Health Maintenance Plan http:// www.
anthem. com 2002
A Health Maintenance Organization
Serving: Most Of Ohio
Enrollment in this Plan is limited. You must
live or work in our Geographic service area to enroll. See page 6 for
requirements.
Enrollment codes for this Plan:
R51 Self Only R52 Self and Family
RI 73-031
For changes in benefits,
see page 7. 1
1
Page 2 3
2002 Health Maintenance Plan 1 Table of Contents
Table of
Contents
Introduction...................................................................................................................................................................
3
Plain
Language..............................................................................................................................................................
3
Inspector General Advisory
..........................................................................................................................................
4
Section 1. Facts about this HMO
plan..........................................................................................................................
5
How we pay providers
................................................................................................................................
5
Your Rights
.................................................................................................................................................
5
Service
Area................................................................................................................................................
6
Section 2. How we change for 2002
............................................................................................................................
7
Program-wide changes
................................................................................................................................
7
Changes to this
Plan....................................................................................................................................
7
Section 3. How you get care
........................................................................................................................................
8
Identification
cards......................................................................................................................................
8
Where you get covered care
........................................................................................................................
8
Plan providers
......................................................................................................................................
8
Plan
facilities........................................................................................................................................
8
What you must do to get covered care
........................................................................................................
8
Primary care
.........................................................................................................................................
9
Specialty care
.......................................................................................................................................
9
Hospital care
......................................................................................................................................
10
Circumstances beyond our control
............................................................................................................
10
Services requiring our prior
approval........................................................................................................
12
Section 4. Your costs for covered
services.................................................................................................................
12
Copayments........................................................................................................................................
12
Deductible
..........................................................................................................................................
12
Coinsurance........................................................................................................................................
12
Your out-of-pocket
maximum...................................................................................................................
12
Section 5. Benefits
.....................................................................................................................................................
13
Overview...................................................................................................................................................
13
(a) Medical services and supplies provided by
physicians and other health care professionals............ 14
(b) Surgical and anesthesia services provided by physicians and
other health care professionals ........ 22
(c)
Services provided by a hospital or other facility, and ambulance services
...................................... 26
(d)
Emergency services
.........................................................................................................................
29
(e) Mental health and substance abuse
benefits.....................................................................................
31
(f) Prescription drug
benefits.................................................................................................................
33
(g) Special
features................................................................................................................................
36
Flexible benefits option 2
2 Page 3 4
2002 Health Maintenance Plan 2 Table of Contents
Table of
Contents (Continued)
24 hour nurse line
Centers of excellence for transplants/ heart surgery
Reciprocity benefit
Discount programs
(h) Dental
benefits................................................................................................................................
38
Section 6. General exclusions --things we don't
cover..............................................................................................
41
Section 7. Filing a claim for covered services
...........................................................................................................
42
Section 8. The disputed claims
process......................................................................................................................
44
Section 9. Coordinating benefits with other
coverage
...............................................................................................
46
When you have…
Other health coverage
........................................................................................................................
46
Original
Medicare..............................................................................................................................
46
Medicare managed care plan
.............................................................................................................
48
TRICARE/ Workers' Compensation/
Medicaid...........................................................................................
49
Other Government
agencies.......................................................................................................................
49
When others are responsible for
injuries....................................................................................................
49
Section 10. Definitions of terms we use in this
brochure............................................................................................
50
Section 11. FEHB
facts...............................................................................................................................................
52
Coverage information
No pre-existing condition
limitation
..................................................................................................
52
Where you get information about enrolling in the
FEHB Program ................................................... 52
Types of coverage available for you and your
family.......................................................................
52
When benefits and premiums
start.....................................................................................................
52
Your medical and claims records are confidential
.............................................................................
53
When you retire
.................................................................................................................................
53
When you lose benefits
When FEHB coverage ends
..............................................................................................................
53
Spouse equity
coverage.....................................................................................................................
53
Temporary Continuation of Coverage (TCC)
...................................................................................
53
Converting to individual
coverage....................................................................................................
54
Getting a Certificate of Group Health Plan
Coverage.........................................................................
54
Long term care insurance is coming later in 2002
.......................................................................................................
55
Index
............................................................................................................................................................................
56
Summary of benefits
....................................................................................................................................................
57
Rates
..............................................................................................................................................................
Back cover 3
3 Page
4 5
2002 Health Maintenance Plan 3 Introduction/ Plain Language
Introduction
Health Maintenance Plan 1351 William Howard Taft
Road
Cincinnati, Ohio 45206-1775
This brochure describes the benefits of
Community Insurance Company, dba Anthem Blue Cross and Blue Shield*, under our
contract (CS 1659) 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, 2002, unless those
benefits are also shown in this brochure.
OPM negotiates benefits and rates
with each plan annually. Benefit changes are effective January 1, 2002, and
changes summarized on page 7. Rates are shown at the end of this brochure.
*An independent licensee of the Blue Cross and Blue Shield Association.
Anthem Blue Cross and Blue Shield is the trade name of Community Insurance
Company. Registered marks Blue Cross and Blue Shield Association.
Plain Language
Teams of Government and health plans' staff worked
on all FEHB brochures to make them responsive, accessible, and understandable to
the public. For instance,
Except for necessary technical terms, we use common words. For instance,
"you" means the enrollee or family
member; "we" means Health Maintenance
Plan.
We limit acronyms to ones you know. FEHB is the Federal Employees Health
Benefits Program. OPM is the
Office of Personnel Management. If we use
others, we tell you what they mean first.
Our brochure and other FEHB plans' brochures have the same format and similar
descriptions to help you compare
plans.
If you have comments or suggestions about
how to improve the structure of this brochure, let OPM know. Visit OPM's
"Rate Us" feedback area at www. opm. gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov.
You may
also write to OPM at the Office of Personnel Management, Office of Insurance
Planning and Evaluation Division, 1900 E Street, NW, Washington, DC 20415-3650.
4
4 Page 5 6
2002 Health Maintenance Plan 4 Inspector General
Advisory
Inspector General Advisory
Stop health care fraud!
Fraud increases the cost of health care for everyone. If you suspect that a
physician, pharmacy, or hospital has charged you for services you did not
receive, billed you twice for the same service, or misrepresented any
information, do the following:
Call the provider and ask for an explanation. There may be an error. If the
provider does not resolve the matter, call us at 800/ 848-9276 and
explain
the situation. If we do not resolve the issue, call or write:
THE HEALTH CARE FRAUD HOTLINE 202/ 418-3300
The United States
Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400 Washington, DC 20415
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB
Program benefits can be prosecuted for fraud. Also, the Inspector General may
investigate anyone
who uses an ID card if the person tries to obtain
services for someone who is not an eligible family member, or is no longer
enrolled in the Plan and
tries to obtain benefits. Your agency may also take
administrative action against you. 5
5 Page 6 7
2002 Health Maintenance Plan 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 Plan
providers, you will not have to submit claim forms or pay bills. You only pay
the copayments, coinsurance, and deductibles described in this brochure. When
you receive emergency services from
non-Plan providers, you may have to
submit claim forms.
You should join an HMO because you prefer the plan's
benefits, not because a particular provider is available. You cannot change
plans because a provider leaves our Plan. We cannot guarantee that any one
physician,
hospital, or other provider will be available and/ or remain
under contract with us.
How we pay providers
We contract with
individual physicians, medical groups, and hospitals to provide the benefits in
this brochure. These Plan providers accept a negotiated payment from us, and you
will only be responsible for your copayments or
coinsurance.
