Beacon Health Plans
http://www.beaconhealth.com
2001
A Health Maintenance Organization
For changes in benefits, see page 7.
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Serving: South Florida Area
Enrollment in this Plan is limited; see page 6
for requirements.
Enrollment codes for this Plan:
4K1 Self Only
4K2 Self and Family
Authorized
for distribution by the:
United States
Office of Personnel
Management
Retirement and Insurance
Service
http://www.opm.gov/insure
RI 73-744
Introduction................................................................................... 4
Plain
Language.................................................................................. 4
Section
1. Facts about this HMO plan......................................................................................................................................... 5
How we pay providers................................................................................................................................................. 5
Patients' Bill of Rights.................................................................................................................................................. 5
Service Area.................................................................................................................................................................. 6
Section
2. How we change for
2001.................................................................................. 7
Program-wide changes................................................................................................................................................. 7
Changes to this Plan.................................................................................................................................................... 7
Section
3. How you get care ......................................................................................................................................... 8
Identification cards....................................................................................................................................................... 8
Where you get covered care....................................................................................................................................... 8
Plan providers........................................................................................................................................................ 8
Plan facilities........................................................................................................................................................... 8
What you must do to get
covered care..................................................................................................................... 8
Primary care............................................................................................................................................................ 8
Specialty care......................................................................................................................................................... 8
Hospital care........................................................................................................................................................... 9
Circumstances beyond our
control.......................................................................................................................... 10
Services requiring our prior
approval...................................................................................................................... 10
Section
4. Your
costs for covered services............................................................................................................................... 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....... 22
(c)
Services provided by a hospital or other facility, and
ambulance services........................................... 26
(d)
Emergency services/accidents..................................................................................................................... 29
(e)
Mental health and substance abuse benefits............................................................................................ 31
(f)
Prescription drug benefits............................................................................................................................. 33
(g)
Special features............................................................................................................................................... 35
(h)
Non-FEHB benefits available to Plan members.......................................................................................... 37
Section
6. General exclusions -- things we
don't cover........................................................................................................... 38
Section
7. Filing a claim for covered services............................................................................................................................ 39
Section
8. The disputed claims process..................................................................................................................................... 40
Section
9. Coordinating benefits with other
coverage............................................................................................................. 42
When you have
Other
health coverage.......................................................................................................................................... 42
Original
Medicare................................................................................................................................................. 42
Medicare
managed care plan.............................................................................................................................. 45
TRICARE/Workers'
Compensation/Medicaid....................................................................................................... 45
Other Government agencies...................................................................................................................................... 46
When others are responsible
for injuries................................................................................................................ 46
Section
10. Definitions of terms we use in this
brochure........................................................................................................ 47
Section
11. FEHB facts.................................................................................................................................................................. 49
Coverage information........................................................................................................................................... 49
No
pre-existing condition limitation.......................................................................................................... 49
Where you get information about enrolling in the FEHB Program....................................................... 49
Types of coverage available for you and your family............................................................................ 49
When
benefits and premiums start............................................................................................................ 50
Your
medical and claims records are confidential................................................................................... 50
When you retire........................................................................................................................................... 50
When you lose benefits....................................................................................................................................... 50
When
FEHB coverage ends....................................................................................................................... 50
Spouse equity coverage............................................................................................................................. 50
Temporary Continuation of Coverage (TCC).......................................................................................... 50
Enrolling in TCC........................................................................................................................................... 50
Converting to individual coverage........................................................................................................... 51
Getting a Certificate of Group Health Plan
Coverage............................................................................. 51
Inspector General
advisory: Stop health care fraud!......................................................................................... 51
Index ................................................................................................................................................................................... 52
Summary
of benefits....................................................................................................................................................................... 54
Rates..Back
cover
Beacon Health Plans
2511 Ponce De Leon Boulevard 5th Floor
Coral Gabels, FL 33134
This brochure describes the benefits of Beacon Health Plans
under our contract (CS 2779) with the
Office of Personnel Management (OPM), as authorized by the Federal Employees
Health Benefits law. This brochure is
the official statement of benefits. No
oral statement can modify or otherwise affect the benefits, limitations, and
exclusions of this brochure.
