A Health Maintenance Organization
Serving: Most of California
Enrollment in this Plan is limited; see
page 6 for requirements.
Enrollment codes for this Plan:
SJ1 Self Only SJ2 Self and Family
Authorized for distribution by the:
RI 73-574
For changes
in benefits,
see page 7.
United States
Office of Personnel ManagemenT
Retirement and Insurance Service http:// www. opm. gov/ insure 1
1 Page 2 3
2001 Access+ 2
Table of Contents
Introduction 4
Plain
Language.....................................................................................................................................................................................
4
Section 1. Facts about this HMO plan
.............................................................................................................................................
5
How we pay
providers.......................................................................................................................................................
5
Patients' Bill of Rights
...................................................................................................................................................
5
Service
Area......................................................................................................................................................................
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
·
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........... 20
(c)
Services provided by a hospital or other facility, and ambulance services
............................................... 23
(d) Emergency services/
accidents..........................................................................................................................
25
(e) Mental health and substance abuse benefits
..................................................................................................
27
(f) Prescription drug benefits
................................................................................................................................
29
(g) Special features
...................................................................................................................................................
31
(h) Dental benefits
.....................................................................................................................................................
32
(i) Non-FEHB benefits available to Plan
members..............................................................................................
33 2
2 Page 3 4
2001 Access+ 3
Section 6. General
exclusions --things we don't
cover.............................................................................................................
34
Section 7. Filing a claim for covered services
............................................................................................................................
35
Section 8. The disputed claims process
.......................................................................................................................................
36
Section 9. Coordinating benefits with other
coverage...............................................................................................................
38
· When you have
··Other health coverage
.......................................................................................................................................
38
··Original
Medicare..............................................................................................................................................
38
··Medicare Managed Care
Plan..........................................................................................................................
40
· TRICARE/ Workers' Compensation/
Medicaid...................................................................................................
40
· Other Government agencies
..................................................................................................................................
40
· When others are responsible for injuries
..........................................................................................................
40
Section 10. Definitions of terms we use in this brochure
........................................................................................................
41
Section 11. FEHB
facts....................................................................................................................................................................
42
Coverage
information...................................................................................................................................................
42
· No pre-existing condition
limitation.................................................................................................................
42
· Where you get information about enrolling in the FEHB
Program........................................................... 42
· Types of coverage available for you and your
family......................................................................................
42
· When benefits and premiums
start..................................................................................................................
43
· Your medical and claims records are confidential
........................................................................................
43
· When you
retire..................................................................................................................................................
43
When you lose benefits
................................................................................................................................................
43
· When FEHB coverage ends
................................................................................................................................
43
· Spouse equity
coverage......................................................................................................................................
43
· Temporary Continuation of Coverage
(TCC).................................................................................................
43
· Enrolling in TCC
.................................................................................................................................................
43
· Converting to individual
coverage....................................................................................................................
44
· Getting a Certificate of Group Health Plan
Coverage..................................................................................
44
Inspector General advisory: Stop health care fraud!
.................................................................................................................
44
Department of Defense/ FEHB Demonstration
Project...............................................................................................................
45
Index.....................................................................................................................................................................................................
47
Summary of benefits
.........................................................................................................................................................................
48
Rates
.....................................................................................................................................................................................
Back cover 3
3 Page
4 5
2001 Access+ 4
Introduction
Blue Shield of California
Access+
50 Beale
Street
San Francisco, CA 94105
This brochure describes the benefits of Blue Shield of California Access+
under our contract (CS2639) with the Office of
Personnel Management (OPM),
as authorized by the Federal Employees Health Benefits law. This brochure is the
official
statement of benefits. No oral statement can modify or otherwise
affect the benefits, limitations, and exclusions of this
brochure.
A person enrolled in this Plan is entitled to the benefits described in this
brochure. If you are enrolled for Self and Family
coverage, each eligible
family member is also entitled to these benefits. You do not have a right to
benefits that were available
before January 1, 2001, unless those benefits
are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes
are effective January 1, 2001, and are summarized
on page 7. Rates are shown
at the end of this brochure.
Plain Language
The President and Vice President are making the
Government's communication more responsive, accessible, and
understandable
to the public by requiring agencies to use plain language. In response, a team
of health plan representatives
and OPM staff worked cooperatively to make
this brochure clearer. Except for necessary technical terms, we use common
words. "You" means the enrollee or family member; "we"
means Blue Shield of California Access+.
The plain language team reorganized the brochure and the way we describe our
benefits. When you compare this Plan with
other FEHB plans, you will find
that the brochures have the same format and similar information to make
comparisons easier.
If you have comments or suggestions about how to improve this brochure, let
us know. Visit OPM's "Rate Us" feedback area
at www. opm. gov/
insure or e-mail us at fehbwebcomments@ opm. gov or write to OPM at Insurance
Planning and Evaluation
Division, P. O. Box 436, Washington, DC 20044-0436.
4
4 Page 5 6
2001 Access+ 5
Section 1. Facts about this
HMO plan
This Plan is a health maintenance organization (HMO). We
require you to see specific physicians, hospitals, and other
providers that
contract with us. These Plan providers coordinate your health care services.
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 except for your annual eye exam. You
only pay the copayments and
coinsurance described in this brochure. When you receive emergency services from
non-Plan
providers, you may have to submit claim forms.
You should join an HMO because you prefer the plan's benefits, not because
a particular provider is available. You cannot
change plans because a
provider leaves our Plan. We cannot guarantee that any one physician, hospital,
or other provider
will be available and/ or remain under contract with us.
How we pay providers
We contract with 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.
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 your health
plan, its 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.
Corporate Form – Blue Shield of California is a not-for-profit
corporation that was founded in 1939.
Fiscal Solvency – Blue Shield of
California meets or exceeds California Department of Managed Health Care
standards for
fiscal solvency, confidentiality of medical records and
transfer of medical records.
"Gag Clauses" – A "gag
clause" is when a physician does not disclose all treatment options based
on cost
considerations. You have the right to have a clear understanding of
the medical condition and any
proposed appropriate necessary treatment
alternatives, including available success/ outcomes
information, regardless
of cost or benefit coverage, so you can make an informed decision before
receiving treatment.
Medical Records – Access+ members have the
right, both under State law and Blue Shield of California policy, to review,
summarize and copy their own medical records. Members can request and will
receive amendments to
their medical records as they are made.
State
Licensing – Access+ has been licensed by the State of California since
1978.
If you want more information about us, call us at 800/ 334-5847, or write to
Blue Shield of California Access+, P. O. Box 7168,
San Francisco, CA
94120-7168. You may also contact us by fax at 916/ 350-8780 or visit our website
at
http:// www. blueshieldca. com. 5
5 Page 6 7
2001 Access+ 6
Service Area
What is this Plan's service area? To enroll with us,
you must live or work in our service area. This is where our providers practice.
Our service area is:
County Name
Alameda
Butte
Contra Costa
Excluded ZIP Codes
None
None
None
El Dorado
Fresno
Kern
Kings
Los Angeles
Madera
Marin
Merced
Napa
Nevada
Orange
Placer
Riverside
Sacramento
San Bernardino
San Diego
San Francisco
San Joaquin
San Luis Obispo
San Mateo
Santa
Barbara
Santa Clara
Santa Cruz
Shasta
Solano
Sonoma
Stanislaus
Tulare
Ventura
Yolo
95613, 95619, 95623, 95633, 95636, 95643, 95651, 95656, 95667, 95672,
95682, 95684, 95709, 95720, 95721, 95726, 95735, and 96150 to 96158
None
93501, 93502, 93504, 93505, 93516, 93519, 93527, 93528, 93554 to
93556,
93560 and 93596
None
90704
None
None
None
None
95724, 95728, 96111 and 96160 to 96162
None
95701, 95714, 95715,
95717, 96140 to 96143, 96145, 96146 and 96148
92225-26
None
92242,
92280, 92304, 92319, 92338 and 92363
91905, 91906, 91934, 91948, 91963,
91980, 91987, 91990 to 91995,
92004 and 92086
None
None
None
None
None
None
None
None
None
None
None
None
None
None
Ordinarily, you must get your care from providers who contract with us. If
you receive care outside
our service area, we will normally pay only for
emergency or urgent care. We will not pay for any
other health care service,
except those that are specifically on page 33 under the heading "Medical
Care for Vacations, Business Travel and College Students."
If you or a covered family member move outside the service area, you can
enroll in another plan. If
your dependents live out of the area (for
example, if your child goes to college in another state), you
should
consider enrolling in a fee-for-service plan or an HMO like ours that has
agreements with
affiliates in other states. See page 33 for details about
our HMO Medical care available for vacations,
business travel and college
students coverage. If you or a family member move, you do not have to
wait
until Open Season to change plans. Contact your employing or retirement office.
6
6 Page 7 8
2001 Access+ 7
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 coinsurance, copays, and day and visit limitations when
you follow
a treatment plan that we approve. Previously, we placed higher patient cost
sharing and shorter day or visit
limitations on mental health and abuse
services than we did on services to treat physical illness, injury, or disease.
· Many healthcare organizations have turned their attention this past
year to improving healthcare quality and patient
safety. OPM asked all FEHB
plans to join them in this effort. You can find specific information on our
patient safety
activities by calling 800/ 334-5847, or checking our website
www. blueshieldca. com. You can find out more about patient
safety on the
OPM website, www. opm. gov/ insure. To improve your healthcare, take these five
steps:
ll Speak up if you have questions and concerns.
ll Keep a list of all
medicines you take.
ll Make sure you get the results of any test procedure.
ll Talk with your doctor and health care team about your options if you need
hospital care.
ll 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 10% for Self Only or 10% for Self and Family.