Your Rights
OPM requires that all FEHB Plans provide certain
information to their FEHB members. You may get information about us, our
networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure) lists the specific
types
of information that we must make available to you. Some of the
required information is listed below:
Disenrollment rates for 2000
Compliance with State and Federal licensing or certification requirements and
the dates met. If noncompliant, the
reason for noncompliance. Accreditations
by recognized accrediting agencies and the dates received
Whether the
carrier meets State, Federal and accreditation requirements for fiscal solvency,
confidentially and transfer of medical record
Years in existence Profit
status
Medical Records Transitional Care
If you want more information about us, call 800/ 228-4375, or write to Mail
No. CC1-014, 1351 William Howard Taft Road, Cincinnati, Ohio 45206-1775. You may
also contact us by fax at 513/ 872-3929 or visit our website at
www. anthem. com. 6
6
Page 7 8
2002
Health Maintenance Plan 6 Section 1
Service Area
To enroll in
this Plan, you must live in or work in our service area. This is where our
providers practice. Our service area is:
Cincinnati Area: In Ohio --Brown, Butler,
Clermont, Clinton, Hamilton, and Warren counties, and ZIP codes 45110 and 45142
in Highland County
Cleveland Area: In Ohio
--Cuyahoga, Geauga, Lake, Lorain, Medina, and Summit counties,
and ZIP codes 44032, 44033, 44066, 44076, 44084, 44085, 44093 and 44099 in
Ashtabula County
Dayton Area: In Ohio --Butler,
Champaign, Clark, Clinton, Greene, Miami, Montgomery, Preble, Shelby, and Warren
counties, ZIP codes 45304, 45313, 45328, 45329, 45331, 45332, 45336, 45352,
45358 and 45380 in Darke
County, 43128 and 43142 in Fayette County, and
43310, 43311, 43318, 43319, 43324, 43331, 43333, 43343 and 43357 in Logan County
Akron-Canton Area: In Ohio --Ashland, Carroll,
Harrison, Holmes, Medina, Portage, Stark, Summit, Tuscarawas, and Wayne counties
Warren-Youngstown Area: In Ohio --Columbiana,
Jefferson, Mahoning, and Trumbull counties
Columbus Area: In
Ohio --Coshocton, Delaware, Fairfield, Franklin, Licking,
Pickaway, and Union counties, and ZIP codes 43029, 43064, 43140, 43143, 43151,
43153 and 43162 in Madison County
Toledo-Defiance Area: In Ohio --Allen, Defiance, Erie,
Fulton, Hancock, Henry, Huron, Lucas, Ottawa, Paulding, Putnam, Seneca,
Williams, and Wood counties, ZIP codes 43407, 43410, 43420, 43431, 43435, 43442,
43448, 43469
and 44841 in Sandusky County, and 45832, 45863, 45886 and 45891
in Van Wert County
Ordinarily, you must receive care from providers who
contract with us. If you receive care outside our service area, we will pay only
for emergency or urgent care benefits. We will not pay for any other health care
services out of our
service area unless the services have prior plan
approval.
If you or a covered family member move outside of our service
area, you can enroll in another plan. If your dependents live out of the area
(for example, if your child goes to college in another state), you should
consider
enrolling in a fee-for-service plan or an HMO that has agreements
with affiliates in other areas. Refer to Section 5( g). Special Features
on page 37 for details regarding our reciprocity benefits. If you or a
family member
move, you do not have to wait until Open Season to change
plans. Contact your employing or retirement office. 7
7
Page 8 9
2002
Health Maintenance Plan 7 Section 2
Section 2. How we change for 2002
Do not rely on these change descriptions; this page is not an official
statement of benefits. For that, go to Section 5, Benefits.
Also, we edited and clarified language throughout the brochure; any
language change not
shown here is a clarification that does not change
benefits.
Program-wide changes
We changed the address for sending
disputed claims to OPM. ( Section 8 )
Changes to this Plan
Your
share of the non-Postal premium will increase by 27% for Self Only or 44% for
Self and Family.
We changed speech therapy benefits by removing the
requirement that services must be required to restore functional speech.
(Section 5( a) )
We no longer limit total blood cholesterol tests to certain age groups.
(Section 5( a) )
We now cover certain intestinal transplants. (Section 5( b)
)
We clarified the Preventive care, adult benefits by removing the entry for
blood lead level testing for adults because it is a test more typically done for
children. ( Section 5( a) )
We clarified the Family planning and Infertility benefits by providing more
examples of covered and not covered benefits. ( Section 5( a) )
We clarified
Surgical procedures to show that we cover a comprehensive range of services,
such as operative procedures. ( Section 5( b) )
The urgent care copay will
increase from $5 to $25 per visit.
The emergency room copay will increase
from $25 to $50 per visit.
The $1,500 calendar year maximum for durable
medical equipment/ orthopedic and prosthetic devices and reconstructive surgery
(breast prostheses) will be removed.
The prescription drug copays for a 30-day supply will increase from: $5 copay
for generic, $12 for formulary name brand and $24 for non-formulary name brand
to $8 for generic, $15 for formulary name brand and $25 for
non-formulary
name brand.
The prescription drug copays for a 90-day supply will increase
from: $10 copay for generic, $24 for formulary name brand and $36 for
non-formulary name brand to $16 for generic, $30 for formulary name brand and
$40 for
non-formulary name brand.
The two consecutive month time limit on
rehabilitative therapy is being eliminated. Physical and occupational therapy
will now be provided for up to 60 visits per year, speech therapy will now be
provided for up to 20 visits
per year and cardiac rehabilitation will now be provided based upon the
Plan's medical policy. 8
8 Page
9 10
2002 Health Maintenance Plan 8 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
800/ 228-
4375.
Where you get covered care You get care from "Plan providers" and
"Plan facilities." You will only pay copayments and/ or coinsurance, and you
will not have to file claims.
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 primary/ specialty/ etc, providers in the provider
directory, which we update periodically. The list is also on our website at
www. anthem. com.
Plan facilities
Plan facilities are hospitals and other facilities in our service area that
we contract with to provide covered services to our members. We list these
in the provider directory, which we update periodically. The list is also on
our website at www. anthem. com.
It depends on the type of care you need. First, you and each family member
must choose a primary care physician (PCP). This decision is
important since
your primary care physician provides or arranges for most of your health care.
How you choose a PCP
1. Ask family and friends about their
doctors. While you're at it, ask health care practitioners you respect, too.
Personal
recommendations can mean a lot.
2. Consider a get-acquainted visit if the
doctor is accepting new patients. (Many doctors do not charge for such an
appointment, but
make sure.) Use this time to ask questions, not to get
advice about specific medical complaints.
Here are some questions you might ask:
What are your office hours?
Who will handle my care when you aren't available?
3. Pay attention.
Does the physician explain things so you can understand? Are you comfortable
talking with him or her? Is the
tone of the conversation friendly and
respectful? Is the physician listening carefully to you?
What you must do to get covered care 9
9
Page 10 11
2002
Health Maintenance Plan 9 Section 3
Primary care Your primary
care physician can be a family practitioner, internist or pediatrician. Your
primary care physician will provide most of your
health care, or give you a
referral to see a specialist.
If you want to change primary care physicians
or if your primary care physician leaves the Plan, call us. We will help you
select a new one.
Specialty care Your primary care physician will refer you to a
specialist for needed care. When you receive a referral from your primary care
physician, you must
return to the primary care physician after the
consultation, unless your primary care physician authorized a certain number of
visits without
additional referrals. The primary care physician must provide
or authorize all follow-up care. Do not go to the specialist for return visits
unless your
primary care physician gives you a referral. However, you may
see optometrists and OB/ GYNS without a referral.
How do I get specialty care?
Except in a medical emergency or when
a primary care doctor has designated another doctor to see patients when he or
she is unavailable,
you must contact your primary care doctor for a referral
before seeing any other doctor or before you obtain special services. Referral
to a
participating specialist is given at the primary care doctor's
discretion; if specialists or consultants are required beyond those
participating with us,
your primary care doctor will make arrangements for
appropriate referrals.
Before going to the specialist, for the initial consultation or for follow-up
care, make sure your primary care doctor has written a referral for you to
take with you to the specialist's office and has indicated the referral
information in your medical records. Your primary care doctor will also
notify us of the referral by telephone, fax or mail. On referrals, the
primary care doctor will give specific instructions to the specialist as to
what services are to be performed. If additional services or visits are
suggested by the specialist, you must first check with your primary care
doctor. If you are receiving services from a doctor who leaves the Plan, we
will pay for covered services until we can arrange with you
for you to be
seen by another participating doctor.
Here are other things you should know
about specialty care:
If you need to see a specialist frequently because of
a chronic, complex, or serious medical condition, your primary care physician
will work with you and the Plan to develop a treatment plan that allows you
to see your specialist for a certain number of visits
without additional
referrals. Your primary care physician will use our criteria when creating your
treatment plan (the physician may
have to get an authorization or approval
beforehand).
If you are seeing a specialist when you enroll with us, 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 us. 10
10 Page
11 12
2002 Health Maintenance Plan 10
Section 3
If you are seeing a specialist and your specialist leaves the
Plan, call your primary care physician, who will arrange for you to see another
specialist. You may receive services from your current specialist until we
can make arrangements for you to see someone else.
If you have a chronic or disabling condition and lose access to your
specialist because we:
Terminate our contract with your specialist for other
than cause
Drop out of the Federal Employees Health Benefits (FEHB) Program
and you enroll in another FEHB Plan
Reduce our service area and you enroll
in another FEHB Plan
you may be able to continue seeing your specialist for
up to 90 days after you receive notice of the change. Contact us or, if we drop
out
of the Program, contact your new plan.
If you are in the second or
third trimester of pregnancy and you lose access to your specialist based on the
above circumstances, you can
continue to see your specialist until the end
of your postpartum care, even if it is beyond the 90 days.
Hospital care Your Plan primary care physician or specialist will make
necessary hospital arrangements and supervise your care. This includes admission
to a skilled nursing or other type of facility.
If you are in the
hospital when your enrollment in our Plan begins, call our customer service
department immediately at 800/ 228-4375. 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.
