This Plan has full accreditation from the
NCQA. See the 2001 Guide
for more
information on NCQA.
RI 73-599
For changes
in benefits
see page 6.
Enrollment codes for this plan:
TE1 Self Only
TE2 Self and Family
Serving: Connecticut
Enrollment in this Plan is limited; see
page 5 for requirements. 1
1 Page 2 3
2 2001
ConnectiCare, Inc. Table of Contents
Table of Contents
Introduction
...................................................................................................................................................................
4
Plain
Language..............................................................................................................................................................
4
Section 1. Facts about this HMO plan
........................................................................................................................
5
How we pay
providers................................................................................................................................
5
Who provides my health
care?...................................................................................................................
5
Patients' Bill of
Rights...............................................................................................................................
5
Service
Area...............................................................................................................................................
6
Section 2. How we change for 2001
...........................................................................................................................
6
Program-wide
changes...............................................................................................................................
6
Changes to this
Plan...................................................................................................................................
6
Section 3. How you get care
.......................................................................................................................................
7
Identification
cards.....................................................................................................................................
7
Where you get covered care
.......................................................................................................................
7
° Plan
providers........................................................................................................................................
7
° Plan facilities
.........................................................................................................................................
7
What you must do to get covered care
.......................................................................................................
7
° Primary
care..........................................................................................................................................
7
° Specialty
care........................................................................................................................................
7
° Hospital care
.........................................................................................................................................
8
Circumstances beyond our control
.............................................................................................................
9
Services requiring our prior
approval.........................................................................................................
9
Section 4. Your costs for covered
services.................................................................................................................
10
°
Copayments.........................................................................................................................................
10
° Deductible
...........................................................................................................................................
10
°
Coinsurance.........................................................................................................................................
10
° Your out-of-pocket
maximum.............................................................................................................
10
Section 5. Benefits
.....................................................................................................................................................
11
Overview..................................................................................................................................................
11
(a) Medical services and supplies provided by physicians and other health
care professionals ............. 12
(b) Surgical and anesthesia services
provided by physicians and other health care professionals .......... 20
(c)
Services provided by a hospital or other facility, and ambulance services
........................................ 23
(d) Emergency services/
accidents.............................................................................................................
26
(e) Mental health and substance abuse
benefits.......................................................................................
28
(f) Prescription drug benefits
...................................................................................................................
30
(g) Special features
...................................................................................................................................
32
(h) Non-FEHB benefits available to Plan
members.................................................................................
33 2
2 Page 3 4
3 2001 ConnectiCare, Inc. Table of Contents
Section 6. General exclusionsÑ 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
.....................................................................................................................
41
When others are responsible for
injuries..................................................................................................
41
Section 10. Definitions of terms we use in this brochure
...........................................................................................
42
Section 11. FEHB facts
...............................................................................................................................................
43
Coverage
information...............................................................................................................................
43
° No pre-existing condition limitation
..................................................................................................
43
° Where you get information about enrolling in the FEHB Program
.................................................. 43
° Types of
coverage available for you and your family
........................................................................ 43
° When benefits and premiums start
....................................................................................................
43
° No pre-existing condition limitation
..................................................................................................
43
° Your medical and claims records are confidential
............................................................................. 44
° When you retire
..................................................................................................................................
44
When you lose
benefits............................................................................................................................
44
° When FEHB coverage ends
...............................................................................................................
44
° Spouse equity coverage
......................................................................................................................
44
° Temporary Continuation of Coverage (TCC)
....................................................................................
44
° Enrolling in
TCC................................................................................................................................
44
° Converting to individual coverage
.....................................................................................................
45
° Getting a Certificate of Group Health Plan Coverage
....................................................................... 45
Inspector General
Advisory.....................................................................................................................
45
Index
............................................................................................................................................................................
46
Summary of benefits
...................................................................................................................................................
47
Rates.............................................................................................................................................................................
48 3
3 Page 4 5
4 2001 ConnectiCare, Inc. Introduction/ Plain
Language
Introduction
ConnectiCare, Inc.
30 Batterson
Park Road, Farmington, CT 06032-2574
This brochure describes the benefits you can receive from ConnectiCare, Inc.
under its contract (CS2662) with the
Office of Personnel Management (OPM),
as authorized by the Federal Employees Health Benefits law. This brochure
is
the official statement of benefits. No oral statement can modify or otherwise
affect the benefits, limitations, and
exclusions of this brochure.
If you are enrolled in this Plan, you are entitled to the benefits described
in this brochure. If you are enrolled for
Self and Family coverage, each
eligible family member is also entitled to these benefits. You do not have a
right to
benefits that were available before January 1, 2001, unless those
benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes
are effective January 1, 2001, and are
summarized on page 6. Rates are shown
at the end of this brochure.
Plain Language
The President and Vice President are making the
Government's communication more responsive, accessible, and
understandable
to the public by requiring agencies to use plain language. In response, a team
of health plan repre-sentatives
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
ConnectiCare, Inc.
The plain language team reorganized the brochure and the way we describe our
benefits. When you compare this
Plan with other FEHB plans, you will find
that the brochures have the same format and similar information to
make
comparisons easier.
If you have comments or suggestions about how to improve this brochure, let
us know. Visit OPM's "Rate Us"
feedback area at www. opm. gov/
retire, 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
5 2001
ConnectiCare, Inc. Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to
see specific physicians, hospitals, and
other providers that contract with
us. These Plan providers coordinate your health care services.
HMOs emphasize preventive care such as routine office visits, physical exams,
well-baby care, and immunizations,
in addition to treatment for illness and
injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit
claim forms or pay bills. You only pay
the copayments and/ or 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 individual physicians,
medical groups, and hospitals to provide the benefits in this brochure.
These Plan providers accept a negotiated payment from us, and you will only
be responsible for your copayments
or coinsurance.
Who provides my health care
ConnectiCare is an Independent
Practice Association (IPA) model Health Maintenance Organization (HMO). It
offers you the services of more than 5,000 physicians, including general
practitioners and specialists. For Plan
records, all members and each family
member must select a primary care doctor. However, members are free to
choose the services of any participating doctor, including specialists,
except as noted below (see What you must
do, specialty care). Your personal
doctor may already participate in ConnectiCare. If so, you may receive
compre-hensive
coverage with no change in your established doctor/ patient
relationship. Also, a wide range of hospitals,
laboratories and pharmacies
participate with ConnectiCare.
Patients' Bill of Rights
OPM requires that all FEHB Plans comply
with the Patients' Bill of Rights, recommended by the President's Advisory
Commission on Consumer Protection and Quality in the Health Care Industry.
You may get information about us,
our networks, providers, and facilities.
OPM's FEHB website (www. opm. gov/ insure) lists the specific types of
information that we must make available to you. Some of the required
information is listed below.
° ConnectiCare complies with all State and
Federal health care regulations.
° Years in existence: 19
°
Profit status: For-profit
If you want more information about us, call 1-800-251-7722, or write to
ConnectiCare, Inc., 30 Batterson Park Road,
Farmington, CT 06032-2574. You
may also contact our Member Services Department by fax at 860-674-2232 or
visit our website at www. connecticare. com
Service Area
To enroll with us, you must live in or work in our
Service Area. This is where our providers practice. Our service
area is: The
state of Connecticut.
Ordinarily, you must get your care from providers who contract with us. If
you receive care outside our service
area, we will pay only for emergency or
urgent care. We will not pay for any other health care services.
If you or a covered family member moves outside of our 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 that has agreements with
affiliates in other areas. This Plan does
provide emergency or urgent care
for college students. If you or a family member move, you do not have to wait
until Open Season to change plans. Contact your employer or retirement
office. 5
5 Page 6
7
6 2001 ConnectiCare, Inc. Section 2
Section 2. How we change for 2001
Program-wide changes
° The plain language team reorganized the brochure and the way we
describe our benefits. We hope this will make
it easier for you to compare
plans.
° This year, the Federal Employees Health Benefits Program is
implementing network mental health and substance
abuse parity. This means
that your coverage for mental health, substance abuse, medical, surgical, and
hospital
services from providers in our plan network will be the same with
regard to copays, coinsurance, and day and
visit limitations when you follow
a treatment plan that we approve. Previously, we placed higher patient cost
sharing
on mental health and substance abuse services than we did on
services to treat physical illness, injury, or disease.
° Many healthcare organizations have turned their attention this past
year to improving healthcare quality and patient
safety. OPM asked all FEHB
plans to join them in this effort. You can find specific information on our
patient
safety activities by calling Member Services at 1-800-251-7722, or
checking our website www. connecticare. 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:
° ° Speak up if you have questions or concerns.
° ° Keep
a list of all the medicines you take.
° ° Make sure you get the
results of any test or procedure.
° ° Talk with your doctor and
health care team about your options if you need hospital care.
° °
Make sure you understand what will happen if you need surgery.
° We clarified the language to show that anyone who needs a mastectomy
may choose to have the procedure performed
on an inpatient basis and remain
in the hospital up to 48 hours after the procedure. Previously, the language
referenced
only women.