·
Second opinions: If there is a question about your diagnosis or if additional
information concerning your condition would
be helpful in determining the
most appropriate plan of treatment, your primary care physician will, upon
request, refer you
to another physician for a second medical opinion. If you
are requesting a second opinion about care you received from
your primary
care physician, a physician within the same Medical Group\ IPA as your primary
care physician will provide
the second opinion. If you are requesting a
second opinion about care received from a specialist, any Plan specialist of
the same equivalent specialty may provide the second opinion. All second
consultations must be authorized by the Plan.
You pay a $10 copay for
a second opinion.
· Mental Health: Blue Shield of California has a contract with U. S.
Behavioral Health Plan (USBHPC) to provide your
covered mental health and
substance abuse services. You must receive all mental health and substance abuse
services
from USBHPC providers, except for urgent or emergency services or
for counseling provided by your Personal Care
Physician. Mental health and
substance abuse providers affiliated with your Personal Care Physician's IPA or
Medical
Group may not be USBHPC providers. You or your Personal Care
Physician must contact USBHPC directly at 877/ 263-
8827 to obtain approval
for mental health and substance abuse services and a referral to USBHPC
providers. 7
7 Page
8 9
2001 Access+ 8
Section
3. How you get care
Identification cards We will send you an
identification (ID) card when you enroll. You should carry your ID card with you
at all times. You must show it whenever you receive
services from a Plan
provider, or fill a prescription at a Plan pharmacy. Until you
receive your
ID card, use your copy of the Health Benefits Election Form, SF-2809,
your
health benefits enrollment confirmation (for annuitants), or your
Employee
Express confirmation letter.
If you do not receive your ID card within 30 days after the effective date of
your
enrollment, or if you need replacement cards, call us at 800/ 334-5847.
Where you get covered care You get care from "Plan
providers" and "Plan facilities." You will only pay copayments
and/ or coinsurance, and you will not have to file claims, except for
your
annual eye examination.
· 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. All Plan
providers
are credentialed, according to national standards.
We list Plan providers in the provider directory, which we update
periodically.
The list is also on our website.
·Plan facilities Plan facilities are hospitals and other
facilities in our service area that we contract
with to provide covered
services to our members. We list these in the provider
directory, which we
update periodically. The list is also on our website.
What you must do 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. You must
complete a Primary Care Physician Selection Form.
·Primary care Your primary care physician can be a general
practitioner, family practitioner,
internist, pediatrician, or an OB/ GYN.
Your primary care physician will provide
most of your health care, or give
you a referral to see a specialist.
If you want to change primary care physicians or if your primary care
physician
leaves the Plan, call us. We will help you select a new one.
·Specialty care Your primary care physician will refer you to a
specialist for needed care.
The exceptions to this are:
1. for true
medical emergencies;
2. when another physician is on call for your
physician;
3. when you self refer to an Access+ participating specialist
(not applicable to
mental health care, infertility, urgent care and allergy
services); and
4. OB/ GYN services provided by an obstetrician/ gynecologist
or family
practitioner within the same IPA/ Medical Group as your primary
care
physician.
5. Mental Health services which must be authorized by
USBHPC.
In all other instances, referral to a specialist is done at the primary care
physician's direction; if non-Plan specialists or consultants are required,
the
primary care physician will arrange appropriate referrals. 8
8 Page 9 10
2001 Access+ 9
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 conditions, your
primary care physician will develop a
treatment plan with you that allows an
adequate number of direct access
visits with that specialist. Your primary
care physician will use our criteria
when creating your treatment plan.
· 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.
We will not pay for you to
see a specialist who does not participate with
our Plan, unless your primary
care physician refers you to a non-plan
specialist for a second opinion.
· 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;
·· 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 or when
clinically appropriate after you receive notice of the change. Contact us
or, if
we drop out of the program, contact your new plan.
If you are in the second or third trimester of pregnancy and you lose access
to
your specialist based on the above circumstances, you can continue to see
your
specialist until the end of your postpartum care, even if it is beyond
the 90 days.
Contact us to coordinate care for these types of cases.
· Hospital care Your Plan primary care physician or specialist
will make necessary hospital
arrangements and supervise your care. This
includes admission to a skilled
nursing or other type of facility.
If you are in the hospital when your enrollment in our Plan begins, call our
customer service department immediately at 800/ 334-5847. If you are new to
the
FEHB Program, we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay for
the
hospital stay until:
· You are discharged, not merely moved to an alternative care center;
· The day your benefits from your former plan run out; or
·
The 92 nd day after you become a member of this Plan, whichever happens
first.
These provisions apply only to the benefits of the hospitalized person. 9
9 Page 10 11
2001 Access+ 10
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. Before giving approval, we
consider if the service is covered, medically necessary, and
follows generally accepted medical practice.
Your personal care physician
must obtain a preauthorization from us for; (1)
prescription drugs that are
not on our drug formulary, (2) organ transplants and
(3) bone marrow
transplants.
If you request a brand name drug, when a generic drug is available and your
personal care physician did not obtain a preauthorization, you will pay your
prescription drug copay and the difference between the price of generic and
brand name drugs.
See page 22 in Section 5( b) for the preauthorization process for organ and
bone
marrow transplants. 10
10 Page 11 12
2001 Access+
11
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.
·Coinsurance Coinsurance is the percentage of our allowable fee
that you must pay for your
care.
Example: In our Plan, you pay 50% of our allowance for infertility services
or
durable medical equipment.
Your out-of-pocket maximum After your copayments and your percentage
of allowable charges for medical
for coinsurance and and surgical
services total $1,000 per person or $2,000 per family enrollment
copayments in any calendar year, you do not have to pay any more for
covered services. However, the following services do not count toward your
out-of-pocket
maximum, and you must continue to pay copayments for these services:
1. your prescription drugs
2. infertility services
3. the Access+
self-referral specialty visit copayments.
For mental health and substance abuse benefits you pay $1,000 in copayments
or
coinsurance for a Self Only enrollment or $2,000 for a Self and Family
enrollment.
After that you do not have to make any further payments the rest
of the year for
authorized treatment or services. However, you must continue
to pay co-payments
for prescription drugs.
Be sure to keep accurate records of your copayments and coinsurances since
you are responsible for informing us when you reach the maximum. 11
11 Page 12 13
2001 Access+ 12
Section 5. Benefits
--OVERVIEW NOTE: This benefits section is divided into subsections. Please
read the important things you should keep in miind 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 for annual eye
exams, or more information about our benefits, contact us at 800/ 334-5847
or at our website at http:// www. blueshieldca. com.
(a) Medical
services and supplies provided by physicians and other health care
professionals.…………… 13-19
·Diagnostic and treatment services
·Lab, X-ray, and other
diagnostic tests
·Preventive care, adult
·Preventive care,
children
·Maternity care
·Family planning
·Infertility services
·Allergy care
·Treatment
therapies
·Rehabilitative therapies
·Hearing services (screening)
·Vision services (screening)
·Orthopedic and prosthetic
devices
·Durable medical equipment (DME)
·Home health
services
·Alternative treatments
·Educational classes and
programs
(b) Surgical and anesthesia services provided by physicians and other health
care professionals .......................... 20-22
·Surgical
procedures
·Reconstructive surgery
·Oral and maxillofacial
surgery
·Organ/ tissue transplants
·Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services
.............................................................. 23-24
·Inpatient hospital
·Outpatient hospital or ambulatory
surgical
center
·Extended care benefits/ skilled nursing care
·Facility benefits
·Hospice care
·Ambulance
(d) Emergency services/
accidents.........................................................................................................................................
25-26
·Medical emergency ·Ambulance
(e) Mental health and substance abuse
benefits................................................................................................................
27-28
(f) Prescription drug benefits
................................................................................................................................................
29-30
(g) Special features
.......................................................................................................................................................................
31
·High risk pregnancies ·Self –referral to specialty
services
(h) Dental benefits
........................................................................................................................................................................
32
(i) Non-FEHB benefits available to Plan members
..................................................................................................................
33 12
12 Page 13
14
2001 Access+ 13
Section 5 (a) Medical
services and supplies provided by physicians and other health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
· Please remember that all benefits are subject to the
definitions, limitations, and
exclusions in this brochure and are payable
only when we determine they are medically
necessary.
· Plan physicians must provide or arrange your care.
· We
have no calendar year deductible.
· Be sure to read Section 4,
Your costs for covered services for valuable information
about how
cost sharing works. Also read Section 9 about coordinating benefits with
other coverage, including with Medicare.
I M
P O
R T
A N
T
Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
· During a hospital stay
· In a skilled nursing facility
· Initial examination of a
newborn child covered under a family
enrollment
· Vaccines for pediatric and adult immunizations
·
Inpatient non-dental treatment of temporomandibular joint( TMJ)
syndrome
Nothing
· Office visits
· Office medical consultations
·
Second opinions
$10 per office visit
· Home visit by physician $25
· Self referral to a Plan
specialist under Access+ option $30 per office visit
· In an urgent
care center $50 per office visit
· Home visit by nurse or health aide
$5 per office visit 13
13 Page
14 15
2001 Access+ 14
Lab,
X-ray and other diagnostic tests
Tests, such as:
· Blood
tests
· Urinalysis
· Pathology
· X-rays
· CAT Scans/ MRI
· Ultrasound
·
Electrocardiogram and EEG
Nothing
· Non-routine Pap tests
· Non-routine mammograms
$10
per test
Preventive care, adult
Routine screenings, such as:
·
Total Blood Cholesterol – once every three years, ages 19 through
64
· Colorectal Cancer Screening, including
··Fecal
occult blood test
··Sigmoidoscopy,screening
–everyfiveyears startingatage50
Nothing
· Prostate Specific Antigen (PSA test) – one annually for men
age 40
and older
Nothing
· Routine Pap test Nothing
Routine mammogram –covered for
women age 35 and older, as follows:
· From age 35 through 39, one
during this five year period
· From age 40 through 49, one every one
or two years
· From age 50 through 64, one every year
· At
age 65 and older, one every two years
Nothing
Not covered: Physical exams required for obtaining or continuing
employment or insurance, attending schools or camp, or travel.