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. 11
11
Page 12 13
2002
Health Maintenance Plan 11 Section 3
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 physician
must obtain precertification for services such as, but not limited to:
All inpatient admissions (except maternity)
Outpatient surgeries such as
but not limited to: hysterectomy, EGD, colonoscopy, tonsillectomy &
adenoidectomy
Cardiac rehabilitation
OB ultrasounds (second and subsequent)
Newborn
admissions that extend beyond the mother's discharge
MRI or MRA
Precertification is a procedure that requires an approval to be obtained from
us before incurring expenses for certain covered services.
When care is
evaluated, the medical necessity will be determined. For admissions, the
appropriate length of stay will also be determined. For
certain services you
will be required to use the provider designated by our Health Care Management
staff.
Medical necessity includes a review of both the service and the setting. When
approved, a copy of the approval will be provided to you, the
physician, and
the hospital or facility. The care will be covered according to your benefits
for the number of days approved unless our concurrent
review determines that
the number of days should be revised. As a result of concurrent review,
additional days of inpatient care may be approved
which exceed the number of
days originally authorized by our Health Care Management staff. With prior
notice by us, the number of days originally
authorized by precertification
may be reduced when it is determined that continued inpatient care is no longer
medically necessary.
Your PCP and other network providers know which services require
precertification and will obtain any required precertification. If a
request
is denied, the provider may request a reconsideration to be completed within 3
days of the request. An expedited reconsideration
may be requested when the
member's health requires an earlier decision.
For emergency admissions, precertification is not required; however, you must
notify your Primary Care Physician of your admission within
24 hours or as
soon as possible within a reasonable period or services after 24 hours could be
denied.
. 12
12 Page 13
14
2002 Health Maintenance Plan 12 Section 4
Section 4. Your costs for covered services
You must share the
cost of some services. You are responsible for:
Copayment A copayment
is a fixed amount of money you pay to the provider, facility, pharmacy, etc.,
when you receive services.
Example: When you see your primary care physician you pay a copayment of $10
per office visit.
Deductible We do not have a deductible.
Coinsurance Coinsurance is the percentage of our negotiated fee that
you must pay for your care.
Example: You pay 20% of our allowance for ambulance services.
Your catastrophic protection out-of-pocket maximum After your
copayments and/ or coinsurance total $1,500 per person or $3,000 per family
enrollment in any calendar year, you do not have to pay
any more for covered
services. However, copayments and/ or coinsurance for the following services do
not count toward your out-of-pocket
maximum, and you must continue to pay copayments and/ or coinsurance for
these services:
Dental services
Prescription drugs
Be sure to keep accurate records of your copayments and/ or coinsurance since
you are responsible for informing us when you reach the maximum. 13
13 Page 14 15
2002 Health Maintenance Plan 13 Section 5
Section 5. Benefits --OVERVIEW
(See page 7 for how our
benefits changed this year and page 57 for a benefits summary.)
Note: This benefits section is divided into subsections. Please read the
important things you should keep in mind at the beginning of each subsection.
Also read the General Exclusions in Section 6; they apply to the benefits
in the
following subsections. To obtain claim forms, claims filing advice,
or more information about our benefits, contact us at 800/ 228-4375.
(a) Medical services and supplies provided by physicians and other health
care professionals………………… 14-21
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 Physical and occupational therapies
Speech
therapy
Hearing services (testing, treatment, and Vision services (testing,
treatment, and
supplies) Foot care
Orthopedic and prosthetic devices
Durable medical equipment (DME)
Home health services Chiropractic
Alternative treatments Educational classes and programs
(b) Surgical and anesthesia services provided by physicians and other health
care professionals ....................... 22-25
Surgical procedures
Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and
ambulance services ..................................................... 26-28
Inpatient hospital Outpatient hospital or ambulatory
surgical center
Extended care benefits/ skilled nursing care facility benefits
Hospice
care Ambulance
(d) Emergency services
........................................................................................................................................
29-30
Medical emergency Ambulance
(e) Mental health and substance abuse
benefits....................................................................................................
31-32
(f) Prescription drug benefits
...............................................................................................................................
33-35
(g) Special features
...............................................................................................................................................
36-37 Flexible benefits option
24 hour nurse line
Reciprocity benefit
Centers of Excellence for
transplants/ heart surgery
Discount programs
(h) Dental benefits
................................................................................................................................................
38-40
Summary of benefits
...................................................................................................................................................
57 14
14 Page 15
16
2002 Health Maintenance Plan 14 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 care.
We have
no calendar year deductible.
Be sure to read Section 4, Your costs for
covered services, for valuable information about how cost sharing works.
Also read Section 9 about coordinating benefits with
other coverage, including with Medicare.
I M
P O
R T
A N
T
Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians, physicians assistants or nurses
In a primary care physician's office
In a specialty physician's office
Office medical consultations
Second surgical opinion
$10 per office visit
Professional services of physicians
In an urgent care center
$25 per
office visit
Professional services of physicians
During a hospital stay
In a
skilled nursing facility
At home
Nothing
Lab, X-ray and other diagnostic tests
Tests, such as:
Blood
tests
Urinalysis
Non-routine mammograms
Pathology
X-rays
Cat
Scans/ MRI
Ultrasound
Electrocardiogram and EEG
Nothing
Not covered: Sleep disorders unless we authorize them All charges 15
15 Page 16 17
2002 Health Maintenance Plan 15 Section 5( a)
Preventive care, adults You pay
Routine screenings, such as:
Total Blood Cholesterol
Colorectal Cancer Screening, including
Fecal
occult blood test
Sigmoidoscopy, screening -every five years starting at age
50
Prostate Specific Antigen (PSA test) -one annually for men age 40 and
older
Routine pap test
Routine mammogram –covered for women age 35 and older,
as follows:
From age 35 through 39, one during this five year period
From age 40
through 64, one every calendar year
At age 65 and older, one every two
consecutive calendar years
Nothing
Not covered: Physical exams required for obtaining or continuing
employment or insurance, attending schools or camp, or travel All charges
Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster
-once every 10 years, ages19 and over (except as provided for under Childhood
immunizations)
Influenza/ Pneumococcal vaccines annually, age 65 and over
$10 per office visit; Nothing for immunizations
Preventive care, children
Childhood immunizations recommended by
the American Academy of Pediatrics $10 per office visit; Nothing for
immunizations
Well-child care charges for routine examinations, immunizations and care
(through age 22)
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)
Nothing if you receive these services during your office visit,
otherwise, $10 per office visit 16
16 Page 17 18
2002 Health
Maintenance Plan 16 Section 5( a)
Maternity care You pay
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
One routine sonogram
Note: Here are some
things to keep in mind:
You do not need to precertify your normal delivery;
see page 11 for other circumstances, such as extended stays for you or your
baby.
You may remain in the hospital up to 48 hours after a regular delivery and 96
hours after a cesarean delivery. We will extend
your inpatient stay if
medically necessary.
We cover routine nursery care of the newborn child
during the covered portion of the mother's maternity stay. We will cover
other care of an infant who requires non-routine treatment only if we cover
the infant under a Self and Family enrollment.
We pay hospitalization and surgeon services (delivery) the same as for
illness and injury. See Hospital benefits (Section 5c) and
Surgery benefits
(Section 5b)
Nothing
Not covered: Subsequent routine sonograms to determine fetal age, size or
sex All charges
Family planning
Voluntary family planning
services, limited to:
Voluntary sterilization
20% of our allowance
Surgically implanted contraceptives (such as Norplant)
Note: We cover
oral and injectable contraceptives (such as Depo provera) under the prescription
drug benefit
Nothing
Intrauterine devices (IUDs)
Diaphragms (when provided in a physician's
office)
Note: See Section 5( f), Prescription drug benefit, for
coverage when purchased through a retail pharmacy
50% of our allowance
Not covered: Reversal of voluntary surgical sterilization
Voluntary abortion except when the life of the mother would be
endangered if the fetus were carried to term or when the pregnancy
is the
result of an act of rape or incest
All charges 17
17 Page 18 19
2002 Health
Maintenance Plan 17 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)
$10 per office visit; 20% of our allowance for
treatment
Diagnosis and treatment of infertility, such as:
Fertility drugs
Note: We cover injectable fertility drugs under medical benefits and oral
fertility drugs under the prescription drug benefit
50% of our allowance
Not covered: Assisted reproductive technology (ART) procedures,
such as:
In vitro fertilization Embryo transfer, gamete GIFT
and zygote ZIFT
Zygote transfer Services and supplies related
to excluded ART procedures
Cost of donor sperm Cost of donor
egg
All charges
Allergy care
Testing and treatment $10 per office visit; 20% of
our allowance for testing
and treatment
Allergy injections 20% of our allowance when performed in
an allergy
Specialist's office; otherwise, $10 per office visit at a Primary
Care
physician's office
Allergy serum 20% of our allowance
Not covered: Provocative food
testing and sublingual allergy desensitization All charges 18
18 Page 19 20
2002 Health Maintenance Plan 18 Section 5( a)
Treatment therapies You pay
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 25
Respiratory and inhalation therapy
Dialysis – Hemodialysis and peritoneal dialysis
Intravenous (IV)/
Infusion Therapy – Home IV and antibiotic therapy
Nothing
Growth hormone therapy (GHT)
Note: Growth hormone is covered under the
prescription drug benefit
Note: We will only cover GHT when we preauthorize
the treatment. We will ask you to submit information that establishes that GHT
is
medically necessary. We will ask you or your physician to submit the
following:
A letter of medical necessity
Laboratory results, and
A growth chart
We will not cover GHT or related services and supplies if you do not
request preauthorization from us.
