RI 73-778
Aetna U. S. Healthcare ® 2001 http:// www. aetnaushc. com/ feds
A Health Maintenance Organization
Serving the following states:
Arizona California
Colorado Connecticut
Georgia Illinois
Indiana
Kansas Kentucky
Louisiana Massachusetts
Michigan Missouri
Nevada
New York North Carolina
Ohio Oklahoma
Rhode Island Tennessee
Texas Washington
Enrollment in this Plan is limited; see page 8 for requirements.
Special Notice:
If you live or work in the following states:
Delaware, Georgia, Illinois,
Indiana, Kentucky, Louisiana, Maine, Missouri,
New York, Ohio, Texas,
Virginia or Washington, your services and enrollment
areas may have
changed. Please see page 16 for details.
This brochure includes benefits for Prudential Health Care members
transferred to Aetna U. S. Healthcare.
For changes
in benefits
see page 16. 1
1
Page 2 3
2001 Aetna U. S. Healthcare HMO 2 Table of Contents
Table of Contents
Introduction
...........................................................................................................................................................................
4
Plain Language
......................................................................................................................................................................
4
Section 1. Facts about this HMO
plan..................................................................................................................................
5
How we pay
providers........................................................................................................................................
5
Patients' Bill of Rights
.......................................................................................................................................
6
Service
Area........................................................................................................................................................
8
Section 2. How we change for
2001...................................................................................................................................
16
Program-wide changes
.....................................................................................................................................
16
Changes to this Plan
.........................................................................................................................................
16
Section 3. How you get care
...............................................................................................................................................
20
Identification cards
...........................................................................................................................................
20
Where you get covered
care.............................................................................................................................
20
Plan providers
............................................................................................................................................
20
Plan
facilities..............................................................................................................................................
20
What you must do to get covered
care.............................................................................................................
20
Primary care
...............................................................................................................................................
20
Specialty care
.............................................................................................................................................
20
Hospital care
..............................................................................................................................................
21
Circumstances beyond our control
..................................................................................................................
22
Services requiring our prior approval
..............................................................................................................
22
Section 4. Your costs for covered
services.........................................................................................................................
23
Copayments................................................................................................................................................
23
Deductible
..................................................................................................................................................
23
Coinsurance................................................................................................................................................
23
Your out-of-pocket maximum
.........................................................................................................................
23
Section 5.
Benefits...............................................................................................................................................................
24
Overview...........................................................................................................................................................
24
(a) Medical services and supplies provided by physicians and
other
health care
professionals..............................................................................................................
25
(b) Surgical and anesthesia services provided by physicians and
other
health care
professionals..............................................................................................................
32
(c) Services provided by a hospital or other facility, and ambulance
services......................................... 35
(d) Emergency services/
accidents
..............................................................................................................
37
(e) Mental health and substance abuse
benefits.........................................................................................
40
(f) Prescription drug benefits
.....................................................................................................................
42
(g) Special
features......................................................................................................................................
45 2
2 Page 3 4
2001 Aetna U. S. Healthcare HMO 3 Table of Contents
(h)
Dental
benefits.......................................................................................................................................
46
(i) Non-FEHB benefits available to Plan members
..................................................................................
49
Section 6. General exclusions Ñ things we
don't cover
...................................................................................................
50
Section 7. Filing a claim for covered services
...................................................................................................................
51
Section 8. The disputed claims
process..............................................................................................................................
52
Section 9. Coordinating benefits with other
coverage
.......................................................................................................
54
When you haveÉ
Other health coverage
..............................................................................................................................
54
Original Medicare
....................................................................................................................................
54
Medicare managed care plan
...................................................................................................................
56
TRICARE/ Workers' Compensation/ Medicaid
...............................................................................................
56
Other Government
agencies.............................................................................................................................
57
When others are responsible for injuries
.........................................................................................................
57
Section 10. Definitions of terms we use in this
brochure
..................................................................................................
59
Section 11. FEHB
facts.......................................................................................................................................................
62
Coverage
information.......................................................................................................................................
62
No pre-existing condition limitation
.......................................................................................................
62
Where you get information about enrolling in the FEHB
Program....................................................... 62
Types of
coverage available for you and your family
............................................................................ 62
When benefits and premiums start
..........................................................................................................
63
Your medical and claims records are
confidential..................................................................................
63
When you
retire........................................................................................................................................
63
When you lose benefits
....................................................................................................................................
63
When FEHB coverage
ends.....................................................................................................................
63
Spouse equity coverage
...........................................................................................................................
63
Temporary Continuation of Coverage
(TCC).........................................................................................
63
Enrolling in
TCC......................................................................................................................................
63
Converting to individual coverage
..........................................................................................................
64
Getting a Certificate of Group Health Plan
Coverage............................................................................
64
Inspector General Advisory
............................................................................................................................
64
Department of Defense/ FEHB Demonstration
Project......................................................................................................
66
Index
....................................................................................................................................................................................
68
Summary of benefits
...........................................................................................................................................................
70
Rates.....................................................................................................................................................................................
71 3
3 Page 4 5
2001 Aetna U. S. Healthcare HMO 4
Introduction/ Plain Language
Introduction
Aetna U. S.
Healthcare, Inc.
1425 Union Meeting Road
P. O. Box 1126, Mail Stop U32A
Blue Bell, PA 19422
This brochure describes the benefits you can receive from Aetna U. S.
Healthcare under our contract (CS 2836) 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 these
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 16. Rates are
shown at the end of this brochure.
Plain language
The President and Vice President are making the
Government's communication more responsive, accessible, and
understandable
to the public by requiring agencies to use plain language. In response, a team
of health plan
representatives and OPM staff worked cooperatively to make
this brochure clearer. Except for necessary technical
terms, we use common
words. "You" means the enrollee or family member; "we" means
Aetna U. S. Healthcare.
The plain language team reorganized the brochure and the way we describe our
benefits. When you compare this Plan
with other FEHB plans, you will find
that the brochures have the same format and similar information to make
comparisons easier.
If you have comments or suggestions about how to improve this brochure, let
us know. Visit OPM's "Rate Us"
feedback area at www. opm. gov/
insure or e-mail us at fehbwebcomments@ opm. gov or write to OPM at Insurance
Planning and Evaluation Division, P. O. Box 436, Washington, DC 20044-0436.
4
4 Page 5 6
2001 Aetna U. S. Healthcare HMO 5 Section 1
Section 1. Facts about this HMO plan
This Plan is a health
maintenance organization (HMO). We require you to see specific physicians,
hospitals, and other
providers that contract with us. These Plan providers
coordinate your health care services.
HMOs emphasize preventive care such as routine office visits, physical exams,
well-baby care, and immunizations, in
addition to treatment for illness and
injury. Our providers follow generally accepted medical practice when
prescribing
any course of treatment.
When you receive services from participating providers, you will not have to
submit claim forms or pay bills. You only
pay the copayments, coinsurance,
and deductibles described in this brochure. When you receive emergency services
from non-Plan providers, you may have to submit claim forms.
You should join an HMO because you prefer the plan's benefits, not because
a particular provider is available.
You cannot change plans because a
provider leaves our Plan. We cannot guarantee that any one physician,
hospital, or other provider will be available and/ or remain under contract
with us.
How we pay providers ° Provider Compensation 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.
This is a direct contract prepayment Plan, which means that participating
providers are neither agents nor employees of the Plan. Rather, they are
independent doctors and providers who practice in their own offices or
facilities. The Plan arranges with licensed providers and hospitals to
provide medical services for both the prevention of disease and the
treatment of illness and injury for benefits covered under the Plan.
Plan providers in our network have agreed to be compensated in
various
ways. Many participating primary care physicians (PCPs) are
paid by
capitation. Under capitation, a physician receives payment for a
patient
whether the physician sees the patient that month or not.
Specialists, hospitals, primary care physicians and other providers in
the Aetna U. S. Healthcare network may also be paid in the following
ways:
Per individual service (fee-for-service at contracted rates),
Per
hospital day (per diem contracted rates),
Under other capitation methods (a
certain amount per member, per month), and
By Integrated Delivery Systems (" IDS"), Independent Practice
Associations (" IPAs"), Physician Medical Groups (" PMGs"),
Physician
Hospital Organizations (" PHOs"), behavioral health
organizations
and similar provider organizations or groups that are paid by
Aetna
U. S. Healthcare; the organization or group pays the physician or
facility
directly. In such arrangements, that group or organization has a
financial incentive to control the costs of providing care.
You are encouraged to ask your physicians and other providers how
they
are compensated for their services, including whether their specific
arrangements include any financial incentives to control costs. 5
5 Page 6 7
2001 Aetna U. S. Healthcare HMO 6 Section 1
Patients' Bill of Rights OPM requires that all FEHB Plans comply
with the Patients' Bill of Rights, recommended by the President's Advisory
Commission on Consumer Protection and Quality in the HealthCare Industry.
You may get information about us, or 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.
Medical Necessity
Covered services include most types of treatment
by PCPs, specialists and hospitals. However, the health plan also
excludes
or limits coverage for some services, including but not limited to cosmetic
surgery and experimental
procedures. In addition, in order to be covered,
all services, including the location (type of facility), duration and costs
of services, must be medically necessary as defined in this Plan and as
determined by us. (See definition on Page 60.)
Direct Access Ob/ Gyn Program
This program allows female members
to visit any participating gynecologist for a routine well-woman exam, including
a Pap smear (if appropriate) and an unlimited number of visits for
gynecologic problems and follow-up care as
described in your benefits plan.
Gynecologists may also refer a woman directly for covered gynecologic services
without the patient's having to go back to her participating primary care
physician. If your Ob/ Gyn is part of an
Independent Practice Association
(IPA), a Physician Medical Group (PMG) or a similar organization, covered care
must
be coordinated through the IPA, the PMG or the similar organization.
Mental Health/ Substance Abuse
In most areas, certain behavioral
health care services (e. g., treatment or care for mental disease or illness,
alcohol abuse
and/ or substance abuse) are managed by an independently
contracted organization. This organization makes initial
coverage
determinations and coordinates referrals; any behavioral health care referrals
will generally be made to
providers affiliated with the organization, unless
your needs for covered services extend beyond the capability of the
affiliated providers. You can receive information regarding the appropriate
way to access the behavioral health care
services that are covered under
your specific plan by calling Member Services at 1-800-537-9384. As with other
coverage determinations, you may appeal behavioral health care coverage
decisions in accordance with the provisions
of your Plan.