Changes to this Plan
Here are the changes for 2001:
°
Currently, there is a $10/$ 20 prescription plan. For 2001, all generic
prescriptions remain at a $10 co-pay.
Name Brand Formulary Prescriptions
will have a $20 co-pay. Name Brand Non-Formulary Prescriptions will
have a
$35 co-pay. When a generic is available, you will continue to share the cost
difference between the
generic and Name Brand Prescription plus the $10
co-pay.
° We again have a "Live or Work" enrollment provision
°
You will now have 20 Chiropractic visits and 40 Physical Therapy (OT, Speech)
visits, both at a $10 co-pay per
visit, per condition, per calendar year.
° Your share of the non-Postal premium will increase by 2.8% for Self
Only or decrease by 13.6% for Self and
Family. 6
6
Page 7 8
7 2001
ConnectiCare, Inc. Section 3
We will send you an identification (ID)
card. You should carry your ID
card with you at all times. You must show it
whenever you receive
services from a Plan provider, or fill a prescription
at a Plan pharmacy.
Until you receive your ID card, use your copy of the
Health Benefits
Election Form, SF-2809, your health benefits enrollment
confirmation
(for annuitants), or your Employee Express confirmation letter.
To get your cards quickly, fax us a copy of your Health Benefits Election
Form with the payroll code printed on the bottom. List your PCP and
provider number for you and each family member on a separate page.
Fax everything to ConnectiCare's Enrollment Department at 860-409-8991.
If you do not receive your ID card within 30 days after the effective
date of your enrollment, or if you need replacement cards, call us at
1-800-251-7722.
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.
Plan providers are physicians and other health care professionals in our
service area with whom we contract to provide covered services to our
members. We credential Plan providers according to national standards.
We list Plan providers in the provider directory, which we update
periodically. The list is also on our website. Since this list changes, it's
best to contact us to confirm that a provider participates.
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.
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 for most of your
health care. You
can choose a PCP from our provider directory. If you
don't provide us with
your PCP, we will select one for you, which you
can change at any time by
calling 1-800-251-7722.
Your primary care physician can be a family practitioner, internist,
general practitioner or pediatrician.
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.
Members may see any participating doctor for covered services without
a
referral with the following exceptions. You must get a referral from a
participating doctor for: cardiovascular lab, cardiac rehabilitation, lab
work, pain management and behavioral medicine, pulmonary rehabili-tation,
radiology, radiation therapy, and physical therapy.
Section 3. How you get care
Identification Cards
Where you get covered care
° Plan providers
° Plan facilities
What you must do
° Primary care
° Specialty care 7
7 Page 8 9
8 2001 ConnectiCare, Inc. Section 3
Your
doctor will both refer you and get Plan authorization for: hospital
admissions (except out-of-service area emergencies), use of surgical
facilities, outpatient alcohol and substance abuse treatment, durable
medical equipment, prostheses, orthopedic devices, home health care,
speech therapy, occupational therapy, out-of-Plan services
(non-partic-ipating
providers), human organ transplants, skilled nursing
facilities
and surgical treatment of morbid obesity.
For information on how to obtain specialty care services, contact us at
1-800-251-7722. A Plan doctor can make arrangements for appropriate
referrals. Do not go to a specialist for services listed above unless a
referral or an authorization and a referral has been issued in advance.
Here are other things you should know about specialty care:
° If you
are seeing a specialist when you enroll in our Plan and he or
she doesn't
participate with us, you must receive treatment from a
specialist who does.
Generally, we will not pay for you to see a
specialist who does not
participate with our Plan. Your primary care
physician will decide what
treatment you need.
° If you are seeing a specialist and your specialist leaves the Plan,
call
your primary care physician, who will arrange for you to see another
specialist. You may receive services from your current specialist
until
we can make arrangements for you to see someone else.
° If you have a chronic or disabling condition and lose access to your
specialist because we:
°° terminate our contract with your specialist for other than cause;
or
°° drop out of the Federal Employees Health Benefits (FEHB)
Program
and you enroll in another FEHB Plan; or
°° reduce our service area and you enroll in another FEHB Plan,
you may be able to continue seeing your specialist for up to 90 days
after you receive notice of the change. Contact us, or, if we drop out
of the Program, contact your new plan.
If you are in the second or third trimester of pregnancy and you lose
access to your specialist based on the above circumstances, you can
continue to see your specialist until the end of your postpartum care,
even if it is beyond the 90 days.
Your Plan primary care physician or specialist will make necessary
hospital arrangements and supervise your care. This includes admis-sion
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 1-800-251-7722. If you
are new to the FEHB Program, we will arrange for you to receive care.
° Specialty care
° Hospital care 8
8 Page 9 10
9 2001 ConnectiCare, Inc. Section 3
If you
changed from another FEHB plan to us, your former plan will
pay for the
hospital stay until:
° You are discharged, not merely moved to an alternative care center; or
° The day your benefits from your former plan run out; or
° The
92nd day after you become a member of this Plan, whichever
happens first.
These provisions apply only to the benefits of the hospitalized person.
Under certain extraordinary circumstances, such as natural disasters,
we
may have to delay your services or we may be unable to provide
them. In that
case, we will make all reasonable efforts to provide you
with the necessary
care.
Your primary care physician or specialist has authority to refer you for
most services. For certain services, however, your physician must obtain
approval from us. Before giving approval, we consider if the service is
covered, medically necessary, and follows generally accepted medical
practice.
We call this review and approval process Plan authorization. Your
physician must obtain Plan authorization for the following services:
cardiovascular lab, cardiac rehabilitation, lab work, pain management
and behavioral medicine, pulmonary rehabilitation, radiology, radiation
therapy, and physical therapy.
Your doctor will both refer you and get Plan authorization for: hospital
admissions (except out-of-service area emergencies), use of surgical
facilities, outpatient alcohol and substance abuse treatment, durable
medical equipment, prostheses, orthopedic devices, home health care,
speech therapy, occupational therapy, out-of-Plan services
(non-partic-ipating
providers), human organ transplants, skilled nursing
facilities
and surgical treatment of morbid obesity.
For information on how to obtain specialty care services, contact us at
1-800-251-7722. A Plan doctor can make arrangements for appropriate
referrals. Do not go to a specialist for services listed above unless a
referral or an authorization and a referral has been issued in advance.
Otherwise, the services may not be covered.
Circumstances beyond our control
Services requiring our prior approval
9
9 Page 10 11
10 2001 ConnectiCare, Inc. Section 4
You
are responsible for:
A copayment is a fixed amount of money you pay to
the provider
when you receive services.
Example: When you see your primary care physician, you pay a
copayment of
$10 per office visit and when you go in the hospital, it's
covered 100%.
The only deductible this plan has is for Durable Medical Equipment,
the
(DME) benefit.
Coinsurance is the percentage of our negotiated fee that you must pay
for
your care. DME has coinsurance.
We do not have an out-of-pocket maximum.
Section 4. Your costs for covered services
You must share the cost of
some services.
° Copayments
° Deductible
° Coinsurance
Your out-of-pocket maximum
10
10 Page 11
12
11 2001 ConnectiCare, Inc. Section 5
Section 5. Benefits ÑOverview (See page 6 for how
our benefits changed this year and page 47 for a benefits summary.)
NOTE: This benefits section is divided into subsections.
Please read the important things you should keep in mind
at the beginning of
each subsection. For more information about our benefits, contact us at
1-800-251-7722 or at
our website at www. connecticare. com
(a) Medical services and supplies provided by physicians and other health
care professionals .......................... 12-19
° Diagnostic and
treatment services ° Rehabilitative therapies
° Lab, X-ray, and
other diagnostic tests ° Hearing services (testing, treatment, and supplies)
° Preventive care, adult ° Vision services (testing, treatment, and
supplies)
° Preventive care, children ° Foot care
°
Maternity care ° Orthopedic and prosthetic devices
° Family planning
° Durable medical equipment (DME)
° Infertility services ° Home
health services
° Allergy care ° Alternative treatments
°
Treatment therapies ° Educational classes and programs
(b) Surgical and anesthesia services provided by physicians and other health
care professionals......................... 20-23
° Surgical procedures
° Oral and maxillofacial surgery
° Reconstructive surgery °
Organ/ tissue transplants
° Anesthesia
(c) Services provided by a hospital or other facility, and ambulance
services....................................................... 23-25
°
Inpatient hospital ° Extended care benefits/ skilled nursing
°
Outpatient hospital or ambulatory care facility benefits
surgical center
° Hospice care
° Ambulance
(d) Emergency services/ accidents
..........................................................................................................................
26-27
° Medical emergency ° Ambulance
(e) Mental health and
substance abuse
benefits.....................................................................................................
28-29
(f) Prescription drug benefits
......................................................................................................................................
30
(g) Special features
......................................................................................................................................................
32
(h) Non-FEHB benefits available to Plan members
....................................................................................................
33
Summary of benefits
...................................................................................................................................................