All
charges.
Routine immunizations as recommended by the United States Public
Health
Service.
· Tetanus-diphtheria (Td) booster – once every 10 years, ages 19
and
over (except as provided for under Childhood immunizations)
· Influenza vaccines, annually, age 50 and older
·
Pneumococcal vaccine for adults 65 and older
· Recommended travel
immunizations
· Hepatitis A, hepatitis B and lyme disease
immunization for
individuals at high risk.
Nothing 14
14 Page
15 16
2001 Access+ 15
Preventive care, children You pay
· Childhood
immunizations recommended by the American Academy
of Pediatrics
Nothing
· Examinations, such as:
··Eye screenings through
age 17 to determine the need for vision
correction.
··Ear screenings through age 17 to determine the need for
hearing
correction
··Examinations done on the day of immunizations ( through age
17)
· Well-child care charges for routine examinations, immunizations
and care (through age 17)
Nothing
Maternity care You pay
Complete maternity (obstetrical) care, such
as:
· Prenatal care
· Delivery
· Postnatal care
Note: Here are some things to keep in mind:
· You 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).
Nothing
Not covered: Routine sonograms to determine fetal age, size or sex All
charges
Family planning
· Physician office visit for
fitting a diaphragm. Nothing
· Surgically implanted contraceptives
· Injectable
contraceptive drugs
· Intrauterine devices (IUDs)
$10 per item
· Voluntary Sterilization
ll Vasectomy
ll Tubal ligation
$75
$100
Not covered: reversal of voluntary
surgical sterilization All charges. 15
15
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Infertility services You pay
Diagnosis and
treatment of infertility, such as:
· Artificial insemination:
·· intravaginal insemination (IVI)
··
intracervical insemination (ICI)
·· intrauterine
insemination (IUI)
· Covered injectable fertility drugs
50% of allowable charges
· Oral fertility drugs $6 at plan pharmacies
Not covered:
· Assisted reproductive technology (ART) procedures, such as:
· ··in vitro fertilization
·
··embryo transfer and GIFT
· Services and
supplies related to excluded ART procedures
· Cost of donor sperm, eggs and frozen embryos and their collection
and storage.
All charges.
Allergy care
Allergy serum Nothing
Testing and treatment
Allergy injection
$10 per office visit
Customized antigens 50% of allowable charges
Not covered: provocative
food testing and sublingual allergy
desensitization
All charges.
Treatment therapies You pay
· Growth hormone therapy (GHT)
Note: We will only cover GHT for medically necessary conditions when
we
have preauthorized the treatment. Such authorization must be obtained
through your primary care physician.
Growth hormone therapy is authorized for medically necessary conditions.
Your physician should get pre-authorization before you begin treatment.
· Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone
marrow
transplants are limited to those transplants listed under
Organ/ Tissue
Transplants on page 22.
· Respiratory and inhalation therapy
· Dialysis –
Hemodialysis and peritoneal dialysis
· Intravenous (IV)/ Infusion
Therapy and antibiotic therapy
$10 per office visit
$10 per office visit 16
16
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Rehabilitative therapies You pay
Physical therapy,
occupational therapy and speech therapy --
· These are covered
benefits when determined by the plan to be
medically necessary and it is
demonstrated that the member's
condition will significantly improve as a
result of the services.
··qualified physical therapists;
··speech
therapists; and
··occupational therapists.
Note: Speech
therapy is limited to treatment of certain speech
impairments of organic
origin. Occupational therapy is limited to
services that assist the member
to achieve and maintain self-care
and improved functioning in other
activities of daily living.
· Cardiac rehabilitation following a heart transplant, bypass surgery
or a myocardial infarction, is provided at a plan facility, if medically
necessary with the appropriate treatment plan.
$10 per visit
Not covered:
· long-term rehabilitative therapy
· exercise programs
All charges.
Hearing services (testing, treatment, and supplies)
·
Hearing testing for children through age 17 (see Preventive care,
children)
Nothing
Not covered:
· all other hearing testing
· hearing aids, testing and examinations for them
All charges.
Vision services (testing, treatment, and supplies)
· Eye
screenings to determine the need for vision correction for
children through
age 17 (see preventive care)
Nothing
· Contact lenses, if medically necessary to treat eye conditions
such as keratoconus and keratitis sicca or when required as a
result of
cataract surgery when no intraocular lens has been
implanted, are covered.
· Annual eye refractions
In addition to the medical and surgical benefits provided for
diagnosis
and treatment of disease of the eye, annual eye refractions
(to provide a
written lens prescription) may be obtained from Medical
Eye Services (MES)
providers. MES directories can be ordered by
calling 800/ 334-5847.
$10 per office visit
Not covered:
· Eyeglasses or contact lenses (See page 33
for details about
eyewear discounts)
· Eye exercises and
orthoptics
· Radial keratotomy, refractive keratoplasty and
other refractive
surgery
All charges. 17
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18
Foot care You pay
Not covered:
·
Routine foot care All charges.
Orthopedic and prosthetic devices
· Surgically implanted
breast implant following mastectomy Nothing
· Surgically implanted
prosthetic devices, such as artificial joints,
pacemakers.
· Inpatient Hospital
· Outpatient Hospital
Nothing
$50 per surgery
· Orthopedic devices (and their repair) such as
braces and functional
foot orthoses.
· Prosthetic services (and their repair) such as artificial limbs and
contact lenses necessary to treat certain medical eye conditions.
Contact the plan for details.
· Externally worn breast prostheses and surgical bras, including
necessary replacements, following a mastectomy
50% of allowable charges
Not covered:
· orthopedic and corrective shoes
· arch supports
· heel pads and heel cups
· lumbosacral supports
· corsets, trusses,
elastic stockings, support hose, and other
supportive devices
· Penile prostheses
All charges.
Durable medical equipment (DME) You pay
Purchase or rental up to
the purchase price, including repair and
adjustment, of durable medical
equipment prescribed by your Plan
physician. Under this benefit, we cover:
· Colostomy/ ostomy supplies;
· Hospital beds;
·
Wheelchairs;
· Crutches;
· Walkers;
· Canes;
· Traction equipment;
· Peak flow monitor for
self-management of asthma;
· Glucose monitor for self-management of
diabetes; and
· Apnea monitor for management of newborns.
Note:
Call us at 800/ 334-5847 as soon as your Plan physician prescribes
this
equipment. We have contracted with health care provider to rent or
sell you
durable medical equipment at discounted rates and will tell you
more about
this service when you call.
50% of allowable charges 18
18 Page 19 20
2001 Access+
19
Not covered:
· Exercise equipment
· Disposable medical supplies for home use
·
Speech/ language assistance devices
· Self-monitoring
equipment, except as listed in the covered section
· Wigs
All charges.
Home health services
· Home health care ordered by a Plan
physician and provided by a
registered nurse (R. N.), Physical Therapist
(PT), Occupational
Therapist (OT), Speech Therapist (ST), Respiratory
Therapist (RT),
licensed vocational nurse (L. V. N.), or home health aide.
· Services include oxygen therapy, intravenous therapy and
medications.
$5 per visit
· Home visit by physician $25 per visit
Not covered:
· nursing care requested by, or for the convenience of, the
patient or
the patient's family;
· nursing care primarily
for hygiene, feeding, exercising, moving the
patient, homemaking,
companionship or giving oral medication.
All charges.
Alternative treatments
Chiropractic Services (with an annual limit
of 20 visits per year) Each
member is allowed a pre-authorized appliance
benefit of up to $50 per
year. Examples of covered appliances are elbow
supports, back supports
(thoracic) and cervical collars. Unlimited
chiropractic discounts are also
available, see mylifepath features on page
33.
$10 per visit
Not covered:
· naturopathic services
·
hypnotherapy
· services for or related to acupuncture (see
page 33 for Non-FEHB
discount information.)
· All charges after the 20 visit annual maximum
All charges
Appliance benefits that are pre-authorized such as
· Elbow
supports
· Back supports (Thoracic)
· Cervical collars
All charges above $50 per year
Educational classes and programs
Coverage is limited to:
· Quarterly health education newsletter
· List of
community educational classes, support groups and
seminars
· Healthwise Handbooks for new members
· First Steps sm
prenatal education program
· Personal health reminders
Nothing 19
19 Page
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2001 Access+ 20
Section 5 (b). Surgical and anesthesia services provided by physicians
and other health care professionals
I M
P O
R T
A N
T
Herearesomeimportant thingstokeepin mindaboutthesebenefits:
· Pleaseremember thatallbenefitsare subjecttothedefinitions,
limitations,andexclusionsin thisbrochureandare
payable onlywhenwedetermine
theyaremedicallynecessary.
· Planphysiciansmustprovide orarrangeyourcare.
· Wehave
nocalendaryeardeductible.
· Besureto readSection4,Your
costsforcoveredservices forvaluableinformationabout howcostsharingworks.
Also readSection9about coordinatingbenefitswithother
coverage,includingwithMedicare.
· Theamountslisted belowareforthe chargesbilledbya
physicianorotherhealth careprofessionalforyour
surgicalcare. Look
inSection5(c) forchargesassociatedwith thefacilitycharge(i.
e.hospital,surgicalcenter,
etc.).