If you are enrolled in this Plan, you are entitled to the
benefits described in this brochure. If
you are enrolled for Self and Family coverage, each eligible family member is
also entitled to these benefits. You do
not have a right to benefits that were available before January 1, 2001, unless
those benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan
annually. Benefit changes are effective
January 1, 2001, and are summarized on page 7.
Rates are shown at the end of this brochure.
The President and Vice President
are making the Governments communication more responsive, accessible, and
understandable to the public by requiring agencies to use plain language. In response, a team of health plan representatives
and OPM staff worked cooperatively to make this brochure clearer. Except for necessary technical terms, we use
common words. You means the enrollee
or family member; " we" means Beacon Health
Plans.
The plain language team reorganized the brochure and the way
we describe our benefits. When you
compare this Plan with other FEHB plans, you will find that the brochures have
the same format and similar information to make comparisons easier.
If you have comments or suggestions about how to improve this
brochure, let us know. Visit OPM's
"Rate Us" feedback area at www.opm.gov/insure or e-mail us at
fehbwebcomments@opm.gov or write to OPM at Insurance Planning and
Evaluation Division, P.O. Box 436, Washington, DC 20044-0436.
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Section 1. Facts about
this HMO plan
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This Plan is a health maintenance organization (HMO). We require you to see specific physicians,
hospitals, and other providers that contract with us. These Plan providers coordinate your health care services.
HMOs emphasize preventive care such as routine office visits,
physical exams, well-baby care, and immunizations, in addition to treatment for
illness and injury. Our providers
follow generally accepted medical practice when prescribing any course of
treatment.
When you receive services from Plan providers, you will not
have to submit claim forms or pay bills.
You only pay the copayments, coinsurance, and deductibles described in
this brochure. When you receive
emergency services from non-Plan providers, you may have to submit claim forms.
You should join an HMO
because you prefer the plans 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. Our providers
compensation include but are not limited to base payment methods (e.g.,
capitation, fee schedule) and additional financial incentives (e.g., bonus,
withhold, etc.).
Patients Bill of
Rights
OPM requires that all FEHB Plans comply with the Patients
Bill of Rights, recommended by the Presidents Advisory
Commission on Consumer Protection and Quality in the Health Care Industry. You may get information about us, ournetworks, providers, and facilities. OPMs 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.
Accreditation Status Accredited by the Accreditation
Association for Ambulatory Health Care, Inc.
Years in existence 4 years
Profit status For Profit
Beacon Health Plans is compliant with State and Federal
licensing, certification and fiscal solvency requirements.
For more information on items listed below call us:
Medical records confidentiality
Provider credentials
Experimental / Investigational medical treatment
approval processes
Customer satisfaction measures
Referral utilization review procedures and processes
Clinical protocols and practice guidelines
Disease management programs
Formulary drug inclusion and exception process
Detailed information about networks and providers
(e.g., education, location, languages spoken, compensation)
If you want more information about us, call 1-800/850-0979, or write to Beacon Health Plans, P.O. Box
14-9080, Coral Gables, FL 33114-9080.
You may also contact us by fax at 305/774-2619 or visit our website at
www.beaconhealth.com.
Service Area
To enroll in this Plan, you
must live in or work in our Service Area. This is where our providers practice. Our Service
Areas are; Dade, Broward and Palm Beach
counties.
Ordinarily, you must get your care from providers who
contract with us. If you receive care
outside our service area, we will pay only for emergency care. We will not pay for any other health care
services.
If you or a covered family member move outside of our service
area, you can enroll in another plan.
If your dependents live out of the area (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. If you or a family member move
away from our service area, you do not have to wait until Open Season to change
plans. Contact your employing or
retirement office.
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Section 2. How we change
for 2001
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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 networkwill be the same with regard to
deductibles, coinsurance, copays, and day and visit limitations when you follow
a treatment plan that we approve.
Previously, we placed shorter day or visit
limitations on mental health and substance abuse services than we did on
services to treat physical illness, injury, or disease.
Many 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 1-800/850-0979,
or writing to Beacon Health Plans,
P.O. Box 14-9080, Coral Gables, FL 33114-9080.