47 11
11 Page 12
13
12 2001 ConnectiCare, Inc. Section 5( a)
I
M
P
O
R
T
A
N
T
I
M
P
O
R
T
A
N
T
You pay
$10 per visit
$20 per visit
Nothing
Nothing
for up to 90 days per calendar year
$10 per visit
$10 per visit
$10 per visit
$10 per house call by a doctor
$10 per office visit
Nothing
Nothing if you receive these services
during your office
visit
Benefit Description
Diagnostic and treatment services
Professional services of physicians
° In physician's office
Professional services of physicians
° In an urgent care center
° During a hospital stay
° In a skilled nursing facility
° Initial examination of a newborn child covered under
a family
enrollment
° Office medical consultations
° Second surgical
opinion
At home
Diagnosis and treatment of illness or injury in
physician's
office, including specialty care
Diagnostic tests in hospital
Vaccines for pediatric and adult
immunizations
Nondental treatment of temporomandibular joint
(TMJ)
syndrome
Services for which a member has no responsibility to pay
Services for intentionally inflicted injuries
Services for injuries
resulting from hazardous activities
Section 5 (a) Medical services and supplies provided by physicians and
other health care professionals
Here are some important things to keep in
mind about these benefits:
° Please remember that all benefits are
subject to the definitions, limitations,
and exclusions in this brochure and
are payable only when we determine they
are medically necessary.
°
Plan physicians must provide or arrange for your care.
° We have no
calendar year deductible, except for DME.
° 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. 12
12 Page 13 14
13 2001
ConnectiCare, Inc. Section 5( a)
Benefit Description
Lab, X-ray
and other diagnostic tests
° In physician's office
° Blood
tests
° Urinalysis
° Pathology
° X-rays
° Cat
Scans/ MRI Ultrasound Electrocardiogram and EEG
° Diagnostic surgical
procedures
° Radiation therapy
° Nuclear medicine studies and
injections
° Non-routine Pap tests
° Non-routine Mammograms
Preventive care, adult
Routine screenings, such as well-baby care,
periodic check-ups
and routine immunizations including these tests as
ordered by
your doctor
° Blood lead level
° Total Blood
Cholesterol
° Colorectal Cancer Screening, including Fecal occult blood
test
°° Sigmoidoscopy, screening as ordered by your doctor
Prostate
Specific Antigen (PSA test) as ordered by your doctor
Routine Pap test
Note: The office visit is covered if Pap test is received on the
same
day; see Diagnosis and Treatment, above.
Routine mammogramÐ 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 calendar years
° From age
50 through 64, one every calendar year
° At age 65 and older, one every
two consecutive calendar years
or as recommended by your doctor
Not covered: Physical exams required for obtaining or continu-ing
employment or insurance, attending schools or camp, or
travel, unless
received according to preventive care schedule.
Routine Immunizations, limited to:
° Tetanus-diphtheria (Td)
boosterÐ once every 10 years, ages 19
and over (except as provided for
under Childhood immunizations)
° Influenza/ Pneumococcal vaccines,
annually, age 65 and over
° Lyme Disease vaccine
Check with your doctor to see if this plan covers other
immunizations
You pay
Nothing, included in hospital stay or
office visit
$10 per visit
$10 per visit
$10 per visit
Nothing if you receive
these services
during your office visit; otherwise,
$10 per visit
Nothing
All charges
Nothing if you receive these services
during your office
visit; otherwise
$10 per visit 13
13 Page 14 15
14 2001
ConnectiCare, Inc. Section 5( a)
You pay
Nothing if you
receive these services dur-ing
your office visit; otherwise $10 per
visit
$10 per visit
$10 for initial visit; then nothing
$10 per visit
All charges.
Benefit Description
Preventive care, children
° Childhood
immunizations recommended by the American
Academy of Pediatrics
° Examinations, such as:
°° Eye exams to determine the need
for vision correction.
°° Ear exams through age 18 to determine the
need for hearing
correction
°° Examinations done on the day of
immunizations (through
age 22)
° Well-child care charges for routine
examinations, immunizations
and care (through age 22)
Maternity care
Complete maternity (obstetrical) care, such as:
° Prenatal care
° Delivery
° Postnatal care
Note: Here are some things to keep in mind:
° You do not need to
pre-certify your normal delivery.
° You may remain in the hospital up to
48 hours after a regular
delivery and 96 hours after a cesarean delivery. We
will extend
your inpatient stay if medically necessary.
° We cover routine nursery care of the newborn child during the
covered portion of the mother's maternity stay. We will cover
other care
of an infant who requires non-routine treatment only
if we cover the infant
under a Self and Family enrollment.
° We pay hospitalization and surgeon services (delivery) the
same as
for illness and injury. See Hospital benefits (Section 5c)
and Surgery
benefits (Section 5b).
Family planning
° Voluntary sterilization
° Surgically
implanted contraceptives
° Injectable contraceptive drugs
°
Intrauterine devices (IUDs)
Not covered: reversal of voluntary surgical sterilization, genetic
counseling. 14
14 Page
15 16
15 2001 ConnectiCare, Inc.
Section 5( a)
Benefit Description
Infertility services
Diagnosis and treatment of infertility, such as:
° Artificial
insemination:
°° intravaginal insemination (IVI)
°°
intracervical insemination (ICI)
°° intrauterine insemination (IUI)
Fertility drugs
Note: We cover injectable fertility drugs under medical
benefits
and oral fertility drugs under the prescription drug benefit (up to
$1,500 per calendar year).
Not covered:
° Assisted reproductive technology (ART) procedures,
such as:
°° in vitro fertilization
°° embryo transfer
and GIFT
° Services and supplies related to excluded ART procedures
° Any
prescription medications used for or in preparation of any
of these
non-covered procedures
° Cost of donor sperm
Allergy care
Testing and treatment
Allergy injection
Allergy serum
Not covered: provocative food testing and sublingual
allergy
desensitization
You pay
$10 per visit
All charges
$10 per visit
Nothing
All charges 15
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Benefit Description
Treatment therapies
° 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
° DialysisÐ Hemodialysis
and peritoneal dialysis
° Intravenous (IV)/ Infusion TherapyÐ Home
IV and
antibiotic therapy
° Growth hormone therapy (GHT)
Note: We will only cover GHT when we
pre-authorize the treat-ment.
Your doctor would have to submit your case in
writing to
the Plan. Your case will be reviewed for medical necessity and,
if approved, you may then seek treatment.
Not covered:
° Vision Therapies
° Physiotherapy (such as
therapeutic muscle exercises, galvanic
or thanscutaneous nerve stimulation,
vapocoolant sprays,
ultrasound or diathermy)
Rehabilitative therapies
Physical therapy, occupational therapy
and speech therapy-°
40 visits per condition, per calendar year, for the
services
of each of the following:
°° qualified physical
therapists;
°° speech therapists; and
°° occupational
therapists.
Note: We only cover therapy to restore bodily function or speech
when
there has been a total or partial loss of bodily function or
functional
speech due to illness or injury. Speech therapy is limited
to the 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. Speech and
occupational therapy
require pre-authorization from the Plan.
° Cardiac rehabilitation following a heart transplant, bypass
surgery
or a myocardial infarction, is provided at a Plan facility
when authorized
in advance by the Plan.
° Chiropractic manipulation therapy is provided on an outpatient
basis for up to 20 visits per calendar year.
You pay
Nothing
All charges
$10 copay per visit
Nothing
$10 copayment per visit 16
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2001 ConnectiCare, Inc. Section 5( a)
Benefit Description
Rehabilitative therapies
Not covered:
° long-term
rehabilitative therapy
° exercise programs
Hearing Services (testing, treatment, and supplies)
° Hearing
testing for children through age 18
(see Preventive care, children)
Not covered:
° all other hearing testing
° hearing aids,
testing and examinations for them
° First hearing aid and testing only
when necessitated by
accidental injury
Vision services (testing, treatment, and supplies)
° Our
vision program includes: frames and lenses, prescription
contact lenses
available only at Plan routine vision providers
(offered at various
discounts, not at $10 copay). For a full
description of the Vision Care
Coverage, please see the
routine vision information located in the
enrollment packet.
° Eye exam to determine the need for vision correction for
children
(see preventive care)
° Annual eye refraction once per calendar year, when obtained
by Plan
providers
Not covered:
° Eye exercises and orthoptics
° Radial
keratotomy and other refractive surgery
Foot care
Routine foot care when you are under active treatment
for a
metabolic or peripheral vascular disease, such as diabetes.
Not covered:
° Cutting, trimming or removal of corns, calluses, or
the free
edge of toenails, and similar routine treatment of conditions
of the foot, except as stated above
° Treatment of weak, strained or flat feet or bunions or spurs;
and
of any instability, imbalance or subluxation of the foot
(unless the
treatment is by open cutting surgery)
You pay
All charges.
$10 per visit
All charges.
25% discount on frames and lenses at or
blow $250; 30% discount over $250
at
plan routine vision providers
$10 per visit
$10 per visit
All charges.
$10 per visit
All charges. 17
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18 2001
ConnectiCare, Inc. Section 5( a)
Benefit Description
Orthopedic
and prosthetic devices
° Artificial limbs and eyes; stump hose
Note: Plan authorization is required and coverage is limited
to the
initial acquisition. This benefit paid under Durable
Medical Equipment.