Ongoing Reviews
We conduct ongoing reviews of those services and
supplies which are recommended or provided by health
professionals to
determine whether such services and supplies are covered benefits under this
Plan. If we determine
that the recommended services and supplies are not
covered benefits, you will be notified. If you wish to appeal such
determination, you may then contact us to seek a review of the
determination.
Authorization
Certain services and supplies under this Plan may
require authorization by us to determine if they are covered benefits
under
this Plan.
Patient Management
We have developed a patient management program
to assist in determining what health care services are covered under
the
health plan and the extent of such coverage. The program assists members in
receiving the appropriate health care
and maximizing coverage for those
health care services.
Only medical directors make decisions denying coverage for services for
reasons of medical necessity. Coverage denial
letters delineate any unmet
criteria, standards and guidelines, and inform the provider and member of the
appeal
process.
Our patient management staff uses national guidelines and resources to guide
the precertification, concurrent review and
retrospective review processes.
Using the information obtained from providers, patient management staff utilize
Milliman & Robertson Health Care Management Guidelines when conducting
concurrent review. If there is no
applicable Milliman & Robertson
Guideline, patient management staff utilizes InterQual ISD criteria. When
applicable,
Medicare National Coverage Decisions are followed for Medicare
managed care members. To the extent certain patient
management functions are
delegated to integrated delivery systems, independent practice associations or
other provider
groups (" Delegates"), such Delegates utilize
criteria that they deem appropriate. 6
6 Page 7 8
2001 Aetna U. S.
Healthcare HMO 7 Section 1
Precertification Certain health
care services, such as hospitalization or outpatient surgery, require
precertification by us to ensure coverage for those services. When
a member
is to obtain services requiring precertification through a Plan
provider,
this provider should precertify those services prior to treatment.
Concurrent Review The concurrent review process assesses the necessity
for continued stay, level of care, and quality of care for members receiving
inpatient services.
All inpatient services extending beyond the initial certification period will
require Concurrent Review.
Discharge Planning Discharge planning may be initiated at any stage of
the patient management process and begins immediately upon identification of
post-discharge
needs during precertification or concurrent review. The
discharge plan
may include initiation of a variety of services/ benefits to be
utilized by
the member upon discharge from an inpatient stay.
Retrospective Record Review The purpose of retrospective review is to
retrospectively analyze potential quality and utilization issues, initiate
appropriate follow-up action based on
quality or utilization issues, and review all appeals of inpatient concurrent
review decisions for coverage and payment of health care services. Our
effort to manage the services provided to members includes the
retrospective review of claims submitted for payment, and of medical
records submitted for potential quality and utilization concerns.
Member Services
Representatives from Member Services are trained
to answer your questions and to assist you in using the Aetna
U. S.
Healthcare plan properly and efficiently. After you receive your ID card, you
can call the Member Services toll-free
number on the card when you need to:
Ask questions about benefits and coverage.
Notify us of changes in your
name, address or telephone number.
Change your primary care physician or
office.
Obtain information about how to file a grievance.
Confidentiality
We protect the privacy of confidential Plan member
medical information. We contractually require that participating
providers
keep member information confidential in accordance with applicable laws.
Furthermore, you have the right to
access you medical records from
participating providers, at any time. Aetna U. S. Healthcare (including its
affiliates and
authorized agents, collectively (" Aetna U. S.
Healthcare") and participating providers require access to member medical
information for a number of important and appropriate purposes, including
claims payment, fraud prevention,
coordination of care, data collection,
performance measurement, fulfilling state and federal requirements, quality
management, utilization review, research and accreditation activities,
preventive health, early detection and disease
management programs.
Accordingly, for these purposes, members authorize the sharing of member medical
information
about themselves and their dependents between Aetna U. S.
Healthcare and Plan providers and health delivery systems.
If you want more information about us, call 1-800-537-9384, or write to 1425
Union Meeting Road, P. O. Box 1126,
Mail Stop U32A, Blue Bell, PA 19422. You
may also contact us by fax at 215-775-6550 or visit our website at
www.
aetnaushc. com/ feds. 7
7 Page 8 9
2001 Aetna U. S.
Healthcare HMO 8 Section 1
Service Area What is this Plan's
service
area?
To enroll with us, you must live or work in our
service area. This is where our
providers practice. Our service area is:
Arizona
2/ 99
This service has Commendable
accreditation from the NCQA.
See the FEHB Guide for more
information on NCQA.
Serving: Phoenix and Tucson areas
Enrollment Code:
WQ1 Self Only
WQ2 Self and Family
Cochise, Graham, Maricopa, Pima, Santa Cruz, Yavapai and Yuma counties and
portions of Pinal as defined by the towns of Apache Junction and Casa Grande
California
9/ 99
This service has Commendable
accreditation from the NCQA.
See the FEHB Guide for more
information on NCQA.
Serving: Northern California area
Enrollment Code:
BU1 Self Only
BU2 Self and Family
Alameda, Contra Costa, Fresno, Madera, Marin, Napa, Sacramento, San
Francisco,
San Mateo, Santa Clara, Santa Cruz, Solano, Sonoma, Stanislaus
and Yolo
counties and portions of El Dorado, Kings, Merced, Placer, San
Joaquin, and
Tulare counties defined by listed towns:
El Dorado: El Dorado Hills, Garden Valley, Lotus, Pilot Hill, Rescue, Shingle
Springs
Kings: Armona, Avenal, Corcoran, Hanford, Kettleman City, Lemoore, Lemoore
Naval Air Station, Stratford
Merced: Atwater, Ballico, Delhi, El Nido, Gustine, Hilmar, Le Grand,
Livingston,
Los Banos, Merced, Snelling, Stevinson, Winton
Placer: Applegate, Auburn, Colfax, Dutch Flat, Forest Hill, Lincoln, Loomis,
Meadow Vista, Newcastle, Penryn, Rocklin, Roseville, Weimar
San Joaquin: Lathrop, Linden, Menteca, Ripon, Stockton, Tracy
Tulare:
Alpaugh, Badger, California Hot Springs, Cutler, Dinuba, Ducor, Exeter,
Farmersville, Goshen, Ivanhoe, Lemon Cove, Lindsay, Orosi, Porterville,
Posey,
Richgrove, Springville, Strathmore, Sultana, Terra Bella, Three
Rivers, Tipton,
Traver, Tulare, Visalia, Waukema, Woodlake
5/ 00
This service has Commendable
accreditation from the NCQA.
See the FEHB Guide for more
information on NCQA.
Serving: Southern California area
Enrollment Code:
2X1 Self Only
2X2 Self and Family
Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa
Barbara
and Ventura counties 8
8 Page 9 10
2001 Aetna U. S.
Healthcare HMO 9 Section 1
Colorado Serving: The Front Range
area
Enrollment Code:
6F1 Self Only
6F2 Self and Family
Adams, Arapahoe, Boulder, Denver, Douglas, El Paso, Elbert, Fremont,
Jefferson,
Larimer, Mesa, Pueblo, and Teller counties
Connecticut
11/ 99
This service has Commendable
accreditation from the NCQA.
See the FEHB Guide for more
information on NCQA.
Serving: All of Connecticut
Enrollment Code:
H11 Self Only
H12
Self and Family
The State of Connecticut
Georgia Serving: The Atlanta, Athens and Augusta areas
Enrollment
Code:
2U1 Self Only
2U2 Self and Family
Barrow, Bartow, Burke, Butts, Cherokee, Clarke, Clayton, Cobb, Columbia,
Coweta, Dawson, Dekalb, Douglas, Fayette, Forsyth, Fulton, Glascock,
Gwinnett,
Hall, Haralson, Heard, Henry, Jackson, Lamar, Lincoln, Madison,
McDuffie,
Newton, Oconee, Oglethorpe, Paulding, Pickens, Pike, Richmond,
Rockdale,
Spalding, Taliaferro, Walton, Warren and Wilkes Counties
Illinois
4/ 00
This service has Commendable
accreditation from the NCQA.
See the FEHB Guide for more
information on NCQA.
Serving: The Chicago area
Enrollment Code:
XC1 Self Only
XC2
Self and Family
Cook, DuPage, Kane, Lake, McHenry and Will counties
Serving: The Metropolitan St. Louis area
Enrollment Code:
D41 Self
Only D42 Self and Family
Madison and St. Clair counties 9
9 Page 10 11
2001 Aetna U.
S. Healthcare HMO 10 Section 1
Indiana Serving: Lake and
Porter counties
Enrollment Code:
XC1 Self Only
XC2 Self and Family
Lake and Porter counties
Serving: Southern Indiana area
Enrollment Code:
7L1 Self Only
7L2 Self and Family
Clark, Floyd, Harrison, Scott and Washington counties
Serving: Southeastern Indiana area
Enrollment Code:
RD1 Self Only
RD2 Self and Family
Dearborn, Franklin, Ohio and Switzerland counties
Kansas Serving: Kansas City Metropolitan area
Enrollment Code:
7K1
Self Only
7K2 Self and Family
Douglas, Franklin, Johnson, Leavenworth, Miami and Wyandotte counties
Kentucky Serving: Lexington and Louisville areas
Enrollment Code:
7L1 Self Only
7L2 Self and Family
Anderson, Bourbon, Bullitt, Clark, Fayette, Franklin, Hardin, Harrison,
Henry,
Jefferson, Jessamine, Larue, Madison, Meade, Nelson, Oldham, Owen,
Scott,
Shelby, Spencer, Trimble, and Woodford counties
Serving: Northern Kentucky area
Enrollment Code:
RD1 Self Only
RD2 Self and Family
Boone, Campbell, Gallatin, Grant, Kenton and Pendleton counties 10
10 Page 11 12
2001 Aetna U. S. Healthcare HMO 11 Section 1
Louisiana
3/ 98
This service has Commendable
accreditation from the NCQA.
See the FEHB Guide for more
information on NCQA.