You can find out more about patient safety on the OPM website,
www.opm.gov/insure. To improve your
healthcare, take these five steps:
Speak
up if you have questions or concerns.
Keep
a list of all the medicines you take.
Make
sure you get the results of any test or procedure.
Talk
with your doctor and health care team about your options if you need hospital
care.
Make
sure you understand what will happen if you need surgery.
We clarified the language to show that anyone
who needs a mastectomy may choose to have the procedure performed on an
inpatient basis and remain in the hospital up to 48 hours after the
procedure. Previously, the language
referenced only women.
Changes to this Plan
Your share of the non-Postal
premium will increase by 19.3% for Self Only or 19.5% for Self and Family.
There are no benefit changes.
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Section
3. How you get care
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Identification cards We
will send you an identification (ID) card when you
enroll. You should carry your ID card with you at all times. You must show it whenever you receive
services from a Plan provider, or fill a prescription at a Plan pharmacy. Until
you receive your ID card, use your copy of the Health Benefits Election Form,
SF-2809, your health benefits enrollment confirmation (for annuitants), or your
Employee Express confirmation letter.
If
you do not receive your ID card within 30 days after the effective date of your
enrollment, or if you need replacement cards, call us at 1-800-850-0979.
Where you get covered care You
get care from Plan providers and Plan facilities. You will only pay copayments and you will not have to file
claims.
Plan providers Plan
providers are physicians and other health care professionals in our service
area that we contract with to provide covered services to our members. We credential Plan providers according to
national standards.Our members
receive services from an integrated network of private practice physicians,
specialists, ancillary providers, pharmacies and hospitals. All participating providers must meet our
contracting and credentialling criteria prior to inclusion in the plan. You must choose a primary care physician
from the plans participating provider directory. Primary care physicians include Internal Medicine, Pediatrics,
and others. Please check the section in
the directory for primary care physicians in your area. Any necessary care will be coordinated by
the primary care physician including but not limited to referrals to
specialist, ordering diagnostic testing and admission to a hospital. However, a woman may see her gynecologist
without having to obtain a referral.
We
list Plan providers in the provider directory, which we update periodically.
Plan facilities Plan
facilities are hospitals and other facilities in our service area that we
contract with to provide covered services to our members. We list these in the provider directory,
which we update periodically.
What you must do It
depends on the type of care you need. First, you and each family
to get covered care member
must choose a primary care physician.
This decision is important since your primary care physician provides or
arranges for most of your health care.
Primary
care Your primary care physician can be
a family practitioner, general practitioner,
internist or pediatrician. Your
primary care physician will provide most of your health care, or give you a
referral to see a specialist.
If
you want to change primary care physicians or if your primary care physician
leaves the Plan, call us. We will help
you select a new one.
Specialty care Your
primary care physician will refer you to a specialist for needed care. However, you may see a gynecologist for an
annual well woman visit, podiatrists (limited visits allowed annually),
chiropractors (limited visits allowed annually), and dermatologists (limited
visits allowed annually) without a referral.
Here
are other things you should know about specialty care:
If you need to see a specialist frequently
because of a chronic, complex, or serious medical condition, your primary care
physician will develop a treatment plan that allows you to see your specialist
for a certain number of visits without additional referrals. Your primary care physician will use our
criteria when creating your treatment plan (the physician may have to get an
authorization or approval beforehand).
If you are seeing a specialist when you
enroll in our Plan, talk to your primary care physician. Your primary care physician will decide what
treatment you need. If he or she
decides to refer you to a specialist, ask if you can see your current
specialist. If your current specialist
does not participate with us, you must receive treatment from a specialist who
does. Generally, we will not pay for
you to see a specialist who does not participate with our Plan.
If you are seeing a specialist and your
specialist leaves the Plan, call your primary care physician, who will arrange
for you to see another specialist. You
may receive services from your current specialist until we can make
arrangements for you to see someone else.
If you have a chronic or disabling condition
and lose access to your specialist because we:
terminate our contract with your specialist
for other than cause; or
drop out of the Federal Employees Health
Benefits (FEHB) Program and you enroll in another FEHB Plan; or
reduce our service area and you enroll in
another FEHB Plan,
you
may be able to continue seeing your specialist for up to 90 days after you
receive notice of the change. Contact us or, if we drop
out of the Program. Contact your new plan.