° Externally worn breast prostheses and surgical bras, including
necessary replacements, following a mastectomy
° Internal prosthetic devices, such as artificial joints, pacemakers,
cochlear implants, and surgically implanted breast implant
following
mastectomy. Note: See 5( b) for coverage of the
surgery to insert the
device.
Not covered:
° orthopedic and corrective shoes
° arch
supports
° foot orthotics
° heel pads and heel cups
°
lumbosacral supports
° corsets, trusses, elastic stockings, support
hose, and other
supportive devices
° prosthetic replacements
provided less than 3 years after the
last one we covered
Durable medical equipment (DME)
Rental or purchase, at our option,
including repair and adjustment,
of durable medical equipment prescribed by
your Plan physician,
such as oxygen and dialysis equipment. Under this
benefit, we
also cover:
° hospital beds;
° wheelchairs (Motorized chairs covered only
with plan approval
of doctors written request detailing medical
necessity.)
° crutches;
° walkers;
° blood glucose
monitors; and
° insulin pumps.
You must get your equipment from our vendors. Your doctor can
help you or
you can call member services at 1-800-251-7722.
You pay
You pay a $100 deductible per calendar
year and 20% of
charges, up to a maxi-mum
plan payment of $1,500 per calendar
year.
All charges.
$100 deductible per calendar year and
20% of charges up to a maximum Plan
payment of $1,500 per calendar year.
Note: Prior Plan authorization is required
and coverage is limited to the
initial
acquisition. 18
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19 2001
ConnectiCare, Inc. Section 5( a)
Benefit Description
Ostomy
Equipment and Supplies
Ostomy equipment and supplies prescribed by your
Plan
physician.
Home health services
° Home health care ordered by a Plan
physician and provided by
a registered nurse (R. N.), licensed practical
nurse (L. P. N.),
licensed vocational nurse (L. V. N.), or home health aides
when
prescribed by your Plan doctor, who will periodically review
the
program for continuing appropriateness and need.
° Services include oxygen therapy, intravenous therapy and
medications.
Not covered:
° nursing care requested by, or for the convenience of,
the
patient or the patient's family; All charges.
Alternative treatments
Chiropractic servicesÑ Chiropractic
manipulation therapy is
provided on an inpatient or outpatient basis for up
to 20 visits
per calendar year.
Naturopathic Doctors if Plan Doctors
Not covered:
° hypnotherapy
° biofeedback
Educational classes and programs
Coverage is limited to:
Diabetes, Heart and Asthma programs
are available. Information can be
obtained by calling Member
Services at 1-800-251-7722.
You pay
$100 deductible per calendar year and
20% of charges
up to a maximum Plan
payment of $1,000 per calendar year.
Note: Prior Plan authorization is required
and coverage is limited to the
initial
acquisition.
Nothing
All charges.
$10 copayment per visit
$10 copay
All charges
Nothing 19
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Section 5 (b). Surgical and anesthesia services provided by physicians and
other health care professionals
Here are some important things to keep in
mind about these benefits:
° Please remember that all benefits are
subject to the definitions, limitations,
and exclusions in this brochure and
are payable only when we determine they
are medically necessary.
°
Plan physicians must provide or arrange your care.
° 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.
° The amounts listed below are for the charges billed by a
physician or other
health care professional for your surgical care. Any
costs associated with the
facility charge (i. e. hospital, surgical center,
etc.) are covered in Section 5 (c).
° YOU MUST GET PRECERTIFICATION OF
SOME SURGICAL PROCEDURES.
Please refer to the precertification information
shown in Section 3 to be sure
which services require precertification and
identify which surgeries require
precertification.
20 2001 ConnectiCare, Inc. Section 5( b)
Benefit Description
Surgical procedures
° Treatment of fractures, including casting
° Normal pre-and post-operative care by the surgeon
° Correction
of amblyopia and strabismus
° Endoscopy procedure
° Biopsy
procedure
° Removal of tumors and cysts
° Correction of
congenital anomalies (see reconstructive surgery)
° Surgical treatment of morbid obesityÐ a condition in which
an
individual weighs 100 pounds or 100% over his or her
normal weight according
to current underwriting standards;
eligible members must be age 18 or over
and Plan must
approve in advance.
° Insertion of internal prosthetic devices must be medically
necessary to restore bodily function and require a surgical
incision (as
opposed to an external prosthetic device).
Examples: artificial joints,
pacemakers, defibrillators and
penile implants.
° Voluntary sterilization
° Norplant (a surgically implanted
contraceptive) and intrauterine
devices (IUDs) Note: Devices are covered
under 5( a).
° Treatment of burns
You pay
$10 per visit
Nothing when approved in advance
by Plan
Nothing
Nothing
$10 per prescription
Nothing 20
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21 2001 ConnectiCare, Inc.
Section 5( b)
Benefit Description
Surgical procedures
Not
covered:
° Reversal of voluntary sterilization
° Routine
treatment of conditions of the foot; see Foot care
° Skin Tag removal
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 congenital anomalies are: protruding ear
deformities; cleft lip; cleft palate; birth marks; webbed fingers;
and
webbed toes.
° All stages of breast reconstruction surgery following a
mastectomy,
such as:
°° surgery to produce a symmetrical appearance on the other
breast;
°° treatment of any physical complications, such as
lymphedemas;
°° breast prostheses and surgical bras and
replacements
(see Prosthetic devices)
Note: If you need a mastectomy, you may choose to have the
procedure
performed on an inpatient basis and remain in the
hospital up to 48 hours
after the procedure.
Not covered:
° Cosmetic surgeryÐ 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
You pay
All charges
Nothing
Nothing
All charges 21
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22 2001 ConnectiCare, Inc.
Section 5( b)
Benefit Description
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
° Other surgical procedures that do not involve the
teeth or their
supporting structures.
Not covered:
° Oral implants and transplants
° Procedures
that involve the teeth or their supporting structures
(such as the
periodontal membrane, gingiva, and alveolar bone)
Organ/ tissue transplants
Limited to:
° Cornea
°
Heart
° Kidney
°Liver
° Lung: SingleÐ Double
° Allogeneic (donor) bone marrow transplants; autologous bone
marrow
transplants (autologous stem cell and peripheral stem
cell support) for the
following conditions: acute lymphocytic
or non-lymphocytic leukemia;
advanced Hodgkin's lymphoma;
advanced non-Hodgkin's lymphoma; multiple
myeloma;
epithelial ovarian cancer; and testicular, mediastinal,
retroperitoneal and ovarian germ cell tumors
Limited BenefitsÐ Treatment for breast cancer, multiple myelo-ma,
and
epithelial ovarian cancer may be provided in an NCI-or
NIH-approved clinical
trial at a Plan-designated Center of
Excellence and if approved by the
Plan's medical director in
accordance with the Plan's protocols.
Note: We cover related medical and hospital expenses of the
donor when we
cover the recipient.
Not covered:
° Donor screening tests and donor search expenses,
except those
performed for the actual donor
° Implants of artificial
organs
° Transplants not listed as covered
You pay
Nothing
All charges.
Nothing
Note: Plan authorization is required at the
time of diagnosis, prior to any evaluative
services and will only be
authorized at
Plan facilities, contracted Centers of
Excellence, or at
facilities that have a pre-determined,
negotiated, daily rate.
All charges. 22
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Benefit Description
Inpatient hospital
° Room and board,
such as ward, semiprivate, or intensive care
accommodations; general nursing
care; and meals and special diets.
NOTE: If you want a private room when it is not medically
necessary, you
pay the additional charge above the semiprivate
room rate.
Other hospital services and supplies, such as:
° Operating, recovery,
maternity, and other treatment rooms
° Prescribed drugs and medicines
° Diagnostic laboratory tests and x-rays
° Administration of
blood and blood products
° Blood or blood plasma, if not donated or
replaced
° Dressings, splints, casts, and sterile tray services
Section 5 (c). Services provided by a hospital or other facility, and
ambulance services
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 and you must be hospitalized
in
a Plan facility.
° Be sure to read Section 4, Your costs for covered
services, for valuable information
about how cost sharing works. Also
read Section 9 about coordinating benefits
with other coverage, including
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).
23 2001 ConnectiCare, Inc. Section 5( b) and Section 5( c)
Benefit Description
Anesthesia
Professional services provided
inÐ
° Hospital (inpatient)
Professional services provided inÐ
° Hospital outpatient
department
° Skilled nursing facility
° Ambulatory surgical
center
° Office
You pay
Nothing
Nothing when prescribed by a Plan doctor.
You pay
Nothing
Nothing
Inpatient hospital continued on next page 23
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24 2001 ConnectiCare, Inc. Section 5( c)
Benefit Description
Inpatient hospital
° Medical
supplies and equipment, including oxygen
° Anesthetics, including nurse
anesthetist services
° Take-home items
° Medical supplies,
appliances, medical equipment, and any
covered items billed by a hospital
for use at home
Not covered:
° Custodial care
° Non-covered facilities, such
as nursing homes, extended care
facilities, schools
° Personal
comfort items, such as telephone, television, barber
services, guest meals
and beds
° Private nursing care
Outpatient hospital or ambulatory surgical center
° 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.