I M
P O
R T
A N
T
Benefit Description You pay
Surgical procedures
·
Treatment of fractures, including casting
· Normal pre-and
post-operative care by the surgeon
· Correction of amblyopia and
strabismus, when medically
necessary.
· Endoscopy procedure
· Biopsy procedure
·
Removal of tumors and cysts
· Correction of congenital anomalies (see
reconstructive surgery)
· Surgical treatment of morbid obesity
– for members who meet Blue
Shield Medical Policy and clinical
criteria for defined procedures
and services that have been approved by
their Personal Care
Physicians.
· Treatment of burns
Nothing in hospital
· Norplant (a surgically implanted contraceptive) and intrauterine
devices (IUDs) Note: Devices are covered under Section 5( a).
$10 per office visit
· Insertion of internal prosthetic devices. See Section 5( a) –
Orthopedic braces and prosthetic devices for device coverage
information.
$10 per procedure
· Outpatient hospital surgery and supplies $50 per surgery
· Voluntary sterilization
·· Vasectomy
·· Tubal Ligation
$75
$100
Not covered:
· Reversal of voluntary sterilization
· Routine treatment of conditions of the foot.
All charges. 20
20 Page 21 22
2001 Access+
21
Reconstructive surgery
· Surgery to correct a
functional defect
· Surgery to correct a condition caused by injury
or illness if:
··the condition produced a major effect on the
member's
appearance and
··the condition can reasonably be expected to be corrected by
such
surgery
· Surgery to correct a condition that existed at or from birth and is
a
significant deviation from the common form or norm. Examples of
congenial anomalies are: protruding ear derformaties, cleft lip, cleft
palate, birth marks, webbed fingers, and webbed toes.
Nothing as an inpatient
· All stages of breast reconstruction surgery following a mastectomy,
such as:
·· surgery to produce a symmetrical appearance on the other
breast;
·· treatment of any physical complications, such as
lymphedemas;
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.
See above.
Not covered:
· Cosmetic surgery – any surgical
procedure (or any portion of a
procedure) performed primarily to improve
physical appearance
through change in bodily form, except repair of
accidental injury
· Surgeries related to sex transformation
All charges
Oral and maxillofacial surgery
Oral surgical procedures, limited
to:
· Reduction of fractures of the jaws or facial bones;
· Surgical correction of cleft lip, cleft palate or severe functional
malocclusion;
· Removal of stones from salivary ducts;
· Excision of leukoplakia or malignancies;
· Excision of
cysts and incision of abscesses when done as
independent procedures; and
· Surgical and anthroscopic treatment of TMJ is covered if prior
history shows conservative medical treatment has failed. Splint
therapy
and physical therapy is covered, see Section 5 (a).
· Other surgical
procedures that do not involve the teeth or their
supporting structures.
Nothing as an inpatient
Not covered:
· Oral implants and transplants
· Procedures that involve the teeth or their supporting
structures
(such as the periodontal membrane, gingiva, and alveolar bone)
All charges. 21
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2001 Access+
22
Organ/ tissue transplants You pay
Limited to:
·
Cornea
· Heart
· Skin
· Heart/ lung
· Kidney
· Kidney/ Pancreas
· Liver
· Lung: Single –Double
Limited Benefits – Allogenic
(donor) bone marrow transplant; autologous
bone marrow transplants (
autologous stem cell and peripheral stem cell
support) for the following
conditions when authorized in writing by the Blue
Shield Medical Director
and performed at approved facilities: acute
lymphocytic or non-lymphocytic
leukemia, advanced Hodgkin's lymphoma,
advance non-Hodgkin's lymphoma,
advanced neuroblastoma, and testicular,
mediastinal, retroperitoneal and
ovarian germ cell tumors. Breast cancer,
multiple myeloma and epithelial
ovarian cancer are covered only when
approved by the Plan's Medical
Director. Related medical and hospital
expenses of the donor are covered
when the recipient is covered by this plan.
Nothing
Not covered:
· Donor screening tests and donor search
expenses, except those
performed for the actual donor
·
Implants of artificial organs
· Transplants not listed as covered
· Pancreas only transplants
· Travel expenses
unless authorized by us
All charges
Anesthesia You pay
Professional services provided in –
· Hospital (inpatient)
· Skilled Nursing Facility
Nothing
Professional services provided in –
· Hospital outpatient
department
· Ambulatory surgical center
· Office
$50 outpatient copay per treatment
or surgery including necessary
supplies 22
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Section 5 (c). Services provided by a hospital or other facility, and
ambulance services
I M
P O
R T
A N
T
Here are some important things to remember about these benefits:
· Please remember that all benefits are subject to the
definitions, limitations, and
exclusions in this brochure and are payable
only when we determine they are
medically necessary.
· Plan physicians must provide or arrange your care and you must be
hospitalized in a
Plan facility.
· We have no calendar year deductible.
· Be sure to read
Section 4, Your costs for covered services for valuable information
about how cost sharing works. Also read Section 9 about coordinating
benefits
with other coverage, including with Medicare.
· The amounts listed below are for the charges billed by the facility
(i. e., hospital or
surgical center) or ambulance service for your surgery
or care. Any costs
associated with the professional charge (i. e.,
physicians, etc.) are covered in Section
5( a) or (b).
I M
P O
R T
A N
T
Benefit Description You pay
Inpatient hospital
Room and board,
such as
· semiprivate or intensive care accommodations;
·
general nursing care;
· meals and special diets when medically
necessary;
· Special duty nursing when medically necessary; and
· Private rooms when medically necessary.
NOTE: If you want a
private room when it is not medically necessary,
you pay the additional
charge above the semiprivate room rate.
Nothing
Other hospital services and supplies, such as:
· Operating,
recovery, delivery room, newborn nursery, 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
· Radiation therapy, chemotherapy, and renal
dialysis
Nothing
Not covered:
· Custodial care
·
Non-covered facilities, such as nursing homes, convalescent
care
facilities, schools
· Personal comfort items, such as
telephone, television, barber
services, guest meals and beds
· Private nursing care
All charges. 23
23 Page 24 25
2001 Access+
24
Outpatienthospital orambulatorysurgicalcenter
·
Operating, recovery, and other treatment rooms
· Prescribed drugs and
medicines
· Diagnostic laboratory tests, X-rays, and pathology
services
· Administration of blood, blood plasma, and other
biologicals
· Blood and blood plasma, if not donated or replaced
· Pre-surgical testing
· Dressings, casts, and sterile
tray services
· Medical supplies, including oxygen
·
Anesthetics and anesthesia service
NOTE: – We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment.
We do
not cover the dental procedures.
$50 per treatment or surgery
including necessary supplies
Not covered: blood and blood derivatives if replaced by the member All
charges
Extendedcarebenefits/ skilled nursingcarefacilitybenefits You
pay
We provide benefits up to 100 days each calendar year when full time
skilled nursing care is necessary and confinement in a skilled nursing
facility is medically appropriate as determined by your Plan physician
and approved by us. Admissions to a sub-acute care setting require
prior
approval and are limited to 100 days each calendar year. All
necessary
services are covered, including:
· Bed, board and general nursing care
· Drugs, biologicals,
supplies, and equipment ordinarily provided
or arranged by the skilled
nursing facility when prescribed by a
Plan physician.
Nothing
Not covered: custodial care, rest cures, domiciliary or convalescent
care and comfort items such as a telephone and television. All charges
after the 100 day annual maximum.
All charges
Hospice care
Supportive and palliative care for a terminally ill
member is covered in
the home or a hospice facility. Care received in the
home is limited to 100
visits per year. Care received in a hospice facility
provides for 100 days
of service, applied against the Extended Care Day
Limits, without
copayment. Services include inpatient and outpatient care,
and family
counseling; these services provided under the direction of a Plan
physician who certifies that the patient is in the terminal stages of
illness, with a life expectancy of approximately six months or less.
Nothing in a hospice facility.
$10 copay per home physician visit
$5
copay per visit of other health
care providers
Not covered: Independent nursing, homemaker services All charges
Ambulance
· Local professional ambulance service when
ordered or authorized
by a Plan physician.
Nothing 24
24 Page 25 26
2001 Access+ 25
Section 5 (d). Emergency
services/ accidents
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
· Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this
brochure.
· We have no calendar year deductible.
· Be sure to read
Section 4, Your costs for covered services for valuable information about
how cost
sharing works. Also read Section 9 about coordinating benefits with
other coverage, including
with Medicare.
I M
P O
R T
A N
T
What is a medical emergency?
A medical emergency is the sudden and
unexpected onset of a condition or an injury that you believe endangers your
life or could result in serious injury or disability, and requires immediate
medical or surgical care. Some problems are
emergencies because, if not
treated promptly, they might become more serious; examples include deep cuts and
broken
bones. Others are emergencies because they are potentially
life-threatening, such as heart attacks, strokes,
poisonings, gunshot
wounds, or sudden inability to breathe. There are many other acute conditions
that we may
determine are medical emergencies – what they all have in
common is the need for quick action.
What to do in case of emergency:
Emergencies within our service area:
If you are in an emergency situation, please call your primary care
physician. In extreme emergencies, if you are unable
to contact your
physician, contact the local emergency system (e. g., the 911 telephone system)
or go to the nearest
hospital emergency room. Be sure to tell the emergency
room personnel that you are a Plan member so they can notify
the Plan. You
or a family member should notify the Plan within 48 hours. It is your
responsibility to ensure that the Plan
has been timely notified.
If you need to be hospitalized, the Plan must be notified within 48 hours or
on the first working day following your
admission, unless it was not
reasonably possible to notify the Plan within that time. If you are hospitalized
in non-Plan
facilities and a Plan physician believes care can be better
provided in a Plan hospital, you will be transferred when
medically feasible
with any ambulance charges covered in full.