50% of our allowance
Physical and occupational therapies
60 visits per condition for
the services of each of the following:
Qualified physical therapists and
Occupational therapists
Note: We only cover therapy to restore bodily
function when there has been a total or partial loss of bodily function due to
illness or injury
Cardiac rehabilitation following a heart transplant, bypass surgery or a
myocardial infarction. Approval is based upon our medical
policy.
Nothing
Not covered: Long-term rehabilitative therapy
Exercise
programs Inpatient hospital stays for physical therapy purposes only
All charges
Speech therapy
20 visits per condition Nothing 19
19 Page 20 21
2002 Health Maintenance Plan 19 Section 5( a)
Hearing services (testing, treatment, and supplies) You pay
Hearing testing for children through age 17 (see Preventive care,
children) $10 per office visit; Nothing if you receive these services during
your office visit
Not covered: All other hearing testing
Hearing aids,
testing and examinations for them
All charges
Vision services (testing, treatment, and supplies)
One eye
refraction per year
Note: See Preventive care, children for eye exams for
children
$10 per office visit
First pair of lenses following cataract surgery 50% of our allowance
Not covered: Eyeglasses or contact lenses and examinations for
them
Eye exercises and vision training Radial keratotomy
.
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
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)
All charges
Orthopedic and prosthetic devices
Artificial limbs and eyes; stump
hose
Externally worn breast prostheses and surgical bras, including
necessary replacements, following a mastectomy
Internal prosthetic devices, such as artificial joints, pacemakers and the
surgical implant following mastectomy
Note: See Section 5( b) for coverage
of the surgery to insert the device
50% of our allowance
Orthopedic and prosthetic devices -Continued on next page 20
20 Page 21 22
2002 Health Maintenance Plan 20 Section 5( a)
Orthopedic and prosthetic devices -Continued You pay
Corrective orthopedic appliances for non-dental treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome
Note: See Section 5( b) for coverage of the medical treatment of TMJ pain
dysfunction syndrome
50% of our allowance up to a $200 maximum
Not covered: Orthopedic and corrective shoes
Arch
supports Foot orthotics
Heel pads and heel cups
All charges
Durable medical equipment (DME)
Rental or purchase, at our option,
including repair and adjustment of durable medical equipment prescribed by your
Plan physician, such as
oxygen and oxygen equipment. Under this benefit, we also cover items such as:
Hospital beds Wheelchairs
Crutches Walkers
Blood glucose monitors;
(when purchased at a participating medical supply provider)
Insulin pumps
First pair of lenses following cataract removal
Medical supplies, such as
surgical dressings and colostomy bags
50% of our allowance
Not covered: Devices and equipment used for environmental control
or to
enhance the environmental setting, such as air conditioners,
humidifiers or air filters
Supplies that can be used by other family
members such as: adhesive tape, band-aids, alcohol and cotton balls
All charges
Home health services
Home health care ordered by a Plan physician
and provided by a registered nurse (RN), licensed practical nurse (LPN), or home
health aide
Services include oxygen therapy, intravenous therapy and
medications
Nothing
Not covered: Nursing care requested by, or for the convenience of,
the patient or
the patient's family Home care primarily for personal
assistance that does not include
a medical component and is not diagnostic,
therapeutic, or rehabilitative
Services primarily for hygiene,
feeding, exercising, moving the patient, homemaking, companionship or giving
oral medication
All charges 21
21 Page 22 23
2002 Health
Maintenance Plan 21 Section 5( a)
Chiropractic You pay
No
benefit All charges
Alternative treatments
No benefit All charges
Educational classes and programs
Coverage is limited to:
Diabetes self-management
$10 per office visit
Smoking cessation (one smoking cessation program per member, per lifetime)
Note: See Section 5( e) for individual or group counseling coverage
Nothing up to $100; All charges thereafter
Not covered: Second and subsequent smoking cessation programs All charges
22
22 Page 23
24
2002 Health Maintenance Plan 22 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by
physicians and other health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are
medically necessary.
Plan physicians must provide or arrange your care.
We have no calendar year deductible.
Be sure to read Section 4, Your
costs for covered services, for valuable information about how cost sharing
works. Also read Section 9 about coordinating benefits with
other coverage, including with Medicare.
The amounts listed below are for
the charges billed by a physician or other health care professional for your
surgical care. Look in Section 5( c) for charges associated
with the facility (i. e. hospital, surgical center, etc).
YOUR PHYSICIAN
MUST GET PRECERTIFICATION FOR SOME SURGICAL PROCEDURES. Please refer to the
precertification information shown in Section 3
to be sure which services require precertification and identify which
surgeries require precertification.
I M
P O
R T
A N
T
Benefit Description You pay
Surgical procedures
A
comprehensive range of services, such as: Operative procedures
Treatment of fractures, including casting Treatment of burns
Normal
pre-and post-operative care by the surgeon Endoscopy procedures
Biopsy
procedures Removal of tumors and cysts
Correction of congenital anomalies
(see Reconstructive surgery) Surgical treatment of morbid obesity --a condition:
In which an individual weighs 100 pounds over, or 100% over his or her
normal weight according to current underwriting
standards That has persisted
for a duration of at least five years
For which physician monitored and
sanctioned non-surgical treatment has been unsuccessful for at least twelve to
eighteen
consecutive months Eligible members must be age 18 or over
Insertion of internal prosthetic devices, such as pacemakers and artificial
joints. See Section 5( a), Orthopedic and prosthetic
devices, for
device coverage information.
Note: Generally, we pay for internal prostheses
(devices) according to where the procedure is done. For example, we pay Hospital
benefits for
a pacemaker and Surgery benefits for insertion of the pacemaker.
Nothing
Surgical procedures -Continued on next page 23
23 Page 24 25
2002 Health Maintenance Plan 23 Section 5( b)
Surgical procedures (Continued) You pay
Voluntary sterilization 20% of our allowance
Not covered: Reversal of voluntary sterilization
Routine
treatment of conditions of the foot; see Foot care in Section 5( a)
All
charges
Reconstructive surgery
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
The
condition produced a major effect on the member's appearance and
The condition can reasonably be expected to be corrected by such surgery
Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form or norm. Examples of
congenital
anomalies are: cleft lip; cleft palate; 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
Nothing
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
50% of our allowance
Not covered: Cosmetic surgery – any surgical procedure (or any
portion of a
procedure) performed primarily to improve physical appearance
through change in bodily form, except repair of accidental injury
Surgeries related to sex transformation
All charges 24
24 Page 25 26
2002 Health
Maintenance Plan 24 Section 5( b)
Oral and maxillofacial surgery You
pay
Oral surgical procedures, limited to:
Reduction of fractures of
the jaws or facial bones
Surgical correction of cleft lip, cleft palate or
severe functional malocclusion
Removal of stones from salivary ducts
Excision of leukoplakia or
malignancies
Excision of cysts and incision of abscesses when done as
independent procedures
Other surgical procedures that do not involve the teeth or their supporting
structures
Nothing
Medical treatment related to temporomandibular joint disease
Note: See
Section 5( a), Orthopedic and prosthetic devices, for appliance cost
Nothing up to $200; All charges thereafter
Not covered: Oral implants and transplants
Procedures
that involve the teeth or their supporting structures (such as the periodontal
membrane, gingiva, and alveolar bone)
Dental care involved in the
treatment of temporomandibular joint (TMJ) pain dysfunction or syndrome
All charges 25
25 Page 26 27
2002 Health
Maintenance Plan 25 Section 5( b)
Organ/ tissue transplants You pay
Limited to: Cornea
Heart Heart/ lung
Kidney Kidney/ Pancreas
Liver Lung: Single –Double
Pancreas Allogeneic (donor) bone marrow transplants
Autologous bone
marrow transplants (autologous stem cell and peripheral stem cell support) for
the following conditions: acute
lymphocytic or non-lymphocytic leukemia;
advanced Hodgkin's lymphoma; advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian cancer;
and testicular, mediastinal, retroperitoneal and ovarian
germ cell tumors
Intestinal transplants (small intestine) and the small intestine with
the
liver or small intestine with multiple organs such as the liver, stomach, and
pancreas
Blue Quality Centers for Transplant (BQCT)
Limited Benefits
-Treatment for breast cancer, multiple myeloma, and epithelial ovarian cancer
may be provided in an NCI-or NIH-approved
clinical trial at a
Plan-designated center of excellence and if approved by the Plan's medical
director in accordance with the Plan's protocols.