Serving: The Baton Rouge, Lafayette, and New Orleans area
Enrollment
Code:
NG1 Self Only
NG2 Self and Family
The parishes of Assumption, Jefferson, Lafourche, Orleans, Plaquemines,
St. Bernard, St. Charles, St. James, St. John the Baptist, St. Tammany,
Terrebone
Baton Rouge area: The parishes of Ascension, Beauregard, Calcasieu, East
Baton
Rouge, East Feliciana, Jefferson Davis, Iberville, Livingston, Pointe
Coupee,
St. Helena, Tangipahoa, West Baton Rouge and West Feliciana
Lafayette area: The parishes of Acadia, Evangeline, Iberia, Lafayette, St.
Landry,
St. Mary, St. Martin and Vermilion
Massachusetts
5/ 00
This service has Commendable
accreditation from the NCQA.
See the FEHB Guide for more
information on NCQA.
Serving: Eastern/ Central Massachusetts and Hampden County areas
Enrollment Code:
NE1 Self Only
NE2 Self and Family
The Boston area, including the counties of Barnstable, Bristol, Essex,
Franklin,
Hampden, Hampshire, Middlesex, Norfolk, Plymouth, Suffolk, and
Worcester
counties
Michigan Serving: The Greater Detroit Metropolitan area
Enrollment
Code:
8Z1 Self Only
8Z2 Self and Family
The Detroit area, including Wayne county and portions of Monroe and Oakland
counties as defined by listed towns
Oakland: Avon Township, Berkeley (City), Birmingham (City), Bloomfield Hills
(City), Bloomfield Township, Clawson (City), Commerce Township, Farmington
Hills (City), Farmington Township, Ferndale (City), Hazel Park (City),
Highland
Township, Huntington Woods (City), Independence Township, Keego
Harbor (City),
Lake Orion Village, Lathrup Village (City), Madison Heights
(City), Novi (City),
Oak Park (City), Orchard Lake Village, Orion Township,
Oxford (City), Pontiac
(City), Pontiac Township, Rochester (City), Royal Oak
(City), Southfield (City),
Southfield Township, Troy (City), West Bloomfield
Township, Walled Lake (City),
Waterford Township, Whitelake Township, Wixom
(City), Wolverine Lake (City)
Monroe: Ash, Bedford, Berlin, Dundee, Erie, Exeter, Frenchtown, Ida, LaSalle,
London, Kaiserville, Summerfield and the cities of Monroe, Luna Pier and
Petersburg. 11
11 Page
12 13
2001 Aetna U. S. Healthcare HMO
12 Section 1
Missouri Serving: Metropolitan Kansas City area
Enrollment Code:
7K1 Self Only
7K2 Self and Family
Buchanan, Cass, Clay, Jackson, Lafayette, Platte and Ray counties
Serving: Metropolitan St. Louis area
Enrollment Code:
D41 Self
Only
D42 Self and Family
Jefferson, St. Charles, St. Louis City, and St. Louis counties
Nevada Serving: Southern Nevada and Las Vegas area
Enrollment Code:
8L1 Self Only
8L2 Self and Family
Clark county
New York
5/ 98
This service has Commendable
accreditation from the NCQA.
See the FEHB Guide for more
information on NCQA.
Serving: New York City area
Enrollment Code:
JC1 Self Only
JC2
Self and Family
Bronx, Dutchess, Kings (Brooklyn), Nassau, New York (Manhattan), Orange,
Putnam, Queens, Richmond (Staten Island), Rockland, Suffolk, Sullivan,
Ulster,
and Westchester counties
Serving: Syracuse and Binghamton areas
Enrollment Code:
TG1 Self
Only
TG2 Self and Family
Broome, Cayuga, Onandoga, Oswego and Tioga counties
North Carolina Serving: The Charlotte/ Metrolina and Raleigh/ Durham areas
Enrollment Code:
3G1 Self Only
3G2 Self and Family
Cabarrus, Durham, Gaston, Iredell, Lincoln, Mecklenberg, Orange, Rowan,
Stanly,
Union and Wake counties 12
12 Page 13 14
2001 Aetna U.
S. Healthcare HMO 13 Section 1
Ohio
4/ 99
This
service has Commendable
accreditation from the NCQA.
See the FEHB
Guide for more
information on NCQA.
Serving: Greater Cincinnati area
Enrollment Code:
RD1 Self Only
RD2 Self and Family
Adams, Brown, Butler, Champaign, Clark, Clermont, Clinton, Greene, Hamilton,
Highland, Logan, Miami, Montgomery, Preble, Shelby and Warren.
Serving: Cleveland and Toledo areas
Enrollment Code:
7D1 Self Only
7D2 Self and Family
Allen, Ashland, Ashtabula, Carroll, Crawford, Cuyahoga, Erie, Geauga,
Hancock,
Hardin, Henry, Holmes, Lake, Lorain, Lucas, Mahoning, Medina,
Ottawa, Portage,
Putnam, Richland, Sandusky, Seneca, Stark, Summit,
Trumbull, Tuscarawas and
Wayne counties and portions of the following
counties defined by listed towns:
Auglaize: Minster, New Bremen, New Hampshire, New Knoxville, Saint John's,
Saint Mary's, Uniopolis, Wapakoneta, and Waynesfield
Columbiana: Beloit, Columbiana, East Rochester, East Palinstine, Elkton,
Hanoverton, Homeworth, Kensington, Leetonia, Libson, Minerva, Negley,
New Waterford, North Georgetown, Rogers, Salem, Salineville,
Washingtonville,
West Point, and Winona
Fulton: Metamora and Swanton
Huron: Collins, Greenwich, Huron, New
London, and Wakeman
Wood: Grand Rapids, Haskins, Millbury, Northwood,
Perrysburg, Rossford,
Stony Ridge, and Walbridge
Serving: Columbus area
Enrollment Code:
7J1 Self Only
7J2 Self
and Family
Coshocton, Delaware, Fairfeld, Fayette, Franklin, Guernsey, Hocking, Knox,
Licking, Madison, Marion, Morgan, Morrow, Muskingum, Nobel, Perry,
Pickaway, Pike, Ross, Scioto and Union counties. 13
13 Page 14 15
2001 Aetna U. S. Healthcare HMO 14 Section 1
Oklahoma Serving: Northeast Oklahoma, Oklahoma City and surrounding
area
Enrollment Code:
8V1 Self Only
8V2 Self and Family
Cleveland, Oklahoma, Pottawatomie, Rogers and Tulsa counties and portions of
the following counties defined by listed towns:
Canadian: Concho, El Reno, Mustang, Piedmont, Union City, and Yukon
Creek: Kellyville, Kiefer, Mounds, Sapulpa
Grady: Amber, Minco, and
Tuttle
Lincoln: Fallis, Jacktown, Meeker, Midway, Payson, Sparks, and
Wellston
Logan: Cedar Valley, Coyle, Guthrie, Meridian, Mulhall, Navina, and
Seward
McClain: Blanchard, Byars, Cole, Criner, Dibble, Goldsby, Newcastle,
Purcell,
Rosedale, and Washington
Osage: Skiatook, Osage, Prue
Wagoner: Choska, Coweta, Fair Oaks, New
Tulsa, Oneta
Rhode Island Serving: All of Rhode Island
Enrollment Code:
5U1
Self Only
5U2 Self and Family
The State of Rhode Island
Tennessee Serving: Nashville and Middle Tennessee areas
Enrollment
Code:
6J1 Self Only
6J2 Self and Family
Bedford, Cannon, Cheatham, Coffee, Davidson, Dekalb, Dickson, Franklin,
Giles,
Hickman, Humphreys, Lawrence, Lewis, Lincoln, Macon, Marshall, Maury,
Moore, Perry, Robertson, Rutherford, Smith, Sumner, Trousdale, Wayne,
Williamson, and Wilson counties 14
14 Page 15 16
2001 Aetna U.
S. Healthcare HMO 15 Section 1
Texas
2/ 98
This
service has Commendable
accreditation from the NCQA.
See the FEHB
Guide for more
information on NCQA.
Serving: Houston area
Enrollment Code:
5B1 Self Only
5B2 Self
and Family
Brazoria, Chambers, Ft. Bend, Galveston, Grimes, Harris, Jefferson, Liberty,
Matagorda, Montgomery, San Jacinto, Walker, Waller, and Wharton counties
Serving: San Antonio area
Enrollment Code:
8X1 Self Only
8X2
Self and Family
Bexar, Comal, Guadelupe and Kendall counties
Washington Serving: Western and Southeast Washington areas
Enrollment
Code:
8J1 Self Only
8J2 Self and Family
Columbia, King, Kitsap, Pierce, Snohomish and Walla Walla counties. 15
15 Page 16 17
2001 Aetna U. S. Healthcare HMO 16 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 coinsurance, copays, and day and visit
limitations when you follow a treatment plan that we approve. Previously,
higher cost sharing and shorter day
limitations were placed 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 Customer Service at 1-800-537-9384, or
checking our website at www. aetnaushc. com/ feds. 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 If you are enrolled in Prudential Healthcare
HMO-Midwest enrollment Code S3 in Indiana, Ohio and Kentucky,
your enrollment will automatically be transferred into Aetna U. S. Healthcare
enrollment Code RD. Please review this
brochure for your benefits.
If you are enrolled in Prudential Healthcare HMO enrollment Code S3 and live
or work in Ripley and Union counties
in Indiana, in Bracken, Carroll
and Mason counties in Kentucky, in Drake county Ohio, you must
select another
Plan under the FEHB Program. The Plan is eliminating these
counties from its service area. If you do nothing, you
will only have
benefits for emergency care and you must travel to the Plan's service area for
other covered services.
See page 8.
If you are enrolled in Prudential Healthcare HMO-New York enrollment Code 9P
in New York City, Long Island,
Hudson Valley counties, New York, your
enrollment will automatically be transferred into Aetna U. S. Healthcare
enrollment Code JC. Please review this brochure for your benefits.
If you are enrolled in Prudential Healthcare HMO-Atlanta enrollment Code EZ
in Georgia, your enrollment will
automatically be transferred into
Aetna U. S. Healthcare enrollment Code 2U. Please review this brochure for your
benefits.
If you are enrolled in Prudential Healthcare HMO enrollment Code UP and VX in
Texas, your enrollment will
automatically be transferred into Aetna
U. S. Healthcare enrollment Codes 5B and 8X, respectfully. Please review this
brochure for your benefits.
If you are enrolled in Code NK in Delaware, your enrollment will be
automatically transferred to the Plan enrollment
Code SU, High Option.