You pay
Nothing
All charges.
Nothing 24
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25 2001 ConnectiCare, Inc.
Section 5( c)
Benefit Description
Extended care benefits/ skilled
nursing care facility benefits
Skilled nursing facility (SNF):
The Plan provides a comprehen-sive
range of benefits for up to 90 days
when full-time skilled
nursing care is necessary and confinement in a
skilled nursing
facility is medically appropriate as determined by a Plan
doctor
and approved by the Plan. All necessary services are covered,
including:
° Bed, board and general nursing care
° Drugs,
biologicals, supplies, and equipment ordinarily
provided or arranged by the
skilled nursing facility when
prescribed by a Plan doctor.
Not covered: custodial care
Hospice care
Hospice Care:
Supportive and palliative care for a terminally ill
member is covered in the
home or hospice facility. Services
include inpatient and outpatient care,
and family counseling;
these services are provided under the direction of a
Plan doctor
who certifies that the patient is in the terminal stages of
illness,
with a life expectancy of approximately six months or less.
Not covered: Independent nursing, homemaker services
Ambulance
° Emergency Ambulance services are covered
°
Non-Emergency use must be requested by your doctor and
pre-approved by the
Plan
You pay
Nothing for up to
90 days per calendar year
All charges.
Nothing
All charges.
Nothing 25
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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
Medicare.
26 2001 ConnectiCare, Inc. Section 5( d)
What is a medical
emergency?
A medical emergency is the sudden and unexpected onset of a
condition or an injury that you believe endangers
your life or could result
in serious injury or disability, and requires immediate medical or surgical
care. Some
problems are emergencies because, if not treated promptly, they
might become more serious; examples include
deep cuts and broken bones.
Others are emergencies because they are potentially life-threatening, such as
heart
attacks, strokes, poisonings, gunshot wounds, or sudden inability to
breathe. There are many other acute conditions
that we may determine are
medical emergenciesÐ 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 urgent care situation within our service area, please call
your primary care doctor (available 24 hours a day through their answering
service). In extreme emergencies,
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 24 hours of an admission to the
hospital unless it was not reasonably
possible to do so. It is your
responsibility to ensure that the Plan has been timely notified.
If you need to be hospitalized in a non-Plan facility, the Plan must be
notified within 24 hours or on the first work-ing
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 Plan doctors
believe 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.
To be covered by this Plan, any follow-up care recommended by non-Plan
providers must be approved by the Plan
or provided by Plan providers.
The Plan pays reasonable charges for emergency services to the extent the
services would have been covered if
received from Plan providers.
Emergencies outside our service area: Benefits are available for any
medically necessary health service that is immediately required because of
injury or unforeseen illness.
If you need to be hospitalized, the Plan must be notified within 24 hours of
an admission or on the first working
day following your admission, unless it
was not reasonably possible to notify the Plan within that time. If a Plan
doctor believes care can be better provided in a Plan hospital, you will be
transferred when medically feasible with
any ambulance charges covered in
full.
To be covered by this Plan, any follow-up care recommended by non-Plan
providers must be approved by the Plan
or provided by Plan providers.
Section 5 (d). Emergency services/ accidents 26
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27 2001 ConnectiCare, Inc. Section 5( d)
Benefit Description
Emergency within our service area
° Emergency care at a doctor's office
° Emergency care at an urgent care center within the service area
° Emergency care as an outpatient or inpatient at a hospital,
including doctors' services
Not covered:
Elective care or non-emergency care
Emergency outside our service area
° Emergency care at a
doctor's office
° Emergency care at an urgent care center outside of the
service area
° Emergency care outside of the service area, at an outpatient or
inpatient at a hospital, including doctors' services
Not covered:
Elective care or non-emergency care
Ambulance
Professional ambulance service when medically
appropriate.
See 5( c) for non-emergency service.
You pay
$10 per visit
$20 for emergency services that are
cov-ered
benefits of this Plan. Copayment
waived if emergency results in
hospital
admission.
$40 for emergency services that are cov-ered
benefits of this Plan.
Copayment
waived if emergency results in hospital
admission.
All charges.
$10 per visit
$20 for emergency services that are
covered benefits of
this Plan. Copayment
waived if emergency results in hospital
admission.
$40 for emergency services that are
covered benefits of this Plan.
Copayment
waived if emergency results in hospital
admission.
All charges.
Nothing 27
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Section 5 (e). Mental health and substance abuse benefits
Parity
Beginning in 2001, all FEHB plans' mental health and substance abuse
benefits
will achieve "parity" with other benefits. This means
that we will provide mental
health and substance abuse benefits differently
than in the past.
When you get our approval for services and follow a treatment plan we
approve, cost-sharing and limitations for Plan mental health and substance
abuse benefits will be no greater than for similar benefits for other
illnesses
and conditions.
Here are some important things to keep in mind about these benefits:
° All benefits are subject to the definitions, limitations, and
exclusions in this
brochure.
° Be sure to read Section 4, Your
costs for covered services for valuable
information about how cost
sharing works. Also read Section 9 about
coordinating benefits with other
coverage, including with Medicare.
° YOU MUST GET PREAUTHORIZATION OF
THESE SERVICES.
See the instructions after the benefits description
below.
28 2001 ConnectiCare, Inc. Section 5( e)
Benefit Description
Mental health and substance abuse benefits
Diagnostic and treatment
services recommended by a Plan
provider and contained in a treatment plan
that we approve.
The treatment plan may include services, drugs, and
supplies
described elsewhere in this brochure.
Note: Plan benefits are payable only when we determine the
care is
clinically appropriate to treat your condition and only
when you receive the
care as part of a treatment plan that we
approve.
° Professional services, including individual or group therapy by
providers such as psychiatrists, psychologists, or clinical social
workers
° Medication management
° Diagnostic tests
° Services
provided by a hospital or other facility
° Services in approved
alternative care settings such as partial
hospitalization, residential
treatment, full-day hospitalization,
facility based intensive outpatient
treatment
You pay
Your cost sharing responsibilities are
no greater than
for other illnesses or
conditions.
$10 per office visit
Nothing
Nothing
$10 per office visit or
nothing depending
on service.
Mental health and substance abuse benefits continue on next page 28
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29 2001 ConnectiCare, Inc. Section 5( e)
Benefit Description
Mental health and substance abuse benefits
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 appropri-ate
treatment plan in favor of
another.
You pay
All charges
Preauthorization
Special transitional benefit
Limitation
To be eligible to receive these benefits you must follow your treatment
plan and all the following authorization processes: Please call
1-800-
424-5669 for all mental health requests. This number is printed on the
back of your ConnectiCare, Inc. member card as well.
° If a mental health or substance abuse professional provider is treating
you under our plan as of January 1, 2001, you will be eligible for
continued coverage with your provider for up to 90 days under the
following 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 this condition applies to you, we will allow you reasonable time to
transfer your care to a Plan mental health or substance abuse profes-sional
provider. During the transitional period, you may continue to
see your
treating provider and will not pay any more out-of-pocket
than you did in
the year 2000 for services. This transitional period
will begin with our
notice to you of the change in coverage and will
end 90 days after you
receive our notice. If we write to you before
October 1, 2000, the 90-day
period ends before January 1 and this
transitional benefit does not apply.
We may limit your benefits if you do not follow your treatment plan. 29
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30 2001 ConnectiCare, Inc. Section 5( f)
Section 5 (f). Prescription drug benefits
Here are some important
things to keep in mind about these benefits:
° We cover prescribed
drugs and medications, as described in the chart
beginning on the next page.
° All benefits are subject to the definitions, limitations and exclusions
in this
brochure and are payable only when we determine they are medically
necessary.
° Be sure to read Section 4, Your costs for covered services, for
valuable
information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including Medicare.
There are important features you should be aware of. These include:
° Who can write your prescription. A licensed physician must
write the prescription.
° Where you can obtain them. You must
fill the prescription at a PCS pharmacy, or by mail for a maintenance
medication. The only exception is for out-of-area emergencies.
Pharmacy: You may obtain your prescriptions at any PCS, Inc. pharmacy.
(In 98% of US Pharmacies)
Mail order: Maintenance medication, those
medications needed for conditions such as diabetes, high blood pres-sure,
epilepsy and heart conditions, can be obtained either via mail order or at
the pharmacy in a 100-day supply.
If you choose mail order at 2X the co-pay,
call Member Services at 1-800-251-7722 to request an order form. If
you
choose to go to your pharmacy, the co-pay will be 3X the co-pay. All rules that
apply to the regular Prescription
Plan apply to the Mail Order Program as
well. Note: Not all drugs are available via mail order and your doctor
must
write a maintenance prescription.
° We use an Open Formulary. We work with our network physicians
and our pharmacy network, PCS, Inc., to
build a Formulary Drug List. This
Formulary Drug List includes over 80% of the drugs currently available in the
market, including all generic and some name brand drugs. Formulary and
Non-Formulary drugs are available at a
cost difference when a generic is
available. Our Formulary is available by calling Member Services at
1-800-251-7722
or on the Web at www. connecticare. com
All members receive educational information describing the Formulary drug
program. Members using non-Formulary
drugs are sent a series of letters
recommending that they speak to their physician about preferred
alternatives.