Note: We cover related medical and hospital expenses of the donor when we
cover the recipient
Nothing in a Plan designated organ transplant facility; 20% of
our
allowance in a participating, non-designated organ transplant
facility
Not covered: Implants of artificial organs
Transplants
not listed as covered Travel expenses related to transplant benefits
All charges
Anesthesia
Professional services provided in: Hospital (inpatient)
Hospital outpatient department Skilled nursing facility
Ambulatory
surgical center Office
Nothing
Not covered: Professional services provided in a dentist's office. See
Section 5( h) for dental benefits. All charges 26
26 Page 27 28
2002 Health Maintenance Plan 26 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and
ambulance services
I M
P O
R T
A N
T
Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine
they are medically necessary.
We have no calendar year deductible.
Plan physicians must provide or arrange your care and you must be
hospitalized in a Plan facility.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
The
amounts listed below are for the charges billed by the facility (i. e., hospital
or surgical center) or ambulance service for your surgery or care.
Any costs associated with the professional charge (i. e., physicians, etc.)
are covered in Sections 5( a) or (b).
YOUR PHYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please
refer to Section 3 to be sure which services
require precertification.
I M
P O
R T
A N
T
Benefit Description You pay
Inpatient hospital
Room and board,
such as: Ward, semiprivate, or intensive care accommodations
General nursing care Meals and special diets
Nursery charges
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 medications
Diagnostic laboratory tests and X-rays
Administration of blood and blood
products Blood or blood plasma, if not donated or replaced
Dressings,
splints, casts, and sterile tray services Medical supplies and equipment,
including oxygen
Anesthetics, including nurse anesthetist services
Nothing
Inpatient hospital -Continued on next page 27
27 Page 28 29
2002 Health Maintenance Plan 27 Section 5( c)
Inpatient hospital (Continued) You pay
Not
covered: Custodial care
Personal comfort items, such as telephone, television, barber services,
guest meals and beds
Private nursing care Inpatient hospital
stays for physical therapy purposes only
Inpatient hospital stays
when the patient checks out Against Medical Advice (A. M. A.)
Take
home drugs Non-covered facilities; such as schools
All charges
Outpatient hospital or ambulatory surgical center
Operating,
recovery, and other treatment rooms Prescribed drugs and medications
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: Services for sleep disorders, unless authorized by the
Plan
Take home drugs
All charges
Extended care benefits/ skilled nursing care facility benefits
Extended care/ skilled nursing facility benefits:
Up to 180 days per calendar year when full-time skilled nursing care is
necessary and confinement in a skilled nursing facility is medically
necessary as determined by a Plan doctor and approved by the Plan.
Days
0 -30
Nothing
Days 31 – 180 50% of our allowance
Not covered: Custodial care All
charges 28
28 Page
29 30
2002 Health Maintenance Plan 28
Section 5( c)
Hospice care You pay
Home Health Care provided
by Hospice nurses Nothing
Not covered: Independent nursing, homemaker services and hospice services
provided in a hospice facility All charges
Ambulance
Local professional ambulance service when medically
appropriate 20% of our allowance 29
29 Page 30 31
2002 Health
Maintenance Plan 29 Section 5( d)
Section 5 (d). Emergency services/
accidents
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure.
We have no calendar year deductible.
Be sure to read Section 4, Your
costs for covered services, for valuable information about how cost sharing
works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
I M
P O
R T
A N
T
What is a medical emergency?
A medical emergency is the sudden and
unexpected onset of a condition or an injury that you believe endangers your
life or could result in serious injury or disability, and requires immediate
medical or
surgical care. Some problems are emergencies because, if not treated
promptly, they might become more serious; examples include deep cuts and broken
bones. Others are emergencies because they are
potentially life-threatening,
such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability
to breathe. There are many other acute conditions that we may determine are
medical emergencies – what
they all have in common is the need for quick
action.
What to do in case of emergency:
Emergencies within our service area:
If you are in an emergency situation, you must contact your primary care
doctor. In extreme emergencies, 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 our member so they can notify us. You or a family
member must notify
your primary care doctor within 24 hours, unless it was not reasonably possible
to do so. It is your responsibility to ensure that your primary care doctor has
been timely notified.
If you need to be hospitalized, we must be notified within 24 hours or on the
first working day following your admission, unless it was not reasonably
possible to notify us within that time. If you are hospitalized
in a
non-Plan facility and our doctors believe care can be better provided in a Plan
hospital, you will be transferred when medically feasible with any ambulance
charges covered in full.
Benefits are available for care from non-Plan providers in a medical
emergency only if you believe delay in reaching a Plan provider would result in
death, disability or significant jeopardy to your condition.
To be covered
by us, any follow-up care recommended by non-Plan 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, we must be
notified within 48 hours or on the first working day following your admission,
unless it was not reasonably possible to notify us within that time. If a Plan
doctor
believes care can be better provided in a Plan hospital, you will be
transferred when medically feasible with any ambulance charges covered in full.
To be covered by us, any follow-up care recommended by non-Plan providers
must be approved by us or provided by Plan providers. 30
30 Page 31 32
2002 Health Maintenance Plan 30 Section 5( d)
Benefit Description You pay
Emergency within our service area
Emergency care at a doctor's office $10 per office visit
Emergency care at an urgent care center or in the outpatient department of a
hospital, including doctors' services $25 per office visit
Emergency care as
an outpatient at a hospital, including doctors' services $50 per visit; if visit
results in an admission,
you pay nothing
Not covered: Elective care or non-emergency care All charges
Emergency outside our service area
Emergency care at a doctor's
office $10 per office visit
Emergency care at an urgent care center or in the outpatient department of a
hospital, including doctors' services $25 per office visit
Emergency care as an outpatient at a hospital, including doctors' services
$50 per visit; if visit results in an admission,
you pay nothing
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 land and air ambulance service when
medically appropriate
See Section 5( c) for non-emergency service
20% of our allowance 31
31 Page 32 33
2002 Health Maintenance Plan 31 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
P O
R T
A N
T
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.
We have no deductible.
Be
sure to read Section 4, Your costs for covered services, for valuable
information about how cost sharing works. Also read Section 9 about coordinating
benefits with other
coverage, including with Medicare.
YOUR PHYSICIAN MUST GET
PREAUTHORIZATION OF THESE SERVICES. See the instructions after the benefits
description below.
I M
P O
R T
A N
T
Benefit 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
illnesses or conditions
Professional services, including medication management, individual therapy or
group therapy by providers such as psychiatrists,
psychologists, or clinical
social workers provided in:
Office
$10 per office visit
Professional services by providers such as psychiatrists, psychologists, or
clinical social workers provided in the office for treatment of tobacco
cessation
Nothing
Professional services, including medication management, individual therapy or
group therapy by providers such as psychiatrists,
psychologists, or clinical
social workers provided in:
Hospital (inpatient) Hospital outpatient
department
Nothing
Mental health and substance abuse benefits -Continued on next page 32
32 Page 33 34
2002 Health Maintenance Plan 32 Section 5( e)
Mental health and substance abuse benefits (Continued)
You pay
Diagnostic tests Nothing
Services provided by a
hospital or other facility
Services in approved alternative care settings
such as partial hospitalization, full-day hospitalization or facility based
intensive
outpatient treatment
Nothing
Not covered: Services we have not approved
Care for
psychiatric conditions that in the professional judgment of
Plan doctors are
not subject to significant improvement through relatively short-term treatment
Psychological testing when not medically necessary to determine
the
appropriate treatment of a short-term psychiatric condition
The same exclusions contained in this brochure that apply to other
benefits apply to these mental health and substance abuse benefits, unless the
services are included in a treatment plan that we approve.
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
Preauthorization To be eligible to receive these benefits you must
obtain a treatment plan and follow all of the following authorization processes:
If you feel you need mental health or substance abuse services, you
may
call: Group Health Associates at 513/ 326-9999 in the Cincinnati area
Magellan Behavioral Health at 800/ 788-4003 outside the Cincinnati area
Group Health Associates or Magellan will work with you to determine your
needs and begin the treatment planning process. Referrals for any
necessary
services will also be handled by Group Health Associates or Magellan.
Your mental health and substance abuse services must be provided by Plan
providers. You may obtain a provider directory by calling us at
800/
228-4375.
Limitation We may limit your benefits if you do not obtain a treatment
plan. 33
33 Page
34 35
2002 Health Maintenance Plan 33 Section 5( f)
Section 5 (f).
Prescription drug benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart
beginning on page 35.