However, you may change to a Standard Option enrollment during Open Season. See
the
Plan's Federal Brochure (RI-73-052) for a complete description. 16
16 Page 17 18
2001 Aetna U. S. Healthcare HMO 17 Section 2
If you are enrolled in Code RD in Indiana, Kentucky, and Ohio, it
will split into four; 7D, 7J, 7L while retaining
RD. Your enrollment will be
automatically transferred into code 7J. If you do nothing, your benefits will
not change;
however, you will pay a higher rate. See page 13 for the Plan's
new enrollment code and service area description.
If you are enrolled in Code 6T in Missouri and Illinois, the
Plan redefined the service area and you must select
another code under this
Plan or another Plan under the FEHB Program. See page 12 for Plan's new
enrollment code
serving these areas.
If you are enrolled in Code TK in Baton Rouge, Louisiana, your
enrollment will be automatically transferred into
Code NG that serves Baton
Rouge, Lafayette and New Orleans areas. We are merging the two codes into one
service
area. See page 11 for a complete description.
If you are enrolled in Code Z1 in Richmond, Virginia, your enrollment
will be automatically transferred to the Plan
enrollment Code XE High
Option. However, you may change to a Standard Option enrollment during Open
Season.
See the Plan's Federal brochure RI-73-052 for a complete
description.
If you are enrolled in Code TS and live or work in Dallas/ Fort Worth,
Texas areas, you must select another Plan
under the FEHB Program. The
Dallas/ Fort Worth area is being eliminated from the Plan's service. If you do
not
change to another Plan during Open Season you will not have benefits in
2001.
If you are enrolled in Code 9M and live or work in Maine, you must
select another Plan under the FEHB Program.
Maine is being eliminated from
the Plan's service area. If you do not change to another Plan during Open Season
you
will not have benefits in 2001.
If you are enrolled in Code 2U and live or work in the Macon, Georgia
area, you must select another Plan under the
FEHB Program. Macon area is
being eliminated from the Plan's service area. If you do nothing you will only
have
benefits for emergency care and you must travel to the Plan's service
area for other covered services. See page 9.
If you are enrolled in Code 8J and live or work in Lewis and Thurston
counties or the cities of Port Angeles, Sequim,
Anacortes in Western
Washington, you must select another Plan under the FEHB Program. The Plan
is eliminating
these counties and cities from its service area. If you do
nothing, you will only have benefits for emergency care and
you must travel
to the Plan's service area for other covered services. See page 15.
The Plan expanded its service area in New York and added TG as a new
enrollment Code. Enrollment Code TG
serves the following New York counties:
Broome, Cayuga, Onondaga, Owsego, and Tioga. See page 12. The Plan
expanded
its service area for enrollment Code NG by adding the following Louisiana
parishes: Baton Rouge parishes
of Ascension, East Baton Rouge, East
Feliciana, Iberville, Livingston, Point Coupee, St. Helena, Tangipahoa, West
Baton Rouge, and West Feliciana; Lafayette area parishes of Evangeline,
Liberia, Lafayette, St. Landry, St. Mary,
St. Martin, Beauregard, Calcasieu,
Jefferson Davis, and the following parishes are increasing from partial to full:
Acadia, Assumption, Plaquemines, St. James, Terrebonne, Washington and
Vermilion. See page 12.
The Plan expanded its Georgia service area by adding Wilkes county.
See page 9.
The Plan expanded its Colorado service area by adding
Mesa county. See page 9.
The Plan expanded its Michigan service area
by adding the following portions of Monroe county: Ash, Bedford,
Berlin,
Dundee, Erie, Exeter, Frenchtown, Ida, LaSalle, London, Kaiserville, Summerfield
townships and the cities of
Monroe, Luna Pier and Petersburg. See page 11.
The Plan expanded its Indiana service area by adding the following
counties: Owen, Pendleton, Gallatin, Franklin
and Bourbon. See page 10.
The Plan expanded its Ohio service area by adding the following
counties: Hancock, Hardin, Henry, Sandusky and
Seneca. See page 13.
The Plan expanded its N. Carolina service area by adding the following
counties: Durham, Orange and Wake. See
page 12.
The mental health/ substance abuse outpatient visit limit of 40 visits has
been eliminated. Visits for these services will
now be treated as any other
illness based on medical necessity. See page 40. 17
17
Page 18 19
2001
Aetna U. S. Healthcare HMO 18 Section 2
The copayment for
specialist office visit has been increased from $10 to $15. See Section 5 (a).
The copayment for home visits by specialist has increased from $15 to $20.
See Section 5 (a).
The mental health/ substance abuse outpatient copay has
been changed to $15 per visit. See Section 5 (e).
The inpatient mental
health/ substance abuse 35-day annual limit has been eliminated and will now
have no day limit.
Inpatient mental health/ substance abuse days will be
treated as any other illness based on medical necessity. See
Section 5 (e).
Prophylaxis (cleaning of teeth ) changed from once every 6 months to cover 2
treatments per year. See Section 5 (h).
Benefits for Dental diagnostic
services changed. See Section 5 (h).
For certain age groups women may now
access additional routine mammograms. See page 26.
Arizona, Code WQ. Your
share of the non-postal premium will increase by 14.4% for Self Only or increase
by
14.4% for Self and Family.
California, Code BU. Your share of the non-postal premium will increase by
10.9% for Self Only or increase by
7.1% for Self and Family.
California, Code 2X. Your share of the non-postal premium will increase by
5.5% for Self Only or increase by 5.5%
for Self and Family.
Colorado, Code 6F. Your share of the non-postal premium will increase by
31.9% for Self Only or increase by
51.0% for Self and Family.
Connecticut, Code H1. Your share of the non-postal premium will increase by
23.3% for Self Only or increase by
15.7% for Self and Family.
Georgia, Code 2U. Your share of the non-postal premium will increase by 1.8%
for Self Only or decrease by 6.4%
for Self and Family.
Illinois, Code XC. Your share of the non-postal premium will increase by 2.2%
for Self Only or increase by 2.7%
for Self and Family.
Indiana, Code XC. Your share of the non-postal premium will increase by 2.2%
for Self Only or increase by 2.7%
for Self and Family.
Indiana, Code RD. Your share of the non-postal premium will increase by 7.9%
for Self Only or increase by 8.2%
for Self and Family.
Kansas, Code 7K. Your share of the non-postal premium will increase by 4.6%
for Self Only or increase by 3.6% for
Self and Family.
Kentucky, Code RD. Your share of the non-postal premium will increase by 7.9%
for Self Only or increase by 8.2%
for Self and Family.
Louisiana, Code NG. Your share of the non-postal premium will increase by
1.5% for Self Only or increase by 8.3%
for Self and Family.
Massachusetts, Code NE. Your share of the non-postal premium will increase by
15.6% for Self Only or increase by
10.0% for Self and Family.
Michigan, Code 8Z. Your share of the non-postal premium will increase by 5.3%
for Self Only or increase by 4.5%
for Self and Family.
Missouri, Code 7K. Your share of the non-postal premium will increase by 4.6%
for Self Only or increase by 3.6%
for Self and Family.
Nevada, Code 8L. Your share of the non-postal premium will increase by 26.0%
for Self Only or increase by 26.0%
for Self and Family. 18
18 Page 19 20
2001 Aetna U. S. Healthcare HMO 19 Section 2
New York, Code JC. Your share of the non-postal premium will increase by
8.2% for Self Only or decrease by 1.0%
for Self and Family.
North Carolina, Code 3G. Your share of the non-postal premium will increase
by 2.4% for Self Only or decrease by
2.1% for Self and Family.
Ohio, Code RD (Greater Cincinnati). Your share of the non-postal premium will
increase by 7.9% for Self Only or
increase by 8.2% for Self and Family.
Oklahoma, Code 8V. Your share of the non-postal premium will increase by
24.2% for Self Only or increase by
25.8% for Self and Family.
Rhode Island, Code 5U. Your share of the non-postal premium will increase by
16.9% for Self Only or increase by
18.8% for Self and Family.
Tennessee, Code 6J. Your share of the non-postal premium will increase by
39.3% for Self Only or increase by 82.5%
for Self and Family.
Texas, Code 5B. Your share of the non-postal premium will increase by 4.8%
for Self Only or increase by 2.8% for
Self and Family.
Texas, Code 8X. Your share of the non-postal premium will increase by 35.4%
for Self Only or increase by 30.9% for
Self and Family.
Washington, Code 8J. Your share of the non-postal premium will increase by
21.1% for Self Only or increase by
19.9% for Self and Family. 19
19 Page 20 21
2001 Aetna U. S. Healthcare HMO 20 Section 3
Section 3. How you get care
Identification cards We will send
you an identification (ID) card when you enroll. You should carry your ID card
with you at all times. You must show it whenever you
receive services from a Plan provider, or 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
1-800-537-9384.
Where you get covered care You get covered care from "Plan
providers" and "Plan facilities." You will only pay copayments or
coinsurance, and you will not have to file claims.
Plan providers
Plan providers are physicians and other health care professionals in our
service area that we contract with to provide covered services to our
members. We credential Plan providers according to national standards.
We list Plan providers in the provider directory, which we update
periodically. The list is also on our website at www. aetnaushc. com/
feds.
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
facilities in the provider directory, which we update periodically. The list
is
also on our website at www. aetnaushc. com/ feds.
What you must do
to get covered care It depends on the type of
care you need. First, you and each family member must choose a primary care
physician. This decision is important since
your primary care physician provides or arranges for most of your health
care. You must select a Plan provider who is located in your service area as
defined by your enrollment code.
Primary care Your primary care physician can be a general
practitioner, family practitioner, internist or pediatrician. Your primary care
physician will
provide or coordinate 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 or visit our website. We will change your
primary care physician to a newly-selected primary care physician.
Specialty care Your primary care physician will refer you to a
specialist for needed care. However, you may see any Plan gynecologist for a
routine well-woman
exam, including a pap smear (if appropriate) and an unlimited number of
visits for gynecological problems and follow-up care as described in your
benefit plan without a referral. You may also see a Plan mental health
provider, Plan vision specialist or a Plan dentist without a referral. 20
20 Page 21 22
2001 Aetna U. S. Healthcare HMO 21 Section 3
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 covered 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 1-800-537-9384. If you are
new to the FEHB
Program, we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay
for the hospital stay until:
You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92 nd day
after you become a member of this Plan, whichever happens first.