If
you are in the second or third trimester of pregnancy and you lose access to
your specialist based on the above circumstances, you can continue to see your
specialist until the end of your postpartum care, even if it is beyond the 90
days.
Hospital care Your
Plan primary care physician or specialist will make necessary hospital
arrangements and supervise your care.
This includes admission to a skilled nursing or other type of facility.
If
you are in the hospital when your enrollment in our Plan begins, call our
customer service department immediately at 1-800/850-0979. If you are new to the FEHB Program, we will
arrange for you to receive care.
If
you changed from another FEHB plan to us, your former plan will pay for the
hospital stay until:
You are discharged,
not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92nd day after you become a member of
this Plan, whichever happens first.
These provisions apply only to the benefits of
the hospitalized person.
Circumstances beyond our control Under certain extraordinary
circumstances, such as natural disasters, we may have to delay your services or
we may be unable to provide them. In
that case, we will make all reasonable efforts to provide you with the
necessary care.
Services requiring our Your
primary care physician has authority to refer you for most services.
prior approval 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 obtaining a referral. Your physician must obtain a referral before
sending you to a specialist (other than those identified that do not require
referrals), diagnostic services, outpatient services, inpatient services,
extensive treatment plans and any other service that we consider medically
necessary.
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Section
4. Your costs for covered services
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You
must share the cost of some services.
You are responsible for:
Copayments A
copayment is a fixed amount of money you pay when you receive services.
Example: When you see your primary care physician you
pay a copayment of $10 per office visit and when you go in the hospital, you
pay nothing per admission.
Deductible We do not have a deductible.
NOTE: If you change plans during open season, you do not have
to start a new deductible under your old plan between January 1 and the
effective date of your new plan. If you
change plans at another time during the year, you must begin a new deductible
under your new plan.
Coinsurance We do not have coinsurance.
Your out-of-pocket maximum After
your copayments total $1,500 per person or $3,000 per family
for copayments enrollment
in any calendar year, you do not have to pay any more for covered
services. However, copayments for the
following services do not count toward your out-of-pocket maximum, and you must
continue to pay copayments for these services:
Prescription drugs.
Be
sure to keep accurate records of your copayments since you are responsible for
informing us when you reach the maximum.
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5. Benefits -- OVERVIEW
(See page 7 for how our benefits changed this year
and page 54 for a benefits summary.)
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NOTE: This benefits section is divided
into subsections. Please read the
important things you should keep in mind at the beginning of each subsection. Also read the
General Exclusions in Section 6; they apply to the benefits in the following
subsections. To obtain claims
forms, claims filing advice, or more information about our benefits, contact us
at 1-800/850-0979
or at our website at www.beaconhealth.com
(a) Medical
services and supplies provided by physicians and other health care
professionals.......................................... 13-21
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Diagnostic
and treatment services
Lab,
X-ray, and other diagnostic tests
Preventive
care, adult
Preventive
care, children
Maternity
care
Family
planning
Infertility
services
Allergy
care
Treatment
therapies
Rehabilitative
therapies
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Hearing
services (testing, treatment, and supplies)
Vision
services (testing, treatment, and supplies)
Foot
care
Orthopedic
and prosthetic devices
Durable
medical equipment (DME)
Home
health services
Alternative
treatments
Educational
classes and programs
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(b)
Surgical and anesthesia services provided by physicians and
other health care professionals.......................... 22-25
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Surgical
procedures
Reconstructive
surgery
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Oral
and maxillofacial surgery
Organ/tissue
transplants
Anesthesia
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(c) Services
provided by a hospital or other facility, and ambulance services............................................................. 26-28
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Inpatient
hospital
Outpatient
hospital or ambulatory surgical center
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Extended
care benefits/skilled nursing care facility benefits
Hospice
care
Ambulance
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(d) Emergency
services/accidents........................................................................................................................................ 29-30
Medical
emergency Ambulance
(e) Mental
health and substance abuse benefits............................................................................................................... 31-32
(f) Prescription
drug benefits................................................................................................................................................ 33-34
(g) Special
features....................................................................................................................................................................... 36
24 hour nurse line; Services for deaf
and hearing impaired; High risk pregnancies; Centers of excellence for
transplants; Accreditation
(h) Non-FEHB
benefits available to Plan members.................................................................................................................. 37
Summary
of benefits....................................................................................................................................................................... 54
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Section 5
(a) Medical services and supplies provided by physicians and other health
care professionals
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I
M
P
O
R
T
A
N
T
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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 and are payable only when we determine they are
medically necessary.