All benefits are subject to the definitions, limitations and exclusions in
this brochure and are payable only when we determine they are
medically
necessary.
We have no calendar year deductible.
Prior authorization is
the process required to dispense certain drugs when the use of a drug is defined
or limited by your medical condition.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
I M
P O
R T
A N
T
There are important features you should be aware of. These include:
Who can write your prescription? A Plan physician or licensed dentist
must write the prescription.
Where you can obtain them. You may fill the prescription at an Anthem
Rx Network Plan pharmacy or by mail for maintenance medication.
We use a
formulary. Prescription drugs are prescribed by Plan doctors and dispensed
in accordance with our prescription drug formulary. All prescription drugs on
the formulary have been
approved by the Food and Drug Administration (FDA).
The formulary consists of medications that have been rigorously reviewed and
selected by a committee of practicing doctors and clinical
pharmacists for
their safety, quality and effectiveness. Coverage will be provided for both
formulary and non-formulary medications when prescribed by a Plan doctor.
However, when non-formulary
drugs are dispensed a higher copay will apply.
We have an open formulary. If your physician believes a name brand product
is necessary or there is no generic available, your physician may prescribe a
name brand drug from a formulary list. This
list of name brand drugs is a preferred list of drugs that we selected to
meet patient needs at a lower cost.
To order a prescription drug listing, call 800/ 228-4375 or visit our
website at
www. anthemprescription. com.
These are the dispensing
limitations. Prescriptions filled by a retail pharmacy or through a mail
order pharmacy have a limitation on days supply and different levels of
copayments based on the
days supply. You may obtain a 30-day supply or one commercially prepared unit
(i. e., one inhaler, one vial ophthalmic medication or insulin) at a Plan
pharmacy or up to a 90-day supply through our
mail order program. Remind
your doctor to write for the maximum days supply. Any continuous therapy
medication presently covered by us within the limits of applicable State and
Federal laws,
can be dispensed through the mail order program. Your
prescriptions will be filled using FDA dispensing guidelines.
Your prescription claims' history and patient profile information will be
used by us to administer your pharmacy program and to identify possible drug
interactions, duplications or other adverse
events that may occur. This
profile allows us to determine if you are trying to refill your prescription too
soon, which could cause your claim to be rejected and could require you to file
again at a later date.
If you receive a name brand drug, whether by mail
order or from a Plan pharmacy, the copayment for the name brand applies
regardless of whether:
A generic equivalent is unavailable The prescription order specifies
"Dispense as Written"
You choose the name brand drug instead of a generic
drug 34
34 Page 35
36
2002 Health Maintenance Plan 34 Section 5( f)
A generic equivalent will be dispensed if it is available, unless your
physician specifically requires a name brand. If you receive a name brand drug
when a Federally-approved generic drug is
available, and your physician has
not specified "Dispense as Written" for the name brand drug, you will still have
to pay the name brand copay.
Why use generic drugs? Generic drugs are lower-priced drugs that are
the therapeutic equivalent to more expensive name brand drugs. They must contain
the same active ingredients and must be
equivalent in strength and dosage to
the original name brand product. Generics cost less than the equivalent name
brand product. The U. S. Food and Drug Administration sets quality standards for
generic drugs to ensure that these drugs meet the same standards of quality
and strength as name brand drugs.
You can save money by using generic drugs. However, you and your physician
have the option to request a name brand if a generic option is available. Using
the most cost-effective medication
saves money.
When you have to file
a claim. Typically you will not have to file a claim for prescription drugs;
however, if you have had to pay for a prescription due to some unforeseen
circumstance, you will
have to submit the original prescription receipt to : Health Maintenance
Plan, Mail No. CC1-014, 1351 William Howard Taft Road, Cincinnati, OH
45206-1775.
Prescription drug benefits begin on the next page 35
35 Page 36 37
2002 Health Maintenance Plan 35 Section 5( f)
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan
physician and obtained from a Plan pharmacy or through our mail order
program:
Drugs and medicines that by Federal law of the United States
requires a physician's prescription for their purchase
FDA-approved prescription drugs, injectable drugs (such as depo provera) and
devices for birth control
Insulin
Disposable needles and syringes needed
to inject covered prescribed medications are covered at the name brand
copayment.
Diabetic supplies including insulin syringes, needles, glucose test tablets
and test tape, Benedict's solution or equivalent, glucose
monitors and
acetone test tablets are covered at the name brand copayment.
Drugs for the treatment of impotence, such as Viagra: HMP requires proof of
medical necessity prior to approving benefits.
Then, this Plan will cover a
maximum of six tablets per month, subject to the following guidelines. The
patient:
– Must be a male over age 18
– Is being treated for erectile dysfunction
(ED) regardless of the cause, and
Is not on medication containing nitrates
Smoking cessation prescription
drugs and medications
Up to a 30-day supply at a Plan pharmacy
$ 8 copay for generic
drugs
$15 copay for formulary name brand drugs
$25 copay for non-formulary name brand drugs
Up to a 90-day supply through the mail order program
$16 copay for
generic drugs
$30 copay for formulary name brand drugs
$40 copay for non-formulary name brand drugs
Note: If there is no generic equivalent available, you will still
have to
pay the name brand copay
Immuno-Suppressive Agent
Fertility drugs
Human growth hormones
50% of our allowance
Not covered: Drugs and supplies for cosmetic purposes
Vitamins, nutrients and food supplements even if a physician
prescribes or administers them
Nonprescription medicines Drugs
available without a prescription or for which there is a
nonprescription
equivalent available Drugs obtained at a Non-network pharmacy except for
out-of-area
emergencies Drugs to enhance athletic performance
Drugs for weight loss purposes (except when authorized by the Plan
doctor for treatment of morbid obesity)
Replacement prescriptions
such as lost, stolen or spilled
2002 Health Maintenance Plan 36 Section 5( g)
Section 5 (g).
Special features
Feature Description
Flexible benefits option Under the flexible benefits option, we
determine the most effective way to provide services.
We may identify
medically appropriate alternatives to traditional care and coordinate other
benefits as a less costly alternative
benefit.
Alternative benefits are
subject to our ongoing review.
By approving an alternative benefit, we
cannot guarantee you will get it in the future.
The decision to offer an alternative benefit is solely ours, and we may
withdraw it at any time and resume regular contract benefits.
Our decision
to offer or withdraw alternative benefits is not subject to OPM review under the
disputed claims process.
24 hour nurse line You have access to Personal Health Advisor (PHA), a
health information service, 24 hours a day, seven days a week. All calls are
completely confidential. You can:
Speak with a registered nurse for help
with everyday health decisions and for health counseling on chronic conditions.
Listen to pre-recorded health care topics in the Audio Health Library.
Locate doctors and hospitals in your area.
You can access Personal Health Advisor by calling 888/ 474-
2258 or through the internet website: www. pha-online. com/ anthem.
Centers of excellence for transplants/ heart
surgery
We use the Blue Quality Centers for Transplant Network (BQCT) as our
transplant network. The network consists of leading medical
facilities
throughout the nation. For a list of transplant hospitals near you, call 800/
824-0581.
We utilize a network of institutions that have met stringent clinical
standards for the following heart services:
Coronary artery bypass graft (CABG)
Percutaneous transluminal coronary
angioplasty (PTCA)
Heart valve procedures
Other major cardiovascular
procedures
You can refer to our provider directory for further information concerning
our transplant and heart surgery centers of excellence.
Special features – Continued on next page 37
37 Page 38 39
2002 Health Maintenance Plan 37 Section 5( g)
Section 5 (g).
Special features (Continued)
Feature Description
Reciprocity benefit Away from Home Care Program
HMP offers guest
memberships at affiliated HMO plans through an Away from Home Care Program.
Whenever you or a family member
is away from the HMP service area for more than 90 days, you may become a
guest member at an affiliated HMO near your destination.
Reasons to consider
a guest membership include extended out-of-town business, children away at
school, dependent children in another state,
or a winter "snowbird"
residency in the South. To determine if a guest membership is available at your
destination, call 800/ 355-6414.
If you or a family member are away from the HMP for less than 90 days you
will only have coverage for emergency or urgent care
services. You will have
to contact your primary care physician to obtain the appropriate referrals for
these services.
Discount programs Anthem Advantage
You can receive negotiated
savings on selected health and wellness services and programs simply by being an
eligible Anthem Blue Cross
and Blue Shield Health Maintenance Plan member. To obtain information about
these programs please call us at 800/ 228-4375 or
visit our website at www. anthem. com. Companies participating in
the Anthem Advantage program include:
Beltone" – free hearing exams and discounts on hearing aids
Complementary Blue SM – discounts on vitamins, herbs, sports
nutrition products, books and videotapes
GlobalFit – discounts at participating fitness clubs
Vision One
– discounts on frames, contacts, bifocals
House of Healing –
soothe your body, mind and soul with discounts on products to help you rev up or
chill out
fatbrain™ – beef up your gray matter with discounts on recommended
titles in the Anthem Bookstore at fatbrain
SafeTech – (a div. Of
Troxel) – preferred pricing on bicycle and inline skating helmets
Safe
Beginnings" – discounts on child-proofing and family safety products
FTD. com – discounts on some internet orders 38
38 Page 39 40
2002 Health Maintenance Plan 38 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 your care.
We have no calendar year deductible.