These provisions apply only to the benefits of the hospitalized person. 21
21 Page 22 23
2001 Aetna U. S. Healthcare HMO 22 Section 3
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
prior approval Your primary care physician
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 precertification. Your Plan
physician must obtain approval for certain services such as hospitalization
or outpatient surgery and the following services:
For artificial insemination you must contact the Infertility Case Manager at
1-800-575-5999;
For surgical treatment of morbid obesity;
For covered
transplant surgery from the Plan's medical director;
When full-time skilled
nursing care is necessary in an extended care facility;
For ambulance transportation service;
You must obtain precertification
from your primary care doctor and Aetna U. S. Healthcare for covered follow-up
care with
nonparticipating provider;
You must contact Customer Service at
1-800-537-9384 for information on precertification before you have mental health
and
substance abuse services; and
For certain drugs before they can be
prescribed. 22
22 Page
23 24
2001 Aetna U. S. Healthcare HMO
23 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the
provider when you receive services.
Example: When you see your primary care physician you pay a copayment
of
$10 per office visit or $15 when you see a participating specialist.
Coinsurance Coinsurance is the percentage of our negotiated fee that
you must pay for your care.
Example: In our Plan, you pay 50% of charges for drugs to treat sexual
dysfunction up to the dosage limits.
Your out-of-pocket maximum We do not have an overall member
out-of-pocket maximum. 23
23 Page 24 25
2001 Aetna U.
S. Healthcare HMO 24 Section 5
Section 5. Benefits Ñ
OVERVIEW
(See page 16 for how our benefits changed this year and page 70 for
a benefits summary.) NOTE: This benefits section is divided into
subsections. Please read the important things you should keep in mind at
the beginning of each subsection. Also read the General Exclusions in Section
6, they apply to the benefits in the
following subsections. For more
information about our benefits, contact us at 1-800-537-9384 or at our website
at
www. aetnaushc. com/ feds.
(a) Medical services and supplies provided by physicians and other health
care professionals.................................... 25
Diagnostic and
treatment services Lab, X-ray, and other diagnostic tests
Preventive care, adult Preventive care, children
Maternity care Family
planning
Infertility services Allergy care
Treatment therapies
Rehabilitative therapies
Hearing services (testing, treatment, and supplies)
Vision services
(testing, treatment, and supplies)
Foot care Orthopedic and prosthetic
devices
Durable medical equipment (DME) Home health services
Alternative
treatments Educational classes and programs
(b) Surgical and anesthesia services provided by physicians and other health
care professionals ................................ 32
Surgical procedures
Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and
ambulance services
............................................................... 35
Inpatient
hospital Outpatient hospital or ambulatory
surgical center
Extended care benefits/ skilled nursing care facility
benefits
Hospice care Ambulance
(d) Emergency services/
accidents.....................................................................................................................................
37
Medical emergency Ambulance
(e) Mental health and substance abuse benefits
...............................................................................................................
40
(f) Prescription drug
benefits............................................................................................................................................
42
(g) Special features
............................................................................................................................................................
45
Services for deaf and hearing-impaired
...............................................................................................................
45 Reciprocity
............................................................................................................................................................
45
High risk pregnancies
...........................................................................................................................................
45 Centers of excellence for transplants/ surgery etc.
...............................................................................................
45
(h) Dental benefits
.............................................................................................................................................................
46
(i) Non-FEHB benefits available to Plan
members.........................................................................................................
49
Summary of benefits
...........................................................................................................................................................
70 24
24 Page 25
26
2001 Aetna U. S. Healthcare HMO 25
Section 5( a)
Section 5 (a) Medical services and supplies provided
by physicians and other health care professionals
I
M
P
O
R
T
A
N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine
they are medically necessary.
Plan physicians must provide or arrange
your covered care.
Be sure to read Section 4, Your costs for covered
services for valuable information about how cost sharing works. Also read
Section 9 about
coordinating benefits with other coverage, including with Medicare.
I
M
P
O
R
T
A
N
T
Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
In physician's office
Office
medical consultations
Second surgical opinion
Initial examination of a
newborn child covered under a family enrollment
$10 per primary care
physician (PCP) visit
$15 per specialist visit
Professional services of physicians
In an urgent care center
During a
hospital stay
In a skilled nursing facility
$10 per PCP visit
$15 per specialist visit
At home $15 per PCP visit
$20 per specialist visit
At home visits by nurses and health aides Nothing
Lab, X-ray and other diagnostic tests
Test, such as:
Blood
tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG
Nothing if you receive
these services during
your office visit;
otherwise, $10 per PCP
visit or $15 per specialist
visit 25
25 Page 26 27
2001 Aetna U. S. Healthcare HMO 26 Section
5( a)
Preventive care, adult You pay
Routine screenings, such
as:
Blood lead level Ñ One annually
Total Blood Cholesterol
Ñ once every three years, ages 19 through 64
Colorectal Cancer Screening, including
Fecal occult blood test
Sigmoidoscopy, screening Ñ every five years starting at age 50
$10 per PCP visit
$15 per specialist visit
Prostate Specific Antigen (PSA test) Ñ one annually for men age 40 and
older
$10 per PCP visit
$15 per specialist visit
Routine pap test
NOTE: No copay for the pap test if performed on
the same day as the
office visit
$10 per PCP visit or
$15 per specialist visit
Routine mammogram Ñ 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
$10 per PCP visit
$15 per specialist visit
Routine Immunizations and boosters Nothing if provided during the office
visit
Not covered:
Physical exams required for obtaining or
continuing employment or insurance, attending schools or camp, or travel.
Immunizations and boosters for travel or work-related exposure
All charges
Preventive care, children
Childhood immunizations recommended by
the American Academy of Pediatrics Nothing
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 visits for routine examinations, immunizations and care (through
age 22)
$10 per PCP visit
$15 per specialist visit 26
26 Page 27 28
2001 Aetna U. S. Healthcare HMO 27 Section
5( a)
Maternity care You pay
Complete maternity (obstetrical)
care, such as:
Prenatal care
Delivery
Postnatal care
NOTE: Here are some things to keep in mind:
You do not need to
precertify your normal delivery; see below for other circumstances, such as
extended stays for you or your baby.
You may remain in the hospital up to 48 hours after a regular delivery and 96
hours after a cesarean delivery. We will cover an extended
inpatient stay if
your Physician determines it is medically necessary.
We cover routine
nursery care of the newborn child during the covered portion of the mother's
maternity stay. We will cover other care of an
infant who requires non-routine treatment only if we cover the infant
under a Self and Family enrollment.
We pay hospitalization and surgeon services (delivery) the same as for
illness and injury. See Hospital benefits (Section 5c) and Surgery
benefits (Section 5b).
$10 for the first PCP visit
only or $15 for the first
specialist
visit only
Not covered: Routine sonograms to determine fetal age, size or sex All
charges
Family planning
Voluntary sterilization
Surgically implanted contraceptives, such as Norplant
Injectable
contraceptive drugs
Intrauterine devices (IUDs)
$10 per PCP visit
$15 per specialist visit
Not covered: reversal of voluntary surgical sterilization, genetic
counseling,
All charges 27
27 Page 28 29
2001 Aetna U.
S. Healthcare HMO 28 Section 5( a)
Infertility services You
pay
Diagnosis and treatment of infertility, such as:
Artificial
insemination:
intravaginal insemination (IVI)
intracervical insemination
(ICI)
intrauterine insemination (IUI)
NOTE: Coverage is for 6
cycles. Artificial insemination must
be authorized. You must contact the
Infertility Case Manager at
1-800-575-5999. You must use our select network
of Plan infertility
providers.
Fertility drugs
NOTE: We cover oral fertility drugs under the
prescription drug benefit.
Injectable fertility drugs are not covered.
$15 per specialist visit
Not covered:
Reversal of voluntary, surgically-induced
sterility.
Treatment for infertility when the cause of the infertility was a previous
sterilization.
Infertility treatment when the FSH level is greater than 19 mIU/ ml.
The purchase, freezing and storage of donor sperm and donor embryos.
Assisted reproductive technology (ART) procedures not shown, such as in
vitro fertilization an embryo transfer including, but not limited to,
GIFT
and ZIFT.
All charges
Allergy care
Testing and treatment
Allergy injection
$10
per PCP visit
$15 per specialist visit
Allergy serum Nothing
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 34.
Respiratory and inhalation therapy
Dialysis Ñ Hemodialysis and
peritoneal dialysis
Intravenous (IV)/ Infusion Therapy Ñ Home IV and
antibiotic therapy
Growth hormone therapy (GHT)
$15 per specialist visit 28
28 Page 29 30
2001 Aetna U.
S. Healthcare HMO 29 Section 5( a)
Rehabilitative therapies
You pay
Physical therapy, occupational therapy, speech therapy and
pulmonary
therapy Ñ
Two consecutive months per condition, beginning with the first day of
treatment for each of the following:
Qualified physical therapies
Speech therapies
Occupational therapy
Pulmonary rehabilitation
NOTE: We only cover speech therapy for 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.
Inpatient rehabilitation is covered under Hospital/ Extended Care
Benefits.
Cardiac rehabilitation following angioplasty, cardiovascular surgery,
congestive heart failure or a myocardial infarction is provided for up
to 3 visits a week for a total of 18 visits.
Physical therapy to treat
temporomandibular joint (TMJ) dysfunction syndrome
$15 per specialist visit
Not covered:
long-term rehabilitative therapy
All charges
Hearing services (testing, treatment, and supplies)
Hearing
testing for children through age 17 (see Preventive care, children) $10
per PCP visit or $15 per specialist visit
Not covered:
All other hearing testing
Hearing aids,
testing and examinations for them
All charges 29
29 Page 30 31
2001 Aetna U.
S. Healthcare HMO 30 Section 5( a)
Vision services (testing,
treatment, and supplies) You pay
Treatment of eye diseases and injury
$10 per PCP visit $15 per specialist visit
Corrective eyeglasses and frames or contact lenses (hard or soft) per 24
month period. All charges over $100
Routine eye refraction based on the
following schedule:
If member wears eyeglasses or contact lenses:
Age 1
through 18 Ñ once every 12-month period
Age 19 and over Ñ once
every 24-month period
If member does not wear eyeglasses or contact lenses:
To age 45 Ñ once every 36-month period
Age 45 and over Ñ once every 24-month period refractions
$10 per PCP visit
$15 per specialist visit
Not covered:
Fitting of contact lenses
Eye exercises
Radial keratotomy and other refractive surgery
All charges
Foot care
Routine foot care when you are under active treatment
for a metabolic or
peripheral vascular disease, such as diabetes.