Benefits are available for care from non-Plan providers in a medical
emergency only if delay in reaching a Plan provider
would result in death,
disability or significant jeopardy to your condition.
Any follow-up care recommended by non-Plan providers must be approved by the
Plan or provided by Plan providers.
The Plan pays reasonable charges for
emergency services to the extent the services would have been covered if
received from Plan providers.
If the emergency results in admission to a hospital, any applicable copay is
waived. 25
25 Page
26 27
2001 Access+ 26
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
· Emergency care as an
outpatient or inpatient at a hospital, including
doctors' services
Note: If the emergency results in admission to a hospital, the copay is
waived.
$50 per visit
Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area
Benefits are available for any medically necessary health service that is
immediately required because of injury or unforeseen illness.
If you need to be hospitalized, the Plan must be notified within 48 hours
or on the first working day following your admissions, unless it was not
reasonably possible to notify the Plan within that time. If you are
hospitalized in non-Plan facilities and a Plan physician believes care can
be better provided in a Plan hospital, you will be transferred when
medically feasible with any ambulance charges covered in full.
Reasonable charges for emergency care services to the extent the
services
would have been covered if received from Plan providers.
Note: If the emergency results in admission to a hospital, the copay is
waived.
· Emergency care at a doctor's office $10 per visit
· Emergency care at an urgent care center
· Emergency care
as an outpatient or inpatient at a hospital, including
doctors' services
$50 per visit
Not covered:
· Elective care or non-emergency care
All charges.
Ambulance
Professional ambulance service when medically
appropriate.
See 5( c) for non-emergency service.
Nothing
Not covered: taxi, wheelchair van, other non-ambulance assisted
transportation
All charges. 26
26
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2001
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Section 5 (e). Mental health and substance abuse benefits
Network Benefit
I M
P O
R T
A N
T
Parity
Beginning in 2001, all FEHB plans' mental health and
substance abuse benefits will
achieve "parity" with other
benefits. This means that we will provide mental health and
substance abuse
benefits differently than in the past.
When you get our approval for services and follow a treatment plan we
approve, cost-sharing
and limitations for Plan mental health and substance
abuse benefits will be no
greater than for similar benefits for other
illnesses and conditions.
Here are some important things to keep in mind about these benefits:
· Please remember that benefits are subject to the definitions,
limitations, and
exclusions in this brochure.
· We have no
calendar year deductible.
· Be sure to read Section 4, Your costs
for covered services for valuable information
about how cost sharing
works. Also read Section 9 about coordinating benefits with
other coverage,
including Medicare.
· YOU MUST GET PREAUTHORIZATION OF THESE
SERVICES. See the
instructions after the benefits description below.
I M
P O
R T
A N
T
Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by Plan provider and
contained in a
treatment plan that we approve. The treatment plan may
include services, drugs, and
supplies described elsewhere in this brochure.
Note: Plan benefits are payable only when we determine the care is
clinically appropriate to
treat your condition and only when you receive the
care as part of a treatment plan that we
approve.
Your cost sharing
responsibilities
are no greater
than for other
illness or
conditions.
· Professional services, including individual or group therapy by
providers such as
psychiatrists, psychologists, or clinical social workers.
· Medication management
$10 per visit
· Diagnostic tests Nothing
· Services provided by a
hospital or other facility
· Services approved in alternative care
settings such as partial hospitalization, half-way
house, residential
treatment, full-day hospitalization, facility based intensive outpatient
treatment
Nothing
Not covered: Services we have not approved.
Note: OPM will base its
review of disputes about treatment plans on the treatment plan's
clinical
appropriateness. OPM will generally not order us to pay or provide one
clinically
appropriate treatment plan in favor of another.
All charges 27
27 Page 28 29
2001 Access+
28
Preauthorization To be eligible to receive these benefits you
must follow your treatment plan
and all the following authorization
processes:
To obtain an authorization, call 877/ 263-8827. You should continue to
identify
yourself as a Blue Shield member and use your Blue Shield
identification card
and identification numbers when contacting USBHPC or its
participating
providers.
Your health care provider should contact USBHPC at 877/ 263-9870 to
obtain information about joining the USBHPC network, obtaining an
authorization for your treatment, or to speak with a member of USBHPC's
clinical staff about issues related to this benefit or your care.
If you would like a copy of a provider directory, you can contact the Blue
Shield Member Services Department at 800/ 334-5847.
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 or when clinically appropriate
under the following conditions:
· If your mental health or substance abuse professional provider with
whom you
are currently in treatment leaves the plan at our request for other
than cause,
or
· If changes to this Plan's benefit structure for
2001 cause your-out-of pocket
costs for your out-of-network provider to be
greater than they were in year
2000.
If these conditions apply to you,
we will allow you reasonable time to transfer
your care to a USBHPC mental
health or substance abuse professional
provider. During the transitional
period, you may continue to see your treating
provider and will not pay any
more out-of-pocket than you did in the year 2000
for services. This
transitional period will begin with our notice to you of the
change in
coverage and will end 90 days after you receive out notice. If we
write to
you before October 1, 2000, the 90-day period ends before January 1,
2001
and this transitional benefit does not apply.
Limitation We may limit your benefits if you do not follow your
treatment plan.
Out-of-Network Benefit
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.
·
See page 27 for In-Network benefits.
· Be sure to read Section 4,
Your costs for covered services for valuable information about how cost
sharing works. Also
read Section 9 about coordinating benefits with other
coverage, including with Medicare.
Description You pay
Out-of-Network mental health and substance
abuse benefits
Not covered out-of-network All charges. 28
28 Page 29 30
2001 Access+ 29
Section 5 (f).
Prescription drug benefits
I
M
P
O
R
T
A
N
T
Here are some important things to keep in mind about these benefits:
· We cover prescribed drugs and medications, as described in the
chart beginning on the next
page.
· All benefits are subject to the definitions, limitations and
exclusions in this brochure and are
payable only when we determine they are
medically necessary.
· We have no calendar year deductible.
· Physicians must
document medical necessity for non-formulary drugs during regular business
hours by calling the Plan's toll-free pharmacy services prior authorization
hotline at 800/ 535-9481.
· Be sure to read Section 4, Your costs for covered services
for valuable information about how
cost sharing works. Also read Section
9 about coordinating benefits with other coverage,
including with Medicare.
I
M
P
O
R
T
A
N
T
There are important features you should know about your prescription
drug benefit. These include:
· Who can write your prescription.
A licensed physician, or other covered provider acting within the scope of
their license.
· Where can you obtain your prescriptions. You must fill the
prescription at a retail plan pharmacy, or plan mail
service pharmacy for a
maintenance medication.
· Mail Order Drug Program. Prescriptions are available by mail
for up to a 90-day supply. Generic drugs will be
dispensed in lieu of name
brand drugs when substitution is permissible by the physician. Call Member
Services
at 800/ 334-5847 to receive a packet for ordering prescriptions
through the mail.
· We use a formulary. Prescription Drug coverage is based on
the use of the prescription Drug Formulary, a
copy of which is available to
you. Non-formulary drugs will be covered when prescribed by a physician and
approved by Blue Shield. Your physician is responsible for obtaining
authorizations from the Plan for all non-formulary
drugs and selected
formulary drugs and drug dosages which require prior authorization for medical
necessity. You should not become directly involved with the Plan for this
pre-authorization process. Instead,
your physicians should document medical
necessity. If all necessary documentation is available from your
physician,
prior authorization approval or denial will be provided to your physician within
two working days of
the request.
· Medications are selected for inclusion in Blue Shield's Outpatient
Prescription Drug Formulary based on
safety, efficacy, and FDA
bio-equivalency data. The Blue Shield Pharmacy and Therapeutics Committee
reviews new drugs and clinical data four times a year.
· Members may call Blue Shield Member Services at 800/ 334-5847 to
find out if a specific drug is included in the
Formulary. New members
receive a printed copy of the formulary with their welcome kits. Formulary
information
is also available on Blue Shield's website at http:// www.
blueshieldca. com.
· In lieu of brand name drugs, generic drugs will be dispensed when
substitution is permissable by the
physician. If you request a brand name
drug when a generic drug is available, you pay the difference between
the
cost of the brand name drug and its equivalent generic drug, plus the copayment.
· Prescription Days Supply Covered: Present your Access+ ID
card at the participating pharmacy. A retail Plan
pharmacy may dispense up
to a 30-day supply for a $6 copay. You will pay $6 per prescription for
out-of-state
emergencies. Maintenance drugs are available in a 90-day supply
with a $6 copay per prescription through the
Plan mail service pharmacy. 29
29 Page 30 31
2001 Access+ 30
Benefit Description You
pay
Covered medications and supplies
We cover the following
medications and supplies prescribed by a Plan physician and
obtained from a
retail Plan pharmacy or through our mail service pharmacy:
· Diabetic supplies limited to disposable insulin syringes, needles,
pen delivery
systems and glucose testing tablets and strips.
· Formulary drugs for sexual dysfunction or sexual inadequacies will
be
covered when the dysfunction is caused by medically documented organic
disease. Prior Plan approval is required and the maximum dosage dispensed
will be limited by the protocols established by the Plan. Certain drugs for
these conditions are not available through the Mail Order option.
· Formulary drugs and medicines that by Federal law of the United
States
require a physician's prescription for their purchase, except as
excluded
below.
· Insulin
· Disposable needles and syringes for the
administration of covered
medications
· Formulary oral contraceptive drugs and diaphragms. ·
Here are some things to keep in mind about our prescription drug program:
· A generic equivalent will be dispensed if it is available, unless
your physician
specifically requires a name brand. If your receive a name
brand drug when a
Federally-approved generic drug is available and your
physician has not
specified Dispense as Written for the name brand drug, you
will pay the
difference in the cost between the name brand drug and the
generic plus the
copayment.