We cover hospitalization for dental
procedures only when a nondental physical impairment exists which makes
hospitalization necessary to safeguard the health of
the patient; we do not cover the dental procedure unless it is described
below.
Be sure to read Section 4, Your costs for covered services,
for valuable information about how cost sharing works. Also read Section 9
about coordinating benefits with
other coverage, including with Medicare.
I M
P O
R T
A N
T
Accidental injury benefit You pay
We cover restorative services
and supplies necessary to promptly repair within three days of an accident (but
not replace) sound natural teeth.
The need for these services must result from an accidental injury.
Nothing
Dental benefits
See benefit chart on the following page. 39
39 Page 40 41
2002 Health Maintenance Plan 39 Section 5( h)
We cover the following dental services when you use a participating
Plan dentist and we have indicated when copayments apply. This benefit
description does not list exclusions. Contact us for specific exclusions at 800/
228-
4375 or 513/ 872-8242 (in the local dialing area).
Dental Benefits
Service You pay
DIAGNOSTIC
X-rays including bite wings and panoramic; oral
examinations and treatment plan; vitality test; and
oral cancer exam
Nothing
PREVENTIVE
Prophylaxis; annual topical application of fluoride to
children age 12, preventive dental instructions
Nothing
RESTORATIVE (Fillings)
Amalgam – one surface
Amalgam – two
surfaces
Amalgam – three surfaces (Build up per tooth)
Plastic or
composite – single surface
Plastic or composite – two surfaces
80% of our allowance
ORAL SURGERY (Including preoperative and postoperative treatments under
local anesthetics)
Extraction (simple)
Alveolectomy per quadrant
Impaction (soft tissue)
Impaction (complete bony)
80% of our allowance
PROSTHODONTICS
Complete upper or lower denture
Cast chrome
partial – upper or lower
Acrylic partial – upper or lower (with clasps)
Repair broken denture
Denture adjustment
Reline upper or lower
complete denture or partial (office)
Reline upper or lower complete denture or partial (laboratory)
Space
maintainers (for primary teeth)
80% of our allowance
Dental Benefits -Continued on next page 40
40 Page 41 42
2002 Health Maintenance Plan 40 Section 5( h)
Dental Benefits (Continued)
Service You pay
PROSTHODONTICS -Continued
Stainless steel crown (for
primary teeth)
Bridge abutments or pontics
80% of our allowance
PERIODONTICS (Under local anesthetics)
Examination, treatment plan
Periodontal, root planing and curettage
Hemisection
Gingivectomy or
gingivoplasty
Osseous surgery (per quadrant)
Equilibration (entire
mouth)
80% of our allowance
ENDODONTICS (Under local anesthetics)
Pulpotomy (including
restoration)
Root canal filling – one canal
Each additional canal
Apicoectomy, performed as separate surgical procedure
80% of our allowance
ORTHODONTICS (Braces)
Initial Consultation
Diagnosis and
treatment plan
(Limited to one, two-year course of phase II treatment per
eligible child up to age 19)
80% of our allowance
Missed appointments without 24 hours prior notification $10.00
ACCIDENTAL INJURY BENEFIT
Restorative services and supplies
necessary to promptly repair within three days of accident (but not
replace) sound natural teeth.
(The need for these services
must result from an accidental injury)
Nothing
Not covered: All other dental services not shown as covered All charges
41
41 Page 42
43
2002 Health Maintenance Plan 41 Section 6
Section 6. General exclusions --things we don't cover
The
exclusions in this section apply to all benefits. Although we may list a
specific service as a benefit, we will not cover it unless your Plan doctor
determines it is medically necessary to prevent, diagnose, or
treat your
illness, disease, injury, or condition.
We do not cover the following:
Care by non-Plan providers except for authorized referrals or emergencies
(see Emergency Benefits)
Services, drugs, or supplies you receive while you
are not enrolled in this Plan
Services, drugs, or supplies that are not
medically necessary
Services, drugs, or supplies not required according to
accepted standards of medical, dental, or psychiatric practice
Experimental or investigational procedures, treatments, drugs or devices
Services, drugs, or supplies related to abortions, except when the life of
the mother would be endangered if the fetus were carried to term or when the
pregnancy is the result of an act of rape or
incest
Services, drugs, or
supplies related to sex transformations or
Services, drugs, or supplies you
receive from a provider or facility barred from the FEHB Program 42
42 Page 43 44
2002 Health Maintenance Plan 42 Section 7
Section 7. Filing a claim for covered services
When you see
Plan physicians, receive services at Plan hospitals and facilities, or obtain
your prescription drugs at Plan pharmacies, you will not have to file claims.
Just present your identification card and pay your copayment or
coinsurance.
You will only need to file a claim when you receive emergency services from
non-plan providers. Sometimes these providers bill us directly. Check with the
provider. If you need to file the claim, here is the process:
Medical and hospital benefits In most cases, providers and facilities
file claims for you. Physicians must file on the form HCFA-1500, Health
Insurance Claim Form.
Facilities will file on the UB-92 form. For claims
questions and assistance, call us at 800/ 228-4375.
When you must file a claim, such as for out-of-area care, submit it on the
HCFA-1500 or a claim form that includes the information shown below.
Bills
and receipts should be itemized and show:
Covered member's name and ID
number
Name and address of the physician or facility that provided the
service or supply
Dates you received the services or supplies
Diagnosis
Type of each
service or supply
The charge for each service or supply
A copy of the
explanation of benefits, payments, or denial from any primary payer such as the
Medicare Summary Notice (MSN) and
Receipts, if you paid for your services
Submit your claims to: Health
Maintenance Plan PO Box 37180
Louisville, KY 40233-7180
Prescription drugs When you must file a claim, such as prescription
drugs that you had to pay for, submit the original itemized Pharmacy receipt
that comes
with the prescription.
Submit your claims to: Health
Maintenance Plan Mail No. CC1-014
1351 William Howard Taft Road Cincinnati,
OH 45206-1775
Other supplies or services When you must file a dental claim, such as
out-of-network care, submit a completed Standard ADA (American Dental
Association )
Claim Form.
Submit your claims to: Dental Network of
America Ohio Claims
Two Transam Plaza Drive Oakbrook Terrace, IL 60181
43
43 Page 44
45
2002 Health Maintenance Plan 43 Section 7
Deadline for filing your claim Send us all of the documents for
your claim as soon as possible. You must submit the claim by December 31 of the
year after the year you
received the service, unless timely filing was
prevented by administrative operations of Government or legal incapacity,
provided the claim was
submitted as soon as reasonably possible.
When we need more information Please reply promptly when we ask for
additional information. We may delay processing or deny your claim if you do not
respond. 44
44 Page
45 46
2002 Health Maintenance Plan 44
Section 8
Section 8. The disputed claims process
Follow this
Federal Employees Health Benefits Program disputed claims process if you
disagree with our decision on your claim or request for services, drugs, or
supplies – including a request for preauthorization:
Step Description
1 Ask us in writing to reconsider our initial
decision. You must: (a) Write to us within 6 months from the date of our
decision; and
(b) Send your request to us at: Health Maintenance Plan, Mail
No. CC1-014,
1351 William Howard Taft Road, Cincinnati, OH 45206-1775; and
(c) Include a statement about why you believe our initial decision was
wrong, based on specific
benefit provisions in this brochure; and
(d)
Include copies of documents that support your claim, such as physicians'
letters, operative reports, bills, medical records, and explanation of benefits
(EOB) forms.
2 We have 30 days from the date we receive your request to: (a) Pay
the claim (or, if applicable, arrange for the health care provider to give you
the care); or
(b) Write to you and maintain our denial --go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider,
we will send you a copy of our request --go to step 3.
3 You or your provider must send the information so that we receive it
within 60 days of our request. We will then decide within 30 more days.
If
we do not receive the information within 60 days, we will decide within 30 days
of the date the information was due. We will base our decision on the
information we already have.
We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
90 days after the date of our letter
upholding our initial decision; or
120 days after you first wrote to us if
we did not answer that request in some way within 30 days; or
120 days after
we asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance
Programs, Contracts Division II, 1900 E Street, NW, Washington, D. C.