See orthopedic and prosthetic devices for information on podiatric shoe
inserts.
$10 per office visit
$15 per specialist visit
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)
Foot orthotics
All charges 30
30 Page 31 32
2001 Aetna U.
S. Healthcare HMO 31 Section 5( a)
Orthopedic and prosthetic
devices You pay
External prosthetic devices which replace all or part of
an internal or external body organ or an external body part
Externally worn breast prostheses and surgical bras, including necessary
replacements, following a mastectomy, orthopedic devices
such as braces and
prosthetic devices such as artificial limbs
Internal prosthetic devices,
such as artificial joints, pacemakers,
cochlear implants, defibrillator,
surgically implanted breast implant
following mastectomy, and lenses
following cataract removal.
Corrective orthopedic appliances for non-dental treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome.
NOTE: Coverage includes repair and replacement when due to growth
or normal wear and tear.
See 5( b) for coverage of the surgery to insert the device.
Nothing
Durable medical equipment (DME)
Rental or purchase, including
replacement, repair and adjustment, of
durable medical equipment prescribed
by your Plan Physician, such as
hospital beds and wheelchairs.
Nothing
Home health services
Home health care ordered by a Plan Physician
and provided by nurses and home health aides. Your Plan Physician will
periodically review
the program for continuing appropriateness and need.
Services include oxygen therapy, intravenous therapy and medications.
Nothing
Not covered:
Homemaker services
All charges
Alternative treatments
Chiropractic services up to 20 visits per
calendar year $10 per PCP visit
$15 per specialist visit
Not covered: Any services not listed above All charges
Educational classes and programs
Our L'il Appleseed ®
Program provides risk screening and assistance for
all pregnant members. We
also offer special benefits, such as educational
literature about pregnancy
and childbirth, $40 reimbursement for
attending prenatal classes, nurse
visits, and discounts on baby products.
Also see the Non-FEHB page for our Member Health Education,
Informed
Health Line and Intelihealth.
Nothing 31
31 Page
32 33
2001 Aetna U. S. Healthcare HMO
32 Section 5( b)
Section 5 (b). Surgical and anesthesia
services provided by physicians and other health care professionals
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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
covered care.
Be sure to read Section 4, Your costs for covered services
for valuable information about how cost sharing works. Also read Section 9
about
coordinating benefits with other coverage, including with Medicare.
The
amounts listed below are for the charges billed by a physician or other health
care professional for your surgical care. Look in Section (c) for
charges associated with the facility (i. e. hospital, surgical center, etc.)
YOU MUST GET PRECERTIFICATION FOR SOME SURGICAL PROCEDURES.
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Benefit Description You pay
Surgical procedures
Treatment of
fractures, including casting
Normal pre-and post-operative care by the
surgeon
Correction of amblyopia and strabismus
Endoscopy procedure
Biopsy procedure
Removal of tumors and cysts
Correction of
congenital anomalies (see reconstructive surgery)
Surgical treatment of
morbid obesity Ñ 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. This procedure must be approved in advance by HMO.
Insertion of internal prosthetic devices. See 5( a) Ñ Orthopedic
braces and prosthetic devices for device coverage information.
Voluntary sterilization
Norplant (a surgically implanted contraceptive)
and intrauterine devices (IUDs) NOTE: Devices are covered under 5( a).
Treatment of burns
$15 per specialist visit
Not covered:
Reversal of voluntary surgically-induced
sterilization
Surgery primarily for cosmetic purposes
Refractive eye surgery,
such as radial keratotomy
Blood and blood derivatives, except blood
derived clotting factors, and the storage of the patient's own blood for later
administration
All charges 32
32 Page 33 34
2001 Aetna U.
S. Healthcare HMO 33 Section 5( b)
Reconstructive surgery You
pay
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.
$15 per specialist visit
Not covered:
Cosmetic surgery Ñ any surgical procedure
(or any portion of a procedure) performed primarily to improve physical
appearance
through change in bodily form, except repair of accidental injury
Surgeries related to sex transformation
All charges
Oral and maxillofacial surgery
Oral surgical procedures, such as:
Treatment of fractures of the jaws or facial bones;
Surgical correction
of congenital defects, such as cleft lip and cleft palate;
Removal of stones from salivary ducts;
Excision of leukoplakia or
malignancies;
Removal of bony impacted wisdom teeth;
Excision of tumors
and cysts
Other surgical procedures that do not involve the teeth or their
supporting structures.
$15 per specialist visit
Not covered:
Dental implants
Dental care involved
with the treatment of temporomandibular joint dysfunction
All charges 33
33 Page 34 35
2001 Aetna U.
S. Healthcare HMO 34 Section 5( b)
Organ/ tissue transplants
You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Liver
Lung: Single Ñ Double
Pancreas
Skin
Tissue
Allogeneic (donor) bone marrow transplants
Autologous bone marrow
transplants (autologous stem cell and peripheral stem cell support) for the
following conditions: acute
lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's
lymphoma;
advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer;
multiple myeloma; epithelial ovarian
cancer; and testicular, mediastinal,
retroperitoneal and ovarian germ
cell tumors
National Transplant Program (NTP) Ñ Transplants which are
non-experimental or non-investigational are a covered benefit. Covered
transplants must be ordered by your primary care doctor and plan
specialist physician and approved by our medical director in advance
of
the surgery. The transplant must be performed at hospitals
specifically
approved and designated by us to perform these
procedures. A transplant is
non-experimental and non-investigational
when we have determined, in our
sole discretion, that the medical
community has generally accepted the
procedure as appropriate
treatment for your specific condition. Coverage for
a transplant where
you are the recipient includes coverage for the medical
and surgical
expenses of a live donor, to the extent these services are not
covered
by another plan or program.
NOTE: We cover related medical and hospital expenses of the donor
when we cover the recipient.
$15 per specialist office
visit and nothing for the
surgery
Not covered:
Transplants not listed as covered
All charges
Anesthesia
Professional services provided in Ñ
Hospital
(inpatient)
Nothing
Hospital outpatient department
Skilled nursing facility
Ambulatory
surgical center
Office
$15 per specialist visit 34
34 Page 35 36
2001 Aetna U.
S. Healthcare HMO 35 Section 5( c)
Section 5 (c). Services
provided by a hospital or other facility, and ambulance services
I
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Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine
they are medically necessary.
Plan physicians must provide or arrange
your covered care and you must be hospitalized in a Plan facility.
Be sure to read Section 4, Your costs for covered services for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
The
amounts listed below are for the charges billed by the facility (i. e., hospital
or surgical center) or ambulance service for your surgery or
covered care. Any costs associated with the professional charge (i. e.,
physicians, etc.) are covered in Section 5( a) or (b).
YOU MUST GET PRECERTIFICATION OF HOSPITAL STAYS.
I
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Benefit Description You pay
Inpatient hospital
Room and board,
such as
Ward, semiprivate, or intensive care accommodations;
General
nursing care; and
Meals and special diets.
NOTE: If you want a private room when it is not medically necessary,
you pay the additional charge above the semiprivate room rate.
Nothing
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
The withdrawal, processing and storage of the patient's own blood
for later administration, and the administration of this blood to the patient
Serum, clotting factors and immunoglobulins
Blood or blood plasma, if not
donated or replaced
Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics, including
nurse anesthetist services
Take-home items
Medical supplies, appliances,
medical equipment, and any covered items billed by a hospital for use at home
Nothing
Inpatient hospital Ñ Continued on the next page 35
35 Page 36 37
2001 Aetna U. S. Healthcare HMO 36 Section
5( c)
Inpatient hospital (Continued) You pay
Not covered:
Custodial care, rest cures, domiciliary or
convalescent cares
Personal comfort items, such as telephone and,
television
All charges
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.
Nothing
Not covered: Blood and blood derivatives, except blood clotting factors,
and the storage of the patient's own blood for later administration.
All
charges
Extended care benefits/ skilled nursing care facility benefits
Extended care benefit: All necessary services during confinement in an
skilled nursing facility with no dollar or day limit when full-time nursing
care is necessary and the confinement is medically appropriate as
determined by a Plan doctor and approved by the Plan.
Nothing
Not covered: custodial care All charges
Hospice care
Supportive and palliative care for a terminally ill member in the home
or
hospice facility, including inpatient and outpatient care and family
counseling, when provided under the direction of a Plan doctor, who
certifies the patient is in the terminal stages of illness, with a life
expectancy of approximately 6 months or less.
Nothing
Ambulance
Ambulance service ordered or authorized by a Plan doctor
Nothing
Not covered: Ambulance services for routine transportation to
receive
outpatient or inpatient services.
All Charges 36
36 Page 37 38
2001 Aetna U. S. Healthcare HMO 37 Section
5( d)
Section 5 (d). Emergency services/ accidents
I
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T
A
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T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure.
Be sure to read Section 4, Your costs for covered services for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
I
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What is a medical emergency?
A medical emergency is the sudden and
unexpected onset of a condition or an injury that you believe
endangers your
life or could result in serious injury or disability, and requires immediate
medical or surgical
care. Some problems are emergencies because, if not
treated promptly, they might become more serious;
examples include deep cuts
and broken bones. Others are emergencies because they are potentially
life-threatening,
such as heart attacks, strokes, poisonings, gunshot
wounds, or sudden inability to breathe. There
are many other acute
conditions that we may determine are medical emergencies Ñ what they all
have in
common is the need for quick action.
What to do in case of emergency:
If you need emergency care, you
are covered 24 hours a day, 7 days a week, anywhere in the world. An
emergency medical condition is one manifesting itself by acute symptoms of
sufficient severity such that a
prudent layperson, who possesses average
knowledge of health and medicine, could reasonably expect the
absence of
immediate medical attention to result in serious jeopardy to the person's
health, or with respect to a
pregnant woman, the health of the woman and her
unborn child.