Plan
physicians must provide or arrange your care.
We have no calendar year
deductible.
Be sure to read Section 4, Your costs for covered services for valuable information about
how cost sharing works. Also read
Section 9 about coordinating benefits with other coverage, including with
Medicare.
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I
M
P
O
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T
A
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Benefit
Description
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You pay
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Diagnostic
and treatment services
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Professional
services of physicians
In physicians
office
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$10
per visit
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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
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$10 per visit
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At home
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Nothing
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Lab, X-ray and other diagnostic tests
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Tests, such as:
Blood
tests
Urinalysis
Non-routine
pap tests
Pathology
X-rays
Non-routine
Mammograms
Cat
Scans/MRI
Ultrasound
Electrocardiogram
and EEG
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Preventive care, adult
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Routine
screenings, such as:
Annual
physical examination
Blood
lead level One annually
Total
Blood Cholesterol once every three years, ages 19 through 64
Colorectal
Cancer Screening, including
Fecal
occult blood test
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$10
per visit
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Sigmoidoscopy, screening every five years
starting at age 50
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$10 per visit
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Prostate
Specific Antigen (PSA test) one annually for men age 40 and older
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$10 per visit
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Routine pap test
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$10 per visit
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Routine mammogram
covered for women age 35 and older, as follows:
From age
35 through 39, one during this five year period
From age
40 through 64, one every calendar year
At age 65
and older, one every two consecutive calendar years
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$10
per visit
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Not
covered: Physical exams required for obtaining or continuing employment or
insurance, attending schools or camp, or travel.
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All charges.
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Routine
Immunizations, limited to:
Tetanus-diphtheria
(Td) booster once every 10 years, ages19 and over (except as provided for
under Childhood immunizations)
Influenza/Pneumococcal
vaccines, annually, age 65 and over
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$10 per visit
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Preventive care, children
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You pay
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Childhood
immunizations recommended by the American Academy of Pediatrics
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$10 per visit
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Preventive care, children (Continued)
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You pay
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Examinations,
such as:
Eye
exams through age 17 to determine the need for vision correction.
Ear
exams through age 17 to determine the need for hearing correction
Examinations
done on the day of immunizations ( through age 22)
Well-child
care charges for routine examinations, immunizations and care (through age
22)
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$10 per visit
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Maternity care
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You pay
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Complete
maternity (obstetrical) care, such as:
Prenatal
care
Delivery
Postnatal
care
Note:
Here are some things to keep in mind:
You
may remain in the hospital up to 48 hours after a regular delivery and 96
hours after a cesarean delivery. We
will extend your inpatient stay if medically necessary.
We
cover routine nursery care of the newborn child during the covered portion of
the mothers 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).
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Nothing
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Not
covered: Routine sonograms to
determine fetal age, size or sex
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All charges
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Family planning
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Voluntary
sterilization
Surgically
implanted contraceptives
Injectable
contraceptive drugs
Intrauterine
devices (IUDs)
Diaphragms
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$10 per visit
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Not
covered: reversal of voluntary
surgical sterilization, genetic counseling,
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All charges.
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Infertility services
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You pay
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Diagnosis
and treatment of infertility, such as:
Artificial insemination:
intravaginal insemination (IVI)
intracervical insemination (ICI)
intrauterine insemination (IUI)
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$10 per visit
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Not covered:
Assisted reproductive technology (ART)
procedures, such as:
in vitro fertilization
embryo transfer and GIFT
Services and supplies related to excluded
ART procedures
Cost of donor sperm
Fertility drugs
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All charges.
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Allergy care
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Testing and treatment
Allergy injection
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$10 per visit
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Allergy serum
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