
SG1 $ 78.02
SG2 $195.82
$ 26.00
$169.04 $ 56.34 $ 92.32 $ 11.70
$ 70.60 $424.28 $152.96 $231.17 $ 35.25
Self Only
Self and Family
QB1 $ 86.59
QB2 $195.82
$ 29.79
$187.61 $ 64.55 $102.22 $ 14.16
$103.17 $424.28 $223.53 $231.17 $ 67.82
Self Only
Self and Family
PW1 $ 78.40
PW2 $195.82
$ 26.13
$169.86 $ 56.62 $ 92.77 $ 11.76
$ 70.78 $424.28 $153.35 $231.17 $ 35.43
2001 CDPHP
Capital Area of New York
Hudson Valley of New York
North and Central New York 52