° These are the dispensing limitations. Prescription drugs
prescribed by a Plan or referral doctor and obtained at
a Plan pharmacy will
be dispensed for up to a 34-day supply; 240 milliliters of liquid (8oz.); 60
grams of ointment,
creams or topical preparation; or one commercially
prepared unit (i. e., one inhaler, one vial ophthalmic medication
or
Insulin) of medication per prescription or refill. You pay a $10 copay per
prescription unit or refill for generic
drugs or for name brand Formulary
drugs when generic substitution is not permissible. When generic substitution
is permissible and, you or your doctor request the Formulary name brand
drug, you pay the price difference between
the generic and name brand drug
as well as the $10 copay per prescription unit or refill. Drugs are prescribed
by
Plan doctors and dispensed in accordance with the Plan's drug Formulary.
Non-Formulary drugs will be covered
when prescribed by a Plan doctor, but at
a higher copay.
NOTE: Not all prescriptions are available through the Maintenance Mail Order
Program depending on the type of
drug, etc. We follow FDA dispensing
guidelines. If you send in your order too soon, it can't be filled. Maintenance
Mail Order refills should be requested after 75% of the prescription is
used. Over the counter when you have 5 days 30
30
Page 31 32
31
2001 ConnectiCare, Inc. Section 5( f)
left. If your prescription is
for more than 34 days (1 month) prescription, you will be charged two and
sometime
three copays depending on how much was dispensed.
If you choose a non-Formulary drug when a generic or Formulary name brand
drug is available, you pay a $10
copayment in addition to the cost
difference between the Formulary and non-Formulary drug, up to 50% of the cost
of the drug. If the cost is less than the copayment, you pay the lesser
amount.
° When you have to file a claim. There are no claims to file for
prescription services received at PCS, Inc. drug
stores. If you are new to
the plan and don't have your card when you first join and need a prescription,
you must
pay for it and call Member Services at 1-800-251-7722 for a
prescription reimbursement form. Refunds take up
to 8 weeks so always use
your card when you get it.
Benefit Description
Covered medications and supplies
We cover
the following medications and supplies prescribed by a
Plan physician and
obtained from a Plan pharmacy or through our
mail order program:
° 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
° Drugs for sexual dysfunction (Contact the plan for dose limits)
° Contraceptive drugs and devices( oral and injectable plus
diaphragms)
° Intraveneous fluids and medicine for home use (covered
implantable
drugs and covered injectable drugs are covered under
medical and surgical
benefits).
Limited Coverage:
Fertility drugs are subject to a $1,500 annual limit.
You pay
You pay a $10 copay per prescription unit
or refill
for generic drugs, a $20 copay for
name brand Formulary drugs and a $35
copay for non-Formulary drugs. When a
generic drug is available, but you
or your
doctor request the Formulary name brand
drug, or non-Formulary
brand drug, you
pay the price difference between the
generic and name
brand drug as well as
the $10 copay per prescription unit or
refill.
Drugs are prescribed by Plan doc-tors
and dispensed in accordance with the
Plan's drug Formulary. Our Formulary is
open and available by calling
Member
Services at 800-251-7722 or by going to
our website www.
connecticare. com. Mail
Order forms are also available by calling
Member
Services. Mail Order follows the
same rules (cost sharing) and provides a
100 day supply for 2X the copay.
Prescription drug benefits continue on next page 31
31 Page 32 33
32 2001 ConnectiCare, Inc. Section 5( f) and 5( g)
Benefit Description
Covered medications and supplies
Here are
some things to keep in mind about our prescription
drug program:
° A generic equivalent will be dispensed if it is available. If you
receive a name brand drug when a Federally-approved generic
drug is
available, you have to pay the difference in cost between
the name brand
drug and the generic.
° We have an open formulary. If your physician believes a name
brand
product is necessary or there is no generic available, your
physician may
prescribe a name brand drug from a formulary list.
This list of name brand
drugs is a preferred list of drugs that we
selected to meet patient needs at
a lower cost. To order a formulary
listing, call 1-800-251-7722.
Not covered:
° Drugs and supplies for cosmetic purposes
° Vitamins, nutrients and food supplements, even if a physician
prescribes or administers them
° Nonprescription medicines
You pay
All Charges
Feature
Services for deaf and
hearing impaired
Description
Call the TDD/ TTY number for the
hearing impaired: 1-800-251-7722.
Section 5 (g). Special Features 32
32
Page 33 34
33
2001 ConnectiCare, Inc. Section 5( h)
Section 5 (h). Non-FEHB
benefits available to Plan members
The benefits on this page are not
part of the FEHB contract or premium, and you cannot file an FEHB disputed
claim about them. Fees you pay for these services do not count toward FEHB
deductibles or out-of-pocket maximums.
Medicare+ Choice plan: We offer this plan for people age 65 or older
and for those who are eligible for Social
Security benefits because of a
disability. To be eligible, you must live in the ConnectiCare service area for
this plan
(Hartford/ New Haven County), be entitled to Medicare Parts A and
be enrolled in Medicare Part B. You must con-tinue
to pay your Medicare Part
B premium.
If you or a family member qualify for coverage, please let us know. You may
also remain enrolled with us.
Medicare will determine who is responsible for
paying for medical services and we will coordinate the payments.
On
occasion, you may need to file a Medicare claim form.
If you are an annuitant or former spouse, you can suspend your FEHB coverage
and enroll in our Medicare+ Choice
plan. For information on suspending your
FEHB enrollment and changing to a our Medicare+ Choice plan, 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. If you involuntarily lose
coverage, or move out of the Medicare+ Choice service area, you may
re-enroll in the FEHB Program at any time.
If you do not have Medicare Part A or B, you can still be covered under the
FEHB Program and your benefits will
not be reduced. We cannot require you to
enroll in Medicare.
For more information on the ConnectiCare65 Medicare+ Choice plan or a free
brochure, call 1-800-883-6565. 33
33 Page 34 35
34 2001
ConnectiCare, Inc. Section 6
Section 6. General exclusionsÑ
things we don't cover
The exclusions in this section apply to all
benefits. Although we may list a specific service as a benefit, we will
not cover it unless your Plan doctor determines it is medically necessary to
prevent, diagnose, or treat your
illness, disease, injury or condition and
we agree, as discussed under "What Services Require Our Prior
Approval" on page 9.
We do not cover the following:
° Care by non-Plan providers except
for authorized referrals or emergencies (see Emergency Benefits);
°
Services, drugs, or supplies you receive while you are not enrolled in this
Plan;
° Services, drugs, or supplies that are not medically necessary;
° Services, drugs, or supplies not required according to accepted
standards of medical, dental, or psychiatric
practice;
° Experimental or investigational procedures, treatments, drugs or
devices;
° Services, drugs, or supplies related to abortions, except
when the life of the mother would be endangered if
the fetus were carried to
term or when the pregnancy is the result of an act of rape or incest;
° Services, drugs, or supplies related to sex transformations;
°
Services, drugs, or supplies you receive from a provider or facility barred from
the FEHB Program; or
° Expenses you incurred while you were not enrolled
in this Plan. 34
34 Page
35 36
35 2001 ConnectiCare, Inc.
Section 7
Section 7. Filing a claim for covered services
In
most cases, providers and facilities file claims for you. Physicians
must
file on the form HCFA-1500, Health Insurance Claim Form.
Facilities will
file on the UB-92 form. For claim questions and assistance,
call us at
1-800-251-7722.
When you must file a claimÑ such as for out-of-area careÑ
submit it
on the HCFA-1500 or a claim form that includes the information
shown below. Bills and receipts should be itemized and show:
°
Covered member's name and ID number;
° Name and address of physician or
facility that provided the service
or supply;
° Dates you received
the services or supplies;
° Diagnosis;
° Type of each service or
supply;
° The charge for each service or supply;
° A copy of the
explanation of benefits, payments, or denial from any
primary payerÑ
such as the Medicare Summary Notice (MSN); and
Receipts, if you paid for
your services.
° Submit your claims to:
Member Services
ConnectiCare, Inc.
30 Batterson Park Road
Farmington, CT 06032-2574
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 administra-tive
operations of
Government or legal incapacity, provided the claim
was submitted as soon as
reasonably possible.
Please reply promptly when we ask for additional information. We
may
delay processing or deny your claim if you do not respond.
Medical, hospital, and drug benefits
Deadline for filing your claim
When we need more information
When you see Plan physicians, receive services at Plan hospitals and
facilities, or obtain your prescription drugs at
Plan pharmacies, you will
not have to file claims. Just present your identification card and pay your
copayment,
coinsurance, or deductible.