$ 6 per plan pharmacy
prescription
$ 6 per mail service
prescription
$6 plus the difference in
price of brand name and
generic drugs
Not covered:
· Drugs available without a prescription or
for which there is a
nonprescription equivalent available
· Intravenous fluids and medications for home use and some
injectable drugs,
such as Depo Provera, are covered under Sections 5( a) or
5( b) Medical or
Surgical services, not the Prescription Drug Benefit.
· Drugs obtained at a non-Plan pharmacy except for out-of-area
emergencies
· Compounded medication with formulary
alternatives or those with no FDA
approved indications
· Medical supplies such as dressings and antiseptics
· Drugs for cosmetic purposes
· Drugs to
enhance athletic performance
· Drugs for weight loss
· Smoking cessation drugs
· Vitamins and
nutritional substances that can be purchased without a
prescription
Note: IUDs and Norplant dispensed by your physician are covered under
Section 5( b) Surgical Services, not the Prescription Drug Benefit.
All Charges 30
30 Page 31 32
2001 Access+
31
Section 5 (g). Special Features
Feature Description
High risk pregnancies The Plan covers the prenatal diagnosis of
genetic disorders of the fetus in high-risk pregnancy cases.
Self-referral to
Specialty services
Access+ allows you to arrange office visits with Plan specialists in the same
Medical Group or IPA as your personal care physician without a referral. A
few physicians are not Access+ providers. You are advised to refer to the
Access+ 2001 Provider Directory for Federal Employees to determine if
your
physician participates in the Access+ self-referral option. Members who
use
this convenient feature are subject to a $30 copayment per specialty
office
visit. If the medical condition requires follow-up care to the same
specialist,
you are encouraged to request that the specialist receive prior
authorization
from your personal care physicians for additional visits at
the regular office
copayment of $10 per visit.
The Access+ specialist includes:
· Examinations and consultations;
· Conventional x-rays of the chest and abdomen;
· X-rays
of bones to diagnose suspected fractures;
· Laboratory services;
· Diagnostic or treatment procedures that would normally be provided
with a referral; and
· Vaccines and antibiotics.
The Access+ specialist visit does not include:
· Diagnostic
imaging such as CAT Scans, MRI or bone density
measurements;
· Services that are not covered benefits or that are not medically
necessary;
· Services of a provider not in the Access+ network;
·
Allergy testing;
· Endoscopic procedures;
· Injectables,
chemotherapy or other infusion drugs (not listed above);
·
Infertility services;
· Emergency services;
· Urgent care
services;
· Inpatient services or facility charges; and
·
Mental health and substance abuse. 31
31 Page 32 33
2001 Access+
32
Section 5 (h). Dental benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
· Please remember that all benefits are subject to the
definitions, limitations, and exclusions in this brochure and
are payable
only when we determine they are medically necessary.
· Plan providers must provide or arrange your care.
· We
have no calendar year deductible.
· We cover hospitalization for
dental procedures only when a nondental physical impairment exists which
makes hospitalization necessary to safeguard the health of the patient; we
do not cover the dental procedure
unless it is described below.
· Be sure to read Section 4, Your costs for covered services
for valuable information about how cost sharing
works. Also read Section
9 about coordinating benefits with other coverage, including with Medicare.
I M
P O
R T
A N
T
Accidental injury benefit
We cover restorative services and supplies
necessary to promptly repair (but not replace) sound natural teeth. The
need
for these services must result from an accidental injury commencing within 90
days of the accidental injury or
within 90 days of medical appropriateness
of treatment and within one year of the injury. You pay a $10 copay per visit.
Dental benefits
We have no other FEHB dental benefits.
Please refer to page 33. For details about a comprehensive, non-FEHB optional
Blue Shield Dental Plan. 32
32 Page 33 34
2001 Access+
33
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits described on this page are neither offered nor guaranteed
under the contract with FEHB, but are made available to all
enrollees and
family members who are members of this Plan. The cost of the benefits described
on this page is not included in the
FEHB premium and any charges for these
services do not count toward any FEHB deductibles or out-of-pocket maximums.
These
benefits are not subject to the FEHB disputed claims procedure.
Blue Shield Dental Option --Comprehensive and Affordable CAUTION: When
shopping for a dental plan, please carefully compare: (1) copayments, (2)
waitingg periods and (3) dues.
Enroll in Access+ and pay dues directly to Blue Shield to join this DHMO
dental plan. Dues can be paid monthly or quarterly (Dues
are also shown on a
biweekly basis for your convenience in comparing costs.). Call 888/ 271-4929 for
a list of dentists, a summary of
benefits and an enrollment form.
Biweekly Dues Monthly Dues Quarterly Dues
Self only $7.41 $16.05
$48.15
Two party $14.28 $30.93 $92.79
Family $21.07 $45.65 $136.95
Care must be received from or arranged by a Blue Shield Dental Option
provider. Below are sample copayments:
Office visits $5 Fillings (per
surface) $15 Root canal (one canal) $125
Bitewing X-rays $0 Metal crowns
(each) $250 Full upper or lower denture $250
Prophylaxis $0 Single, routine
extraction $20 Orthodontics (children only) $1,800
Receive Discounts from Vision One Eyecare Program on Frames and Lenses
Federal employees with Access+ coverage can enjoy savings of up to 66.7%
on frames and lenses through our Vision One Eyecare
Program at almost 250
Cole Vision California locations. Cole Vision services are available in the
optical departments of many Sears,
Montgomery Ward and JCPenney stores, at
Pearle Vision locations and at offices of participating private practice
doctors. There is
no added premium for this money-saving feature. Simply
present your Access+ identification card when you pay for your eyewear
and
the discounts are automatic.
For coverage of eye refractions see page 17.
Significant Discounts through the mylifepath sm Program -Acupuncture,
Massage & More
Access+ offers you participation in mylifepath, which
entitles you to significant discounts on health and wellness services. When
you see a practitioner in the mylifepath network, you'll experience
substantial savings on acupuncture, chiropractic, massage, fitness
centers,
health spas, and wellness programs. You will be responsible for all charges
remaining after the discounts. For more details
on all features, please call
888/ 999-9452. Also visit our website, mylifepath. com for health information
and news about other value-added
features.
Medical Care for Vacations, Business Travel and College Students
You, and your eligible family members are covered for urgent and
emergency care in all 50 states while you are on vacation or
business
travel. There are no additional premiums for this coverage. "Guest
membership" is also available on a temporary basis for
members and
dependents who will be living away from home and who need a local primary care
provider. You pay office copayments,
which vary from state to state ($ 5 to
$25) for guest visits and $50 for urgent care visits. For additional information
on these
coverages, call 800/ 334-5487.
Blue Shield 65 Plus, A Medicare+ Choice Prepaid Plan
This Plan
offers Medicare recipients the opportunity to enroll in the Plan through
Medicare. As indicated on page 40, annuitants and
former spouses with FEHB
coverage and Medicare Part B may elect to drop their FEHB coverage and enroll in
a Medicare prepaid
plan if one is available in their area. They may then
later reenroll in the FEHB Program. Most Federal annuitants have Medicare Part
A. Those without Medicare Part A may join this Medicare prepaid plan but
will have to pay for hospital coverage in certain instances
in addition to
the Part B premium. Before you join the plan, ask whether the plan covers
hospital benefits and, if so, what you will
have to pay. Contact your
retirement system for information on dropping your FEHB enrollment and changing
to a Medicare prepaid
plan. Contact us at 888/ 713-0000 for information on
the Medicare prepaid plan and the cost of that enrollment. Blue Shield 65 Plus
is
now available in Kern, Los Angeles, Orange, Riverside, San Bernardino,
San Diego, and Ventura counties.
Benefits on this page are not part of the FEHB Contract 33
33 Page 34 35
2001 Access+ 34
Section 6. General
exclusions --things we don't cover
The exclusions in this section apply
to all benefits. Although we may list a specific service as a benefit, we
will not
cover it unless your Plan physician determines it is medically
necessary to prevent, diagnose, or treat your illness,
disease, injury or
condition.
We do not cover the following:
· Care by non-Plan providers except
for authorized referrals or emergencies (see Emergency Benefits);
·
Services, drugs, or supplies you receive while you are not enrolled in this
Plan;
· Services, drugs, or supplies that are not medically
necessary;
· Services, drugs, or supplies not required according to
accepted standards of medical, dental, or mental
health practice;
· Experimental or investigational procedures, treatments, drugs or
devices;
· Services, drugs, or supplies related to abortions, except
when the life of the mother would be endangered if
the fetus were carried to
term or when the pregnancy is the result of an act of rape or incest;
· Services, drugs, or supplies related to sex transformations;
· Services, drugs, or supplies you receive from a provider or
facility barred from the FEHB Program;
· Services, drugs or supplies
related to sexual dysfunction or sexual inadequacies (including penile
prostheses) except as provided for medically documented treatment of
organically based conditions; or
· Services performed by a close relative (the spouse, child, brother,
sister, or parent of a member) or a person
who ordinarily resides in the
member's home. 34
34 Page
35 36
2001 Access+ 35
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
except for your annual eye examination. Just present your identification card
and
pay your copayment or coinsurance.
You will also 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 In most cases, providers and facilities file
claims for you. Physicians
drug benefits must file on the form
HCFA-1500, Health Insurance Claim Form. Facilities will file on the UB-92 form.