Whether you are in or out of an Aetna U. S. Healthcare HMO service area, we
simply ask that you follow the
guidelines below when you believe you need
emergency care.
Call the local emergency hotline (ex. 911) or go to the nearest emergency
facility. If a delay would not be detrimental to your health, call your primary
care provider. Notify your primary care provider as soon as
possible after receiving treatment.
After assessing and stabilizing your
condition, the emergency facility should contact your primary care physician so
they can assist the treating physician by supplying information about your
medical history.
If you are admitted to an inpatient facility, you or a family member or
friend on your behalf should notify your primary care physician or us as soon as
possible.
What to Do Outside Your Aetna U. S. Healthcare HMO Service Area
Members who are traveling outside their HMO service area or students who
are away at school are covered
for emergency and urgently needed care.
Urgent care may be obtained from a private practice physician, a
walk-in
clinic, an urgent care center or an emergency facility. Certain conditions, such
as severe vomiting,
earaches, sore throats or fever, are considered
"urgent care" outside your Aetna U. S. Healthcare HMO service
area
and are covered in any of the above settings.
If, after reviewing information submitted to us by the provider that supplied
care, the nature of the urgent or
emergency problem does not qualify for
coverage, it may be necessary to provide us with additional
information. We
will send you an Emergency Room Notification Report to complete, or a Member
Services
representative can take this information by telephone. 37
37 Page 38 39
2001 Aetna U. S. Healthcare HMO 38 Section
5( d)
Follow-up Care after Emergencies All follow-up care should
be coordinated by your PCP. Follow-up care with nonparticipating providers is
only covered
with a referral from your primary care physician and
pre-approval from Aetna U. S. Healthcare. Whether you were
treated inside or
outside your Aetna U. S. Healthcare service area, you must obtain a referral
before any follow-up care
can be covered. Suture removal, cast removal,
X-rays and clinic and emergency room revisits are some examples of
follow-up
care.
What to do in case of emergency:
Emergencies within our service area:
If you are in an emergency situation, call you primary care doctor. In
extreme emergencies or if you are unable to contact your doctor, 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 your primary care doctor. You or a family member must notify your primary
care
doctor as soon as possible after receiving emergency care. It is your
responsibility to ensure that your primary care
doctor has been timely
notified.
If you need to be hospitalized, the Plan must be notified as soon as
possible. If you are hospitalized in non-Plan facilities
and 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-participating providers must be approved by us or
provided by 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 as soon as
possible. 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-participating providers must be approved by us or
provided by plan
providers.
Benefit Description You pay
Emergency within our service area
Emergency care at a doctor's office $10 per PCP visit $15 per specialist
visit
Emergency care as an outpatient in a hospital or an urgent care center
NOTE: If the emergency results in admission to a hospital, the copay
is
waived.
$35 per visit
Not covered: Elective care or non-emergency care All charges
Emergency outside our service area
Emergency care at a
doctor's office $10 per PCP visit $15 per specialist visit
Emergency care as an outpatient in a hospital or an urgent care center
NOTE: If the emergency results in admission to a hospital, the copay
is
waived.
$35 per visit
Emergency outside our service area Ñ Continued on the next page
38
38 Page 39
40
2001 Aetna U. S. Healthcare HMO 39
Section 5( d)
Emergency outside our service area (continued) You
pay
Not covered:
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care
could have been foreseen before leaving the service area
Medical and hospital costs resulting from a normal full-term delivery of a
baby outside the service area.
All charges
Ambulance
Professional ambulance service when medically
appropriate.
See 5( c) for non-emergency service.
Nothing for covered
care
Not covered: air ambulance All charges 39
39
Page 40 41
2001
Aetna U. S. Healthcare HMO 40 Section 5( e)
Section 5 (e).
Mental health and substance abuse benefits
Network Benefit
I
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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.
I
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A
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Description You pay
Mental health and substance abuse benefits
All 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.
Your cost sharing
responsibilities are no
greater than for other
illness or conditions.
Professional services, including individual or group therapy by providers
such as psychiatrists, psychologists, or clinical social
workers
Medication management
$15 per visit
Diagnostic tests $15 per visit
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
Nothing
Not covered:
Services we have not approved
Out of
network mental health and substance abuse services
NOTE: OPM will base its review of disputes about treatment plans on
the
treatment plan's clinical appropriateness. OPM will generally not order
us to pay or provide one clinically appropriate treatment plan in favor of
another.
All charges 40
40 Page 41 42
2001 Aetna U.
S. Healthcare HMO 41 Section 5( e)
Preauthorization To be
eligible to receive these benefits you must follow your treatment plan and all
the following authorization processes:
Contact Customer Services at
1-800-537-9384 to identify providers and
obtain information on the referral
process.
Special transitional benefit If a mental health or substance abuse
professional provider is treating you under our plan as of January 1, 2001, you
will be eligible for continued
coverage with your provider for up to 90 days
under the following
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.
If this condition applies to you, we will allow you
reasonable time to
transfer your care to a participating mental health or
substance abuse
professional provider. During the transitional period, you
may continue to
see your treating provider and will not pay any more
out-of-pocket than
you did in the year 2000 for services. This transitional
period will begin
with our notice to you of the change in coverage and will
end 90 days after
you receive 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.
Network limitation We may limit your benefits if you do not follow
your treatment plan.
How to submit network claims Mail your itemized
bills to Aetna U. S. Healthcare, P. O. Box 1125, Blue Bell, PA 19422. 41
41 Page 42 43
2001 Aetna U. S. Healthcare HMO 42 Section
5( f)
Section 5 (f). Prescription drug benefits
I
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A
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Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart
beginning on the next page.
All benefits are subject to the definitions, limitations and exclusions in
this brochure and are payable only when we determine they are medically
necessary.
Be sure to read Section 4, Your costs for covered services
for valuable information about how cost sharing works. Also read Section 9
about
coordinating benefits with other coverage, including with Medicare.
Certain drugs require your doctor to get precertification from the Plan
before they can be prescribed under the Plan. Upon approval by the Plan, the
prescription is good for the current calendar year or a specified time
period,
whichever is less.
I
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There are important features you should be aware of. These include:
Who can write your prescription. A licensed physician or dentist must
write the prescription.
Where you can obtain them. You must fill
non-emergency prescriptions at a Plan pharmacy for up to a 30-day supply, or by
mail for a 31-90 day supply of medication (if authorized by your physician).
Please
call Member Services at 1-800-537-9384 for more details on how to use the
mail order program. In an
emergency or urgent care situation, you may fill
your covered prescription at any retail pharmacy. If you
obtain your
prescription at a pharmacy that does not participate with the plan, you will
need to pay the
pharmacy the full price of the prescription and submit a
claim for reimbursement subject to the terms and
conditions of the plan.
We use a formulary. Drugs are prescribed by Plan doctors and dispensed
in accordance with the Plan's drug formulary. The Plan's formulary does not
exclude medications from coverage, but requires a higher
copayment for nonformulary drugs. Nonformulary drugs will be covered when
prescribed by a Plan
doctor. Certain drugs require your doctor to get
precertification from the Plan before they can be
prescribed under the Plan.
Visit our website at www. aetnaushc. com/ feds to review our Formulary
Guide
or call 1-800-537-9384.
Precertification. Your pharmacy benefits plan includes our
precertification program. Precertification helps encourage the appropriate and
cost-effective use of certain drugs. These drugs must be pre-authorized by
our Pharmacy Management Precertification Unit before they will be covered.
Only your physician or
pharmacist in the case of an antibiotic or analgesic
can request prior authorization for a drug.
The precertification program is based upon current medical findings,
manufacturer labeling, FDA
guidelines and cost information.
The drugs requiring precertification are subject to change. Visit our website
for the current Precertification
List.
These are the dispensing limitations. Covered prescription drugs
prescribed by a licensed physician or dentist and obtained at a Participating
Plan Pharmacy may be dispensed for up to a 30-day supply.
Members must obtain a 31-to 90 day supply of covered prescription medication
through mail order.
When you have to file a claim. Send your itemized
bill( s) to: Aetna U. S. Healthcare, P. O. Box 1125, Blue Bell, PA 19422.
Prescription drug benefits Ñ Begin on the next page. 42
42 Page 43 44
2001 Aetna U. S. Healthcare HMO 43 Section
5( f)
Benefit Description You pay
Covered medications and
supplies
We cover the following medications and supplies prescribed by a
Plan
physician or dentist and obtained from a Plan pharmacy or through our
mail order program:
Drugs for which a prescription is required by Federal law
Oral
contraceptive drugs.
Insulin
Disposable needles and syringes need to
inject covered prescribed medication, including insulin.
Diabetic supplies limited to lancets, alcohol swabs, urine test strips/
tablets, and blood glucose test strips
Contraceptive drugs and devices
Oral fertility drugs
Intravenous fluids and medications for home use, implantable drugs, such as
Norplant, IUDs and some injectable drugs are covered. See
Section 5 (a) for details.
Limited benefits
Drugs to treat
sexual dysfunction are limited. Contact the Plan for dose limits.
Depo Provera is limited to 5 vials per calendar year.
One diaphragm per
calendar year
$5 per covered generic
formulary prescription/ refill
(up to a 30 day
supply) or $10
for a 31-to 90-day supply
through mail order
$10 per covered brand name
formulary prescription/ refill
(up to a 30
day supply) or $20
for a 31-to 90-day supply
through mail order
$25 per covered non-formulary
(generic or brand)
prescription/ refill
(up to a 30
day supply) or $50 for a 31-
to 90-day supply through mail
order
50%
$10 copay per vial
$10 per diaphragm
Here are some things to keep in mind about our prescription drug program:
A generic equivalent may be dispensed if it is available, and where allowed
by law.
To request a copy of the Aetna U. S. Healthcare Medication Formulary Guide,
call 1-800-537-9384. The information in the Medication
Formulary Guide is
subject to change. Please visit our website at
www. aetnaushc. com/ feds
for current Medication Formulary Guide
information.
Covered medications and supplies Ñ Continued on the next page
43
43 Page 44
45
2001 Aetna U. S. Healthcare HMO 44
Section 5( f)
Covered medications and supplies
(Continued) You pay
Not covered:
Drugs available without a prescription or for which there is a
nonprescription equivalent available, (i. e., an over-the-counter (OTC)
drug)
Drugs obtained at a non-Plan pharmacy except when related
to out-of-area emergency care
Vitamins and nutritional substances that can be purchased without
prescription.
Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes
Drugs to enhance athletic
performance.
Smoking-cessation drugs and medication, including, but
not limited to, nicotine patches and sprays.
Injectable fertility drugs
Drugs used for the purpose of weight
reduction (i. e., appetite suppressants)
All charges 44
44 Page 45 46
2001 Aetna U.
S. Healthcare HMO 45 Section 5( g)
Section 5 (g). Special
Features
Feature Description
Services for the deaf and
hearing-impaired
1-800-628-3323
Reciprocity benefit If you need to visit a participating primary care
physician for a covered service, and you are 50 mile or more away from home you
may visit a
primary care physician from our Plan's approved network.
Call 1-800-537-9384 for provider information and location
Select a
doctor from 3 primary care doctors in that area
The Plan will authorize you
for one visit and any tests or X-rays ordered by that primary care physician.
You must coordinate all subsequent visits through your own participating care
physician.
High-risk pregnancies Our L'il Appleseed ® Program provides risk
screening and assistance for all pregnant members. We also offer special
benefits, such as educational
literature about pregnancy and childbirth, $40
reimbursement for
attending prenatal classes, nurse visits, and discounts on
baby products.
Centers of excellence for
transplants/ heart
surgery/ etc
Our National Medical Excellence Program ® coordinates services for
complicated or rare illnesses and transplants. The National Medical
Excellence Program is unique to Aetna U. S. Healthcare and has been created
for members with particularly difficult conditions such as rare cancers and
other complicated diseases and disorders.
Usually, the recommended treatment can be found in your area. But if your
needs extend beyond your region, the National Medical Excellence Program
may be available to send you to out-of-area experts.
The first priority is to determine an appropriate treatment program. If your
treatment program cannot be provided in the local area, we will arrange and
pay for covered care as well as related travel expenses to wherever the
necessary care is available. Prior approval is required.
Travel benefit/ services
overseas
Our National Medical Excellence Program is a case management program
that
provides consistency in the coordination of care for life threatening
and
complex illnesses. This includes bone marrow and solid organ
transplants,
investigational and new technology (when covered), and
unique services that
are offered at a limited number of medical facilities.
We also coordinate
care for members if they need covered care that is not
available in their
local area and if they become ill when traveling
temporarily outside the
Continental United States. 45
45 Page 46 47
2001 Aetna U.
S. Healthcare HMO 46 Section 5( h)
Section 5 (h). Dental
benefits
I
M
P
O
R
T
A
N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and
exclusions in this brochure and are payable only when we
determine they are
medically necessary.
Plan dentists must provide or arrange covered care.
We cover
hospitalization for dental procedures only when a nondental physical
impairment exists which makes hospitalization necessary to safeguard the
health of
the patient; we do not cover the dental procedure unless it is
described below.
Be sure to read Section 4, Your costs for covered services for
valuable information
about how cost sharing works. Also read Section 9 about
coordinating benefits with
other coverage, including with Medicare.
I
M
P
O
R
T
A
N
T
Accidental injury benefit
No benefits other than those listed
on the following schedule.
Dental Benefits You pay
Service
Diagnostic
Office visit
for oral evaluation Ñ limited to 2 visits per year
Bitewing x-rays
Ñ limited to 2 sets of bitewing x-rays per year
Entire x-ray series
Ñ limited to 1 entire x-ray series in any 3 year period
Periapical
x-rays and other dental x-rays Ñ as necessary
Diagnostic models
Preventive
Prophylaxis (cleaning of teeth) Ñ limited to 2
treatments per year
Topical fluoride Ñ limited to 2 courses of
treatment per year and to
children under age 18
Oral hygiene instruction
Restorative (Fillings)
Amalgam (primary) 1 surface
Amalgam
(primary) 2 surfaces
Amalgam (primary) 3 surfaces
Amalgam (primary) 4
surfaces
Amalgam (permanent) 1 surface
Amalgam (permanent) 2 surfaces
Amalgam (permanent) 3 surfaces
Amalgam (permanent) 4 surfaces
$5
$5
$5
$5
$5
$5
$5
$5
$5
$5
$5
$5
$5
$5
$5
$5
Dental Benefits Ñ Continued on next page 46
46 Page 47 48
2001 Aetna U. S. Healthcare HMO 47 Section
5( h)
Dental Benefits (Continued) You pay
Service
Prosthodontics Removable
Denture adjustments (complete
or partial/ upper or lower)
Endodontics
Pulp cap Ñ direct
Pulp cap Ñ indirect
$5
$5
$5
NOTE: The above services are only covered when provided by your
participating primary care dentist in
accordance with the terms of your
Plan. If rendered by a participating specialist, they are provided at reduced
fees. Pediatric dentists are considered specialists. Certain other
services will be provided by your primary
care dentist at reduced fees. A
partial list appears below. Ask your primary care dentist for a complete
schedule of current reduced member fees. All member fees must be paid
directly to the participating dentist.
Each employee and dependent must select a primary care dentist from the
directory and include the dentist's
name on the enrollment or provider
selection form.
The following procedures are also available from your participating primary
care dentist up to the maximum
fee shown. These same services received
from a participating specialist may require you to pay a fee that is
higher
than the stated maximum. Call your participating primary care dentist or
participating dental specialist
for the specific fee in your area.
Service
You pay up to
a maximum fee of
Diagnostic
Sealant Ñ per permanent tooth
Space
maintainer
Restorative (Fillings)
Resin (anterior) 1 surface
Resin
(anterior) 2 surfaces
Resin (anterior) 3 surfaces
Resin (anterior) 4 or
more surfaces or incisal angle
Metallic inlay
$ 35
$445
$ 85
$115
$140
$150
$580
Prosthodontics, removable
Complete denture, (upper or lower)
Immediate denture (upper or lower)
Partial denture resin base (upper or
lower)
Partial denture cast metal framework with resin base (upper or lower)
Denture repairs
Add tooth to existing partial
Add clasp to existing
partial
$820
$885
$630
$955
$120
$105
$120
Dental benefits Ñ Continued on next page 47
47 Page 48 49
2001 Aetna U. S. Healthcare HMO 48 Section
5( h)
Dental Benefits (Continued)
Service
You pay up to
a maximum fee of
Prosthodontics, removable (Continued)
Denture rebase
Denture relines
Interim denture (complete or partial/ upper or lower)
Tissue conditioning
Prosthodontics, fixed
Bridge pontic
Metallic inlay/ onlay
Cast metal retainer for resin bonded prosthesis
Crown porcelain
Crown cast
Recement bridge
Post and core
Oral surgery
Extractions (nonsurgical and tissue impacted)
Anesthesia (general in office, first half-hour session)
$300
$260
$370
$ 85
$685
$650
$250
$685
$690
$ 65
$250
$380
$215
Periodontics (Gum treatment)
Gingivectomy per quadrant
Gingival curretage per quadrant
Periodontal surgery
Provisional
splinting
Scaling and root planing per quadrant
Periodontal maintenance
procedure
Endodontics (Root canal)
Therapeutic pulpotomy
Root canals
(anterior, bicuspid, molar) excluding final restoration
Apicoectomy Ñ
anterior
Orthodontics
Pre-orthodontic treatment visit
Fully banded case
(adult age 19 and over)
Fully banded case (child age 18 and under)
$250
$120
$605
$125
$120
$ 85
$100
$605
$405
$280
$4,400
$4,400
Specific fees vary by area of the country up to the stated maximum. Ask
your primary care dentist for a complete schedule of reduced fees.
Services not received from a participating dental provider are not
covered. We offer no other dental benefits than those shown above.
All
charges 48
48 Page
49 50
2001 Aetna U. S. Healthcare HMO
49 Section 5 (i)
Section 5 (i). Non-FEHB benefits available to
Plan members
The benefits and programs 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.
Member Health Education With our programs, Aetna U. S. Healthcare
offers special health education, preventive care and wellness programs. We
provide our members with materials that promote a healthy lifestyle and good
health.
The Healthy Eating ª Program is an easy-to-follow
approach to better health through good nutrition. It's designed to
provide
members and their families with information to develop a long term healthy
eating plan that is also realistic.
Members will also understand how to
reduce their risk of illness and disease, manage their weight, increase their
energy
level and boost their ability to fight illness.
Our Healthy Breathing ® Smoking-Cessation Program will help
you safely quit smoking with educational materials,
phone support and
discounts on over-the-counter smoking-cessation products. The member may also
enroll in an eight-to-
twelve week smoking-cessation program.
Informed Health ® Line Provides eligible members with telephone
access to registered nurses experienced in providing information on a variety
of health topics. Informed Health Line is available 24 hours a day, 7 days a
week. You may call Informed Health Line at
1-800-556-1555, Informed health
Line nurses cannot diagnose, prescribe medication or give medical advice.
Intelihealth ® We offer InteliHealth, our affiliate website (www.
intelihealth. com) that provides timely, relevant, reliable and
easy-to-understand
health information online. Established in 1996, InteliHealth has received
international acclaim for the
second straight year by being named the
"People's Choice" in the Webby Awards health category. The Webby
awards
are presented annually by the International Academy of Digital Arts
and Sciences.
Vision One ®1 You are eligible to receive significant discounts on
eyeglasses, contact lenses and nonprescription items including
sunglasses and eyewear products through the Vision One Program
(1-800-793-8616) at more than 4,000 locations
across the country. The
discount enriches our routine vision care coverage provided in your health plan,
which includes
an eye exam from a participating provider. If your health
plan also includes coverage for eyewear such as prescription
eyeglasses or
contact lenses, your out-of-pocket expenses can be reduced when you use your
Vision One discount.
Medicare Managed Care Plan Enrollment This Plan offers Medicare
recipients enrolled in codes (WQ, 2X and parts of JC only) the opportunity to
enroll in the
Plan through Medicare. As indicated on page 56, annuitants and
former spouses with FEHB coverage and Medicare Part
B may elect to drop
their FEHB coverage and enroll in a Medicare managed care plan when one is
available in their
area. They may then later reenroll in the FEHB Program.
Most Federal annuitants have Medicare Part A. Those without
Medicare Part A
may join this Medicare prepaid plan but will probably have to pay for hospital
coverage in additio