You will only need to file a claim when you receive emergency services from
non-plan providers. Sometimes these
providers bill us directly. Check with
the provider. If you need to file the claim, call Member Servicers at 800
251-7722
to obtain an out-of-area claim form. Then, here is the process: 35
35 Page 36 37
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 ñ including a request for pre-authorization:
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: Member Services 30 Batterson
Park Road, Farmington, CT 06032-2574; and
(c) Include a statement about why
you believe our initial decision was wrong, based on specific benefit
provisions in this brochure; and
(d) Include copies of documents that
support your claim, such as physicians' letters, operative reports, bills,
medical records, and explanation of benefits (EOB) forms.
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 denialÐ 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
requestÐ go to step 3.
3 You or your provider must send the information so that we receive it
within 60 days of our request. We will then decide within 30 more days.
If we do not receive the information within 60 days, we will decide within 30
days of the date the information
was due. We will base our decision on the
information we already have.
We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
° 90 days after the date of our letter upholding our initial decision; or
° 120 days after you first wrote to usÑ if we did not answer that
request in some way within 30 days; or
° 120 days after we asked for
additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance
Programs, Contracts Division III,
Branch II, P. O. Box 436, Washington, D.
C. 20044-0436.
Send OPM the following information:
° A statement about why you
believe our decision was wrong, based on specific benefit provisions in this
brochure;
° Copies of documents that support your claim, such as
physicians' letters, operative reports, bills, medical
records, and
explanation of benefits (EOB) forms;
° Copies of all letters you sent to
us about the claim;
° Copies of all letters we sent to you about the
claim; and
° Your daytime phone number and the best time to call.
Note: If you want OPM to review different claims, you must clearly identify
which documents apply to which claim.
Note: You are the only person who has
a right to file a disputed claim with OPM. Parties acting as your
representative,
such as medical providers, must provide a copy of your
specific written consent with the review request.
Note: The above deadlines may be extended if you show that you were unable to
meet the deadline because of
reasons beyond your control.
36 2001 ConnectiCare, Inc. Section 8 36
36
Page 37 38
37
2001 ConnectiCare, Inc. Section 8
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
pre-authorization/ prior approval, then call us at
1-800-251-7722 and we
will expedite our review; or
(b) We denied your initial request for care or pre-authorization/ prior
approval, then:
°° If we expedite our review and maintain our
denial, we will inform OPM so that they can give your claim
expedited
treatment too, or
°° You can call OPM's Health Benefits Contracts
Division III, Branch II at 202/ 606-0737 between 8 a. m. and 5 p. m.
eastern
time.
Step Description 37
37 Page 38 39
38 2001
ConnectiCare, Inc. Section 9
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 cov-erage
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.
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-State 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 is available everywhere in the United
States.
It is the way most people get their Medicare Part A and Part B
benefits. You
may go to any doctor, specialist, or hospital that accepts
Medicare.
Medicare pays its share and you pay your share. Some
things are not covered
under Original Medicare, like prescription drugs.
When you are enrolled in this Plan and Original Medicare, you still
need
to follow the rules in this brochure for us to cover your care.
Your care
must continue to be authorized by your Plan PCP, or precer-tified
as
required.
When Medicare is primary, we will cover what they don't assuming all
other rules have been followed.
When you have other health coverage
° What is Medicare?
°
The Original Medicare Plan
Section 9. Coordinating benefits with other coverage
(Primary payer chart begins on next page.) 38
38 Page 39 40
39 2001 ConnectiCare, Inc. Section 9
The
following chart illustrates whether Original Medicare or this Plan should be the
primary payer for you accord-ing
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 youÑ or your covered
spouseÑ are age 65 or over and... Then the primary payer is
Original
Medicare This Plan
1) Are an active employee with the Federal government (including
when you
or a family member are eligible for Medicare solely
because of a
disability),
2) Are an annuitant,
3) Are a reemployed annuitant with the Federal
government when...
(a) The position is excluded from FEHB,
or.........................................................
(b) The position
is not excluded from
FEHB......................................................................................
Ask your employing office which of these applies to you.
4) Are a Federal judge who retired under title 28, U. S. C., or a Tax
Court judge who retired under Section 7447 of title 26, U. S. C.
(or if
your covered spouse is this type of judge),
5) Are enrolled in Part B only, regardless of your employment status,
(for Part B services) (for other
services)
6) Are a former Federal employee receiving Workers' Compensation
and the
Office of Workers' Compensation Programs has determined (except for claims)
that you are unable to return to duty, related to Workers'
Compensation)
B. When youÑ or a covered family memberÑ have Medicare
based on end stage renal disease (ESRD) and...
1) Are within the first 30 months of eligibility to receive Part A
benefits solely because of ESRD,
2) Have completed the 30-month ESRD coordination period and are
still
eligible for Medicare due to ESRD,
3) Become eligible for Medicare due to ESRD after Medicare became
primary
for you under another provision,
C. When you or a covered family member have FEHB and...
1) Are
eligible for Medicare based on disability,
(a) And are an annuitant or
...................................................................................
(b) And are an active
employee...........................................................................................................
39
39 Page 40 41
40 2001 ConnectiCare, Inc. Section 9
In
most cases, if you inform your provider that your have two cover-ages,
they
will send the claims to the carriers. But, this is something
they do as a
convenience. You are always ultimately responsible to
submit your claims to
the carriers you deal with.
Claims processÐ You probably will never have to file a claim form
when you have both our Plan and Medicare.
° When we are the primary payer, we process the claim first.
°
When Original Medicare is the primary payer, Medicare processes
your claim
first. In most cases, your claims will be coordinated
automatically and we
will pay the balance of covered charges. You
will not need to do anything.
To find out if you need to do something
about filing your claims, call us at
1-800-251-7722.
If you are eligible for Medicare, you may choose to enroll in and get
your Medicare benefits from a Medicare managed care plan. These are
health care choices (like HMOs) in some areas of the country. In most
Medicare managed care plans, you can only go to doctors, specialists,
or
hospitals that are part of the plan. Medicare managed care plans
cover all
Medicare Part A and B benefits. Some cover extras, like pre-scription
drugs.
To learn more about enrolling in a Medicare+ Choice
plan, contact Medicare
at 1-800-MEDICARE (1-800-633-4227) or at
www. medicare. gov. If you enroll
in a Medicare+ Choice plan, the fol-lowing
options are available to you:
This Plan and our Medicare+ Choice plan: You may enroll in our
Medicare+ Choice plan and also remain enrolled in our FEHB plan. In
this
case, we do waive any of our copayments, coinsurance, or
deductibles for
your FEHB coverage because the +Choice plan picks
up the bill.
This Plan and another Plan's Medicare+ Choice plan: You may
enroll
in another plan's Medicare+ Choice plan and also remain
enrolled in our FEHB
plan. We will still provide benefits when your
Medicare+ Choice plan is
primary and will supplement that plan
assuming you went to our providers and
follow our rules..
Suspended FEHB coverage and a Medicare+ Choice plan: If you
are an
annuitant or former spouse, you can suspend your FEHB
coverage and enroll in
a Medicare+ Choice plan. 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.
Note: If you choose not to enroll in Medicare Part B, you can still be
covered under the FEHB Program. We cannot require you to enroll in
Medicare.
TRICARE is the health care program for members, eligible dependents
of
military persons and retirees of the military. TRICARE includes the
CHAMPUS
program. If both TRICARE and this Plan cover you, we
pay first. See your
TRICARE Health Benefits Advisor if you have
questions about TRICARE
coverage.
° Medicare managed care plan
° Enrollment in Medicare Part B
TRICARE 40
40 Page
41 42
41 2001 ConnectiCare, Inc.
Section 9
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
set-tlement
or other similar proceeding that is based on a claim you
filed under OWCP or similar laws.
Once OWCP or similar agency pays its maximum benefits for your
treatment,
we will cover your benefits. You must use our providers.
When you have this Plan and Medicaid, we pay first.
We do not cover
services and supplies when a local, State, or Federal
Government agency
directly or indirectly pays for them.
When you receive money to compensate you for medical or hospital
care for
injuries or illness caused by another person, you must reim-burse
us for any
expenses we paid. However, we will cover the cost of
treatment that exceeds
the amount you received in the settlement.
If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our subroga-tion
procedures.
Workers' Compensation
Medicaid
When other Government agencies are
responsible for
your care
When others are responsible for injuries
41
41 Page 42
43
42 2001 ConnectiCare, Inc. Section 10
Section 10. Definitions of terms we use in this brochure
Calendar
year January 1 through December 31 of the same year. For new enrollees, the
calendar year begins on the effective date of their
enrollment and ends on
December 31 of the same year.
Copayment A copayment is a fixed amount
of money you pay when you receive covered services. See page 10.
Coinsurance Coinsurance is the percentage of our allowance that you
must pay for your care. See page 10.
Covered services Care we provide
benefits for, as described in this brochure.
Custodial care Home
Health Care, light duty services at your home.
Deductible A
deductible is a fixed amount of covered expenses you must incur for certain
covered services and supplies before we start paying
benefits for those
services. See page 10.
Experimental or How do you decide if a service
is experimental or investigational? investigational services ConnectiCare
uses outside medical experts and scientific literature
reviews for
determining whether a medical service is considered
investigational and/ or
experimental.