For claims questions and assistance, call us at 800/ 334-5847
When you must file a claim --such as for out-of-area care --submit it on the
HCFA-1500 or a claim form that includes the information shown below. Bills
and
receipts should be itemized and show:
· Covered member's name and ID number;
· Name and address
of the physician or facility that provided the service or
supply;
· Dates you received the services or supplies;
· Diagnosis;
· Type of each service or supply;
· The charge for each
service or supply;
· A copy of the explanation of benefits, payments,
or denial from any primary
payer --such as the Medicare Summary Notice
(MSN); and
· Receipts, if you paid for your services.
Submit your claims
to: Blue Shield of California
Access+ Member Services
P. O. Box 272550
Chico, CA 95927
Deadline for filing your claim Send us all of the documents for your
claim as soon as possible. You must submit the claim by December 31 of the year
after the year you received the service,
unless timely filing was prevented
by administrative operations of Government or
legal incapacity, provided the
claim was submitted as soon as reasonably
possible.
When we need more information Please reply promptly when we ask for
additional information. We may delay processing or deny your claim if you do not
respond. 35
35 Page
36 37
2001 Access+ 36
Section 8. The disputed claims process
Follow this Federal
Employees Health Benefits Program disputed claims process if you disagree with
our decision on your
claim or request for services, drugs, or supplies
– including a request for preauthorization:
Step Description
1 Ask us in writing to reconsider our initial decision. You must: (a)
Write to us within 6 months from the date of our decision; and
(b) Send your
request to us at: Blue Shield of California, Administrative review, PO Box
272540, Chico, CA 95927-
2540. You may call our MSD at 800/ 334-5847 and
request an initial appeal form, C-4456. We will mail or fax the form
to you.
(c) Include a statement about why you believe our initial decision was wrong,
based on specific benefit provisions in
this brochure; and
(d) Include copies of documents that support your claim, such as physicians'
letters, operative reports, bills, medical
records, and explanation of
benefits (EOB) forms.
2 We have 30 days from the date we receive your request to: (a) Pay
the claim (or, if applicable, arrange for the health care provider to give you
the care); or
(b) Write to you and maintain our denial --go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider,
we will send you a copy of our request—
go to step 3.
3 You or your provider must send the information so that we receive it
within 60 days of our request. We will then decide within 30 more days.
If
we do not receive the information within 60 days, we will decide within 30 days
of the date the information was due.
We will base our decision on the
information we already have.
We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
· 90 days after the date of our
letter upholding our initial decision; or
· 120 days after you first
wrote to us --if we did not answer that request in some way within 30 days; or
· 120 days after we asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance
Programs, Contracts Division II, P. O. Box 436
Washington, D. C. 20044-0436.
36
36 Page 37 38
2001 Access+ 37
Send OPM the following
information:
· A statement about why you believe our decision was
wrong, based on specific benefit provisions in this
brochure;
· Copies of documents that support your claim, such as physicians'
letters, operative reports, bills, medical
records, and explanation of
benefits (EOB) forms;
· Copies of all letters you sent to us about the claim;
·
Copies of all letters we sent to you about the claim; and
· Your
daytime phone number and the best time to call.
Note: If you want OPM to review different claims, you must clearly identify
which documents apply to which claim.
Note: You are the only person who has
a right to file a disputed claim with OPM. Parties acting as your
representative, such as medical providers, must provide a copy of your
specific written consent with the review
request.
Note: The above deadlines may be extended if you show that you were unable to
meet the deadline because of
reasons beyond your control.
5 OPM will review your disputed claim request and will use the
information it collects from you and us to decide whether our decision is
correct. OPM will send you a final decision within 60 days. There are no other
administrative appeals.
6 If you do not agree with OPM's decision, your only recourse is to
sue. If you decide to sue, you must file the suit against OPM in Federal court
by December 31 of the third year after the year in which you received the
disputed services, drugs or supplies. This is the only deadline that may not be
extended.
OPM may disclose the information it collects during the review
process to support their disputed claim decision. This
information will
become part of the court record.
You may not sue until you have completed the disputed claims process.
Further, Federal law governs your lawsuit,
benefits, and payment of
benefits. The Federal court will base its review on the record that was before
OPM when
OPM decided to uphold or overturn our decision. You may recover
only the amount of benefits in dispute.
NOTE: If you have a serious or life threatening condition (one that
may cause permanent loss of bodily functions or
death if not treated as soon
as possible), and
a) We haven't responded yet to your initial request for care or
preauthorization/ prior approval, then call us at 800/ 334-
5847 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 II at
202/ 606-3818 between 8 a. m. and 5 p. m. eastern time. 37
37 Page 38 39
2001 Access+ 38
Section 9. Coordinating
benefits with other coverage
When you have other health coverage You
must tell us if you are covered or a family member is covered under another
group health plan or have automobile insurance that pays health care expenses
without regard to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full
as
the primary payer and the other plan pays a reduced benefit as the
secondary
payer. We, like other insurers, determine which coverage is
primary according to
the National Association of Insurance Commissioners'
guidelines.
When we are the primary payer, we will pay the benefits described in this
brochure.
When we are the secondary payer, we will determine our allowance. After the
primary plan pays, we will pay what is left of our allowance, up to our
regular
benefit. We will not pay more than our allowance.
· What is Medicare? Medicare is a Health Insurance Program for:
·· People 65 years of age and older.
·· Some
people with disabilities, under 65 years of age.
·· People
with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a
transplant).
Medicare has two parts:
·· Part A (Hospital Insurance).
Most people do not have to pay for Part A.
·· Part B (Medical
Insurance). Most people pay monthly for Part B.
If you are eligible for Medicare, you may have choices in how you get your
health care.
Medicare+ 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 personal care physician.
We will not waive any of our copayments or coinsurances.
(Primary
payer chart begins on next page.) 38
38 Page 39 40
2001 Access+
39
The following chart illustrates whether original Medicare or this
Plan should be the primary payer for you according to your
employment status
and other factors determined by Medicare. It is critical that you tell us if you
or a covered family member
has Medicare coverage so we can administer these
requirements correctly.
Primary Payer Chart
A. When either you --or your covered spouse --are
age 65 or over and … Then the primary payer is…
OriginalMedicare This Plan
1) Are anactiveemployeewith
theFederalgovernment(including whenyouora
familymemberare
eligibleforMedicaresolely becauseofadisability), ü
2) Are an annuitant, ü
3) Are a re-employed annuitant with the
Federal government when
a) The position is excluded from FEHB, or ü
b) The position is not excluded from FEHB
Ask your employing office which
of these applies to you.
ü
4) Are a Federal judge who retired under title 28, U. S. C., or a Tax
Court judge who retired under Section 7447 of title 26, U. S. C. (or if
your covered spouse is this type of judge), ü
5) Are enrolled in Part B only, regardless of your employment status, ü
(for Part B services) ü (for other
services)
6) Are a former
Federal employee receiving Workers' Compensation
and the Office of Workers'
Compensation Programs has determined
that you are unable to return to duty,
ü
(exceptforclaimsrelated
toWorkers'
Compensation.)
B. When you --or a covered family member --have Medicare based on
end
stage renal disease (ESRD) and…
1) Are within the first 30 months of eligibility to receive Part A
benefits solely because of ESRD, ü
2) Have completed the 30-month ESRD coordination period and are
still
eligible for Medicare due to ESRD, ü
3) Become eligible for Medicare due to ESRD after Medicare became
primary
for you under another provision, ü
C. When you or a covered family member have FEHB and…
1)
Are eligible for Medicare based on disability, and
a) Are an annuitant, or
ü
b) Are an active employee ü 39
39
Page 40 41
2001
Access+ 40
· 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
plans,
you can only go to doctors, specialists, or hospitals that are part of the
Plan. Medicare managed care plans cover all Medicare Plan 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 another Plan's Medicare+ Choice plan: You may enroll in
another
plan's Medicare managed care plan and also remain enrolled in our
FEHB plan.
We will still provide benefits when your Medicare managed care
plan is primary,
even out of the managed care plan's network and/ or service
area (if you use our
Plan providers), but we will not waive any of our
copayments or coinsurance.
Suspended FEHB coverage and a Medicare+ Choice 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.) Medicare 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+ Choice service area.
· Enrollment in Note: If you choose not to enroll in Medicare
Part B, you can still be
Medicare Part B covered under the FEHB
Program. We cannot require you to enroll in Medicare.
TRICARE TRICARE is the health care program for eligible dependents of
military persons and retirees of the military. TRICARE includes the CHAMPUS
program. If both
TRICARE and this Plan cover you, we pay first. See your TRICARE Health
Benefits Advisor if you have questions about TRICARE coverage.
Workers' Compensation We do not cover services that:
· You
need because of a workplace-related disease or injury that the Office of
Workers' Compensation Programs (OWCP) or a similar Federal or State agency
determines they must provide; or
· OWCP or a similar agency pays for through a third party injury
settlement or
other similar proceeding that is based on a claim you filed
under OWCP or
similar laws.
Once OWCP or a similar agency pays its maximum benefits for your treatment,
we
will cover your benefits. You must use our providers.
Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies We do not cover services and supplies
when a local, State,
are responsible for your care or Federal
Government agency directly or indirectly pays for them.
When others are responsible When you receive money to compensate you
for medical or hospital
for injuries care for injuries or illness
caused by another person, you must reimburse us for any expenses we paid.
However, we will cover the cost of treatment that exceeds
the amount you received in the settlement.
If you do not seek damages you
must agree to let us try. This is called
subrogation. If you need more
information, contact us at 530/ 666-2238 for our
subrogation procedures. 40
40 Page 41 42
2001 Access+ 41
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.
Coinsurance Coinsurance is the percentage of our allowance that you
must pay for your care.
Covered services Care we provide benefits
for, as described in this brochure.
Experimental or Access+ covers drugs, devices that are medically
indicated and biological
investigational services products no longer
considers to be investigational by the Food and Drug Administration. Coverage
for other procedures are reviewed by and decided by
the Blue Shield of California Medical Policy Committee. The primary criteria
are
that the proposed new procedures are safe and effective.