Group health coverage Health Insurance sold only to group employers
Medical necessity Medical care provided for illness or injury that is
determined by national standards to be Medically Necessary. Like a Mammogram,
etc.
Us/ We Us and we refer to ConnectiCare, Inc.
Yo u You
refers to the enrollee and each covered family member. 42
42 Page 43 44
43 2001 ConnectiCare, Inc. Section 11
We
will not refuse to cover the treatment of a condition that you had
before
you enrolled in this Plan solely because you had the condition
before you
enrolled.
See www. opm. gov/ insure. Also, your employing or retirement office
can
answer your questions, and give you a Guide to Federal
Employees 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.
Self Only coverage is for you alone. Self and Family coverage is for
you,
your spouse, and your unmarried dependent children under age
22, including
any foster children or stepchildren your employing or
retirement office
authorizes coverage for. Under certain circum-stances,
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 fam-ily.
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 fami-ly
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.
The benefits in this brochure are effective on January 1. If you are
new
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.
No pre-existing condition limitation
Where you can get information
about enrolling in the FEHB
Program
Types of coverage available for you and your family
When benefits and premiums start
Section 11. FEHB facts 43
43 Page 44 45
44 2001
ConnectiCare, Inc. Section 11
We will keep your medical and claims
information confidential. Only
the following will have access to it:
° OPM, this Plan, and subcontractors when they administer this con-tract;
° 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, 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 require-ment,
you may be eligible
for other forms of coverage, such as tempo-rary
continuation of coverage
(TCC).
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.
If you are divorced from a Federal employee or annuitant, you may not
continue to get benefits under your former spouse's enrollment. But,
you
may be eligible for your own FEHB coverage under the spouse
equity law. If
you are recently divorced or are anticipating a divorce,
contact your
ex-spouse's employing or retirement office to get RI 70-5,
the Guide to
Federal Employees Health Benefits Plans for Temporary
Continuation of
Coverage and Former Spouse Enrollees, or other
information about your
coverage choices.
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.
Your medical and claims records are confidential
When you retire
When you lose benefits
° When FEHB coverage ends
° Spouse equity coverage
° TCC 44
44 Page 45 46
45 2001 ConnectiCare, Inc. Section
You may
convert to an individual policy if:
°° Your coverage under TCC or
the spouse equity law ends. If you
canceled your coverage or did not pay
your premium, you cannot
convert;
°° You 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.
If you leave the FEHB Program, we will give you a Certificate of
Group
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 cer-tificate
from those plans.
Stop health care fraud! Fraud increases the cost of health care for
everyone. If you suspect that a physician, pharmacy, or hospital has
charged you for services you did not receive, billed you twice for the
same service, or misrepresented any information, do the following:
° Call the provider and ask for an explanation. There may be an error.
° If the provider does not resolve the matter, call us at
1-800-251-
7722 and explain the situation.
° If we do not resolve the
issue, call THE HEALTH CARE FRAUD
HOTLINEÐ 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.
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 administra-tive
action against
you.
° Converting to individual
coverage
Getting a Certificate of Group Health Plan Coverage
Inspector General
Advisory
° Penalties for Fraud 45
45 Page 46 47
46 2001
ConnectiCare, Inc. Index
Accidental injury 26
Allergy tests
15
Alternative treatment 19
Ambulance 27
Anesthesia 23
Autologous bone marrow
transplant 22
Biopsies 20
Birthing
centers 14
Blood and blood plasma 23
Breast cancer screening 13
Casts 20
Catastrophic protection 47
Changes for 2001 6
Chemotherapy 16
Childbirth 14
Cholesterol tests 13
Circumcision
20
Claims 35
Coinsurance 10
Colorectal cancer screening 13
Congenital anomalies 20
Contraceptive devices and drugs 31
Coordination of benefits 38
Covered providers 7
Crutches 18
Deductible 10
Definitions 42
Diagnostic services 13
Disputed claims review 36
Donor expenses (transplants) 22
Dressings
23
Durable medical equipment (DME)
18
Educational classes and
programs 19
Effective date of enrollment 43
Emergency 26
Experimental or investigational 42
Eyeglasses 17
Family
planning 14
Fecal occult blood test 13
General Exclusions 34
Hearing services 17
Home health services 19
Hospice care 25
Home nursing care 19
Hospital 23
Immunizations 13
Infertility 15
Inhospital physician care 20
Inpatient Hospital Benefits 23
Insulin
31
Laboratory and pathological
services 13
Machine
diagnostic tests 12
Magnetic Resonance Imagings
(MRIs) 13
Mail
Order Prescription Drugs 30
Mammograms 13
Maternity Benefits 14
Medicaid 41
Medically necessary 42
Medicare 38
Mental
Conditions/ Substance Abuse
Benefits 28
Neurological testing 12
Newborn care 14
Non-FEHB Benefits 33
Nursery charges 14
Obstetrical care 14
Occupational therapy 16
Ocular injury 12
Office visits 12
Oral and maxillofacial surgery 22
Orthopedic
devices 18
Ostomy and catheter supplies 19
Out-of-pocket expenses 19
Outpatient facility care 24
Oxygen 18
Pap test 13
Physical examination 13
Physical therapy 16
Physician 7
Precertification 23
Preventive care, adult 13
Preventive care,
children 14
Prescription drugs 30
Preventive services 13
Prior
approval 9
Prostate cancer screening 13
Prosthetic devices 18
Psychologist 28
Psychotherapy 28
Radiation therapy 13
Rehabilitation therapies 16
Room and board 23
Skilled nursing
facility care 25
Speech therapy 13
Splints 23
Sterilization procedures 20
Subrogation 41
Substance abuse 28
Surgery 20
Anesthesia 23
Oral 22
Outpatient 24
Reconstructive 21
Syringes 31
Temporary continuation of
coverage 44
Transplants 22
Treatment therapies 16
Vision
services 17
Well child care 14
Wheelchairs 18
Workers'
compensation 41
X-rays 13
Index
Do not rely on this page; it is for your convenience and
does not explain your benefit coverage. 46
46
Page 47 48
47
2001 ConnectiCare, Inc. Summary of benefits
Summary of benefits
for ConnectiCare, Inc.Ñ 2001
° Do not rely on this chart
alone. All benefits are provided in full unless indicated and are subject to
the
definitions, limitations, and exclusions in this brochure. On this page
we summarize specific expenses we cover;
for more detail, look inside.
° If you want to enroll or change your enrollment in this Plan, be sure
to put the correct enrollment code from the
cover on your enrollment form.
° We only cover services provided or arranged by Plan physicians, except
in emergencies.
Benefits
Medical services provided by physicians:
°
Diagnostic and treatment services provided in the office......
Services provided by a hospital:
° Inpatient
.................................................................................
° Outpatient
...............................................................................
Emergency benefits:
°
In-area.....................................................................................
° Out-of-area
.............................................................................
Mental health and substance abuse treatment ..........................
Prescription Drugs
....................................................................
Dental Care
...............................................................................
Vision Care
...............................................................................
Special features:
Services for deaf and hearing impaired
Protection against catastrophic costs
(your out-of-pocket
maximum).................................................
You Pay
Office visit copay:
$10 primary care; $10 specialist
Nothing
Day surgery, Nothing
Walk-In, $20 copay
$40 per
$40 per
$10 copay outpatient
100% inpatient
$10 Generic
$20 Name Brand Formulary
$35 Name Brand Non-Formulary
Cost sharing applies when
generic is available
No benefit
$10 Routine Exam, Discounts
available on eyewear and
contacts
Nothing
You must share the cost of some
services. This is called either a
copayment (a set dollar amount)
or coinsurance (a set percentage
of
charges). Please remember you
must pay this amount when you
receive
services.
Page
11
11
26
28
30
Ñ
17
32
47 47
47 Page
48
High Option
Self Only TE1 $73.73 $24.58 $159.76
$53.25 $87.25 $11.06
High Option
Self + Family TE2 $193.09 $64.36 $418.36 $139.45 $228.49
$28.96
Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type of Code Gov't Your Gov't Your USPS Your Enrollment Share Share
Share Share Share Share
48 2001 ConnectiCare, Inc. 2001 Rate Information
2001 Rate Information for ConnectiCare
Authorized for distribution
by the:
United States Office of
Personnel Management
Non-Postal rates apply to most non-Postal enrollees. If you are in a
special enrollment category, refer to the FEHB
Guide for that category or
contact the agency that maintains your health benefits enrollment
Postal rates apply to most career U. S. Postal Service employees. In
2001, two categories of contribution rates,
referred to as Category A rates
and Category B rates, will apply for certain career employees. If you are a
career
postal employee but not a member of a special postal employment
class, refer to the category definitions in "The
Guide to Federal
Employees Health Benefits Plans for United States Postal Service
Employees," RI 70-2, to deter-mine
which rate applies to you.
Postal rates do not apply to non-career postal employees, postal retirees,
certain special postal employment classes
or associate members of any postal
employee organization. Such persons not subject to postal rates must refer to
the applicable "Guide to Federal Employees Health Benefits
Plans."
All of Connecticut 48