Plan allowance Plan allowance is the amount we use to determine our
payment and your coinsurance for covered services. These are negotiated lower
provider rates and
savings are passed on to you.
Us/ We Us and we refer to Blue Shield of California Access+ or
USBHPC for mental health and substance abuse coverage.
You You
refers to the enrollee and each covered family member. 41
41 Page 42 43
2001 Access+ 42
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a
condition that you had
limitation before you enrolled in this Plan
solely because you had the condition before you enrolled.
Where you can get information See www. opm. gov/ insure. Also, your
employing or retirement office
about enrolling in the can answer your
questions, and give you a Guide to Federal Employees
FEHB Program
Health Benefits Plans, brochures for other plans, and other materials
you need to make an informed decision about:
· When you may change your enrollment;
· How you can cover
your family members;
· What happens when you transfer to another
Federal agency, go on leave
without pay, enter military service, or retire;
· When your enrollment ends; and
· When the next open
season for enrollment begins.
We don't determine who is eligible for
coverage and, in most cases, cannot
change your enrollment status without
information from your employing or
retirement office.
Types of coverage available Self-Only coverage is for you alone. Self
and Family coverage is for
for you and your family you, your spouse,
and your unmarried dependent children under age 22, including any foster
children or stepchildren for which your employing or
retirement office authorizes coverage. Under certain circumstances, you may
also continue coverage for a disabled child 22 years of age or older who is
incapable of self-support.
If you have a Self-Only enrollment, you may change to a Self and Family
enrollment if you marry, give birth, or add a child to your family. You may
change your enrollment 31 days before to 60 days after that event. The Self
and
Family enrollment begins on the first day of the pay period in which the
child is
born or becomes an eligible family member. When you change to Self
and Family
because you marry, the change is effective on the first day of
the pay period that
begins after your employing office receives your
enrollment form; benefits will
not be available to your spouse until you
marry.
Your employing or retirement office will not notify you when a family
member is
no longer eligible to receive health benefits, nor will we. Please
tell us
immediately when you add or remove family members from your coverage
for any
reason, including divorce, or when your child under age 22 marries
or turns 22.
If you or one of your family members is enrolled in one FEHB plan, that
person
may not be enrolled in or covered as a family member by another FEHB
plan. 42
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2001 Access+ 43
When
benefits and The benefits in this brochure are effective on January 1. If
you are new
premiums start to this Plan, your coverage and premiums
begin on the first day of your first pay period that starts on or after January
1. Annuitants' premiums begin on January 1.
Your medical and claims We will keep your medical and claims
information confidential. Only
records are confidential the following
will have access to it:
· OPM, this Plan, and subcontractors when they administer this
contract;
· This Plan, and appropriate third parties, such as other
insurance plans and the
Office of Workers' Compensation Programs (OWCP),
when coordinating
benefit payments and subrogating claims;
· Law enforcement officials when investigating and/ or prosecuting
alleged civil
or criminal actions;
· OPM and the General Accounting Office when conducting audits;
· Individuals involved in bona fide medical research or education
that does not
disclose your identity; or
· OPM, when reviewing a disputed claim or defending litigation about a
claim.
When you retire When you retire, you can usually stay in the FEHB
Program. Generally, you must have been enrolled in the FEHB Program for the last
five years of your Federal service. If you do not meet this
requirement, you
may be eligible for other forms of coverage, such as Temporary Continuation of
Coverage (TCC).
When you lose benefits
·When FEHB coverage ends You will
receive an additional 31 days of coverage, for no additional premium,
when:
·· Your enrollment ends, unless you cancel your enrollment, or
·· You are a family member no longer eligible for coverage.
You may be eligible for spouse equity coverage or Temporary Continuation of
Coverage.
· Spouse equity If you are divorced from a Federal employee or
annuitant, you may not
coverage continue to get benefits under your
former spouse's enrollment. But, you may
be eligible for your own FEHB
coverage under the spouse equity law. If you are
recently divorced or are
anticipating a divorce, contact your ex-spouse's
employing or retirement
office to get RI 70-5, the Guide to Federal Employees
Health Benefits
Plans for Temporary Continuation of Coverage and Former
Spouse Enrollees,
or other information about your coverage choices.
·TCC If you leave Federal service, or if you lose coverage
because you no longer
qualify as a family member, you may be eligible for
Temporary Continuation of
Coverage (TCC). For example, you can receive TCC
if you are not able to
continue your FEHB enrollment after you retire.
You may not elect TCC if you are fired from your Federal job due to gross
misconduct.
Get the RI 79-27, which describes TCC, and the RI 70-5, the Guide to
Federal
Employees Health Benefits Plans for Temporary Continuation of
Coverage and
Former Spouse Enrollees, from your employing or retirement
office or from
www. opm. gov/ insure. 43
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Converting to You may convert to a non-FEHB individual policy if:
individual coverage ·· Your coverage under TCC or the
spouse equity law ends. If you canceled your coverage or did not pay your
premium, you cannot
convert;
·· You decided not to receive coverage under TCC
or the spouse equity
law; or
·· You are not eligible for coverage under TCC or the spouse
equity law.
If you leave Federal service, your employing office will notify
you of your right
to convert. You must apply in writing to us within 31 days
after you receive this
notice. However, if you are a family member who is
losing coverage, the
employing or retirement office will not notify
you. You must apply in writing to
us within 31 days after you are no longer
eligible for coverage.
Your benefits and rates will differ from those under the FEHB Program;
however,
you will not have to answer questions about your health, and we
will not impose
a waiting period or limit your coverage due to pre-existing
conditions.
Getting a Certificate of If you leave the FEHB Program, we will give
you a Certificate of Group
Group Health Plan Coverage Health Plan
Coverage that indicates how long you have been enrolled with us. You can use
this certificate when getting health insurance or other health care coverage.
Your new plan must reduce
or eliminate waiting periods, limitations, or exclusions for health related
conditions based on the
information in the certificate, as long as you
enroll within 63 days of losing coverage under this Plan.
If you have been enrolled with us for less than 12 months, but were
previously
enrolled in other FEHB plans, you may also request a certificate
from those plans.
Inspector General Advisory Stop health care fraud! Fraud increases the
cost of health care for everyone. If you suspect that a physician, pharmacy, or
hospital has charged you for services
you did not receive, billed you twice
for the same service, or misrepresented any
information, do the following:
· Call the provider and ask for an explanation. There may be an error.
· If the provider does not resolve the matter, call us at 800/
334-5847 and
explain the situation.
· If we do not resolve the
issue, call THE HEALTH CARE FRAUD
HOTLINE--202/ 418-3300 or write to:
The United States Office of
Personnel Management, Office of the Inspector
General Fraud Hotline,
1900 E Street, NW, Room 6400, Washington, DC 20415.
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB
Program benefits can be prosecuted
for fraud. Also, the Inspector General
may investigate anyone who uses an ID
card if they try to obtain services
for a person who is not an eligible family
member, or are no longer enrolled
in the Plan and try to obtain benefits. Your
agency may also take
administrative action against you. 45
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46
Department of Defense/ FEHB Demonstration Project
What is it?
The Department of Defense/ FEHB Demonstration Project allows some active and
retired uniformed service members and their dependents to enroll in the FEHB
Program. The
demonstration will last for three years and began with the 1999
open season for the year
2000. Open season enrollments will be effective
January 1, 2001. DoD and OPM have set
up some special procedures to
implement the Demonstration Project, noted below.
Otherwise, the provisions
described in this brochure apply.
Who is eligible DoD determines who is eligible to enroll in the FEHB
Program. Generally, you may enroll if:
· You are an active or retired uniformed service member and are
eligible for Medicare;
· You are a dependent of an active or retired
uniformed service member and are eligible
for Medicare;
· You are a qualified former spouse of an active or retired uniformed
service member
and you have not remarried; or
· You are a survivor dependent of a deceased active or retired
uniformed service
member; and
· You live in one of the geographic demonstration areas.
If you are eligible to enroll in a plan under the regular Federal Employees
Health Benefits
Program, you are not eligible to enroll under the DoD/ FEHBP
Demonstration Project.
The demonstration areas · Dover AFB, DE · Commonwealth
of Puerto Rico · Fort Knox, KY · Greensboro/ Winston Salem/ High
Point, NC
· Dallas, TX · Humboldt County, CA area
·
New Orleans, LA · Naval Hospital, Camp Pendleton, CA
· Adair
County, IA area · Coffee County, GA area
When you can join You may enroll under the FEHB/ DoD Demonstration
Project during the 2000 open season, November 13, 2000, through December 11,
2000. Your coverage will begin January 1, 2001.
DoD has set-up an
Information Processing Center (IPC) in Iowa to provide you with
information
about how to enroll. IPC staff will verify your eligibility and provide you with
FEHB Program information, plan brochures, enrollment instructions and forms.
The toll-free
phone number for the IPC is 877/ DOD-FEHB (877/ 363-3342).
You may select coverage for yourself (Self Only) or for you and your family
(Self and
Family) during the 2000 and 2001 open seasons. Your coverage will
begin January 1 of the
year following the open season during which you
enrolled.
If you become eligible for the DoD/ FEHB Demonstration Project outside of
open season,
contact the IPC to find out how to enroll and when your
coverage will begin.
DoD has a web site devoted to the Demonstration Project. You can view
information such
as their Marketing/ Beneficiary Education Plan, Frequently
Asked Questions,
demonstration area locations and zip code lists at www.
tricare. osd. mil/ fehbp. You can
also view information about the
demonstration project, including "The 2001 Guide to
Federal Employ