20415-3630. 45
45 Page
46 47
2002 Health Maintenance Plan 45
Section 8
Section 8. The disputed claims process (Continued)
Send OPM the following information:
A statement about why you
believe our decision was wrong, based on specific benefit provisions in this
brochure;
Copies of documents that support your claim, such as physicians' letters,
operative reports, bills, medical records, and explanation of benefits (EOB)
forms;
Copies of all letters you sent to us about the claim;
Copies of
all letters we sent to you about the claim; and
Your daytime phone number
and the best time to call.
Note: If you want OPM to review different claims, you must clearly identify
which documents apply to which claim.
Note: You are the only person who has a right to file a disputed claim with
OPM. Parties acting as your representative, such as medical providers, must
include a copy of your specific written consent with the
review request.
Note: The above deadlines may be extended if you show that you were unable
to meet the deadline because of reasons beyond your control.
5 OPM will review your disputed claim request and will use the
information it collects from you and us to decide whether our decision is
correct. OPM will send you a final decision within 60 days. There are no
other administrative appeals.
6 If you do not agree with OPM's decision, your only recourse is to
sue. If you decide to sue, you must file the suit against OPM in Federal court
by December 31 of the third year after the year in which you received
the
disputed services, drugs, or supplies or from the year in which you were denied
precertification or prior approval. This is the only deadline that may not be
extended.
OPM may disclose the information it collects during the review process to
support their disputed claim decision. This information will become part of the
court record.
You may not sue until you have completed the disputed claims
process. Further, Federal law governs your lawsuit, benefits, and payment of
benefits. The Federal court will base its review on the record that was
before OPM when OPM decided to uphold or overturn our decision. You may
recover only the amount of benefits in dispute.
Note: If you have a serious or life threatening condition (one that
may cause permanent loss of bodily functions or death if not treated as soon as
possible), and
(a) We haven't responded yet to your initial request for care
or preauthorization/ prior approval, then call us at 800/ 228-4375 and we will
expedite our review; or
(b) We denied your initial request for care or
preauthorization/ prior approval, then:
If we expedite our review and
maintain our denial, we will inform OPM so that they can give your claim
expedited treatment too, or
You can call OPM's Health Benefits Contracts Division II at 202/ 606-3818
between 8 a. m. and 5 p. m. eastern time. 46
46
Page 47 48
2002
Health Maintenance Plan 46 Section 9
Section 9. Coordinating benefits
with other coverage
When you have other health coverage You must tell us
if you are covered or a family member is covered under another group health plan
or have automobile insurance that pays health
care expenses without regard
to fault. This is called "double coverage."
When you have double coverage,
one plan normally pays its benefits in full as the primary payer and the other
plan pays a reduced benefit as the
secondary payer. We, like other insurers, determine which coverage is primary
according to the National Association of Insurance
Commissioners'
guidelines.
When we are the primary payer, we will pay the benefits
described in this brochure.
When we are the secondary payer, we will determine our allowance. After the
primary plan pays, we will pay what is left of our allowance, up
to our
regular benefit. We will not pay more than our allowance.
What is
Medicare? Medicare is a Health Insurance Program for:
People 65 years of
age and older.
Some people with disabilities, under 65 years of age. People
with End-Stage Renal Disease (permanent kidney failure
requiring dialysis or a transplant).
Medicare has two parts:
Part A
(Hospital Insurance). Most people do not have to pay for Part A. If you or your
spouse worked for at least 10 years in
Medicare-covered employment, you should be able to qualify for premium-free
Part A insurance. (Someone who was a Federal
employee on January 1, 1983 or
since automatically qualifies.) Otherwise, if you are age 65 or older, you may
be able to buy it.
Contact 800/ MEDICARE (800/ 633-4227) for more
information.
Part B (Medical Insurance). Most people pay monthly for Part B.
Generally, Part B premiums are withheld from your monthly Social
Security check or your retirement check.
If you are eligible for
Medicare, you may have choices in how you get your health care. Medicare managed
care plan is the term used to
describe the various health plan choices available to Medicare beneficiaries.
The information in the next few pages shows how we
coordinate benefits with
Medicare, depending on the type of Medicare managed care plan you have.
The Original Medicare Plan (Part A or Part B) The Original Medicare
Plan (Original Medicare) is available everywhere in the United States. It is the
way everyone used to get Medicare
benefits and is the way most people get
their Medicare Part A and Part B benefits now. You may go to any doctor,
specialist, or hospital that
accepts Medicare. The Original Medicare Plan pays its share and you pay your
share. Some things are not covered under Original Medicare,
like
prescription drugs.
When you are enrolled in Original Medicare along with
this Plan, you still need to follow the rules in this brochure for us to cover
your care.
Your care must continue to be authorized by your Plan PCP, or precertified as
required.
We will not waive any of our copayments and/ or coinsurance.
(Primary
payer chart begins on next page.) 47
47 Page 48 49
2002 Health
Maintenance Plan 47 Section 9
The following chart illustrates whether
the Original Medicare Plan or this Plan should be the primary payer for
you according to your employment status and other factors determined by
Medicare. It is critical that you tell us if you or
a covered family member
has Medicare coverage so we can administer these requirements correctly.
Primary Payer Chart
A. When either you --or your covered spouse --are age 65 or over and …
Then the primary payer is…
Original Medicare This Plan
1) Areanactiveemployee withthe
Federalgovernment(includingwhen you or afamilymemberare
eligibleforMedicaresolely becauseofadisability),
2) Are an annuitant,
3) Are a reemployed annuitant with the Federal
government when…
a) The position is excluded from FEHB, or…………………………… ………..
b) The position is not excluded from FEHB…………………………….
(Ask your employing
office which of these applies to you.)
……………………..………
1) Are a Federal judge who retired under title 28, U. S. C., or a Tax Court
judge who retired under Section 7447 of title 26, U. S. C. (or if
your
covered spouse is this type of judge),
2) Are enrolled in Part B
only, regardless of your employment status, (for Part B
services)
(for other services)
3) Are a former Federal employee receiving Workers' Compensation and the
Office of Workers' Compensation Programs has
determined that you are unable
to return to duty,
(except for claims related to Workers'
Compensation.)
B. When you --or a covered family member --have
Medicare based on end stage renal disease (ESRD) and…
1) Are within the first 30 months of eligibility to receive Part A benefits
solely because of ESRD,
2) Have completed the 30-month ESRD coordination
period and are still eligible for Medicare due to ESRD,
3) Become eligible
for Medicare due to ESRD after Medicare became primary for you under another
provision,
C. When you or a covered family member have FEHB and…
1) Are eligible for Medicare based on disability, and
a) Are an
annuitant, or
b) Are an active employee, or
c) Are a former spouse of an annuitant,
or
d) Are a former spouse of an active employee
Please note, if your Plan physician does not participate in Medicare, you
may have to file a claim with Medicare on occasion. 48
48 Page 49 50
2002 Health Maintenance Plan 48 Section 9
Claims process when
you have the Original Medicare Plan: You probably will never have to file a
claim when you have both our Plan and
the Original Medicare Plan.
When
we are the primary payer, we process the claim first.
When Original Medicare
is the primary payer, Medicare processes your claim first. In most cases, your
claims will be coordinated
automatically. You will not need to do anything.
To find out if you need to do something about filing your claims, call us at
800/ 228-
4375.
We do not waive any costs when you have the Original
Medicare Plan: When Original Medicare is the primary payer, we do not waive
any out-of-pocket costs.
Medicare managed care plan If you are
eligible for Medicare, you may choose to enroll in and get your Medicare
benefits from another type of Medicare+ Choice plan --a
Medicare managed care plan. These are health care choices (like HMOs) in some
areas of the country. In most Medicare managed care plans, you
can only go
to doctors, specialists, or hospitals that are part of the plan. Medicare
managed care plans provide all the benefits that Original
Medicare covers.
Some cover extras, like prescription drugs. To learn more about enrolling in a
Medicare managed care plan, contact
Medicare
at 800/ MEDICARE (800/ 633-4227) or at www. medicare. gov.
If you enroll in a Medicare managed care plan, the following options are
available to you:
This Plan and our Medicare managed care plan: You may enroll in our
Medicare managed care plan and also remain enrolled in our FEHB
plan. In
this case, we do not waive any of our copayments and/ or coinsurance for your
FEHB coverage.
This Plan and another plan's Medicare managed care plan: You may
enroll in another plan's Medicare managed care plan and also
remain enrolled
in our FEHB plan. We will still provide benefits when your Medicare managed care
plan is primary, even out of the managed
care plan's network and/ or service
area (if you use our Plan providers), but we will not waive any of our
copayments and/ or coinsurance. If you
enroll in a Medicare managed care
plan, tell us. We will need to know whether you are in the Original Meicare Plan
or in a Medicare managed
care plan so we can correctly coordinate benefits
with Medicare.
Suspended FEHB coverage to enroll in a Medicare managed
care plan: If you are an annuitant or former spouse, you can suspend your
FEHB coverage to enroll in a Medicare managed care plan, eliminating your
FEHB premium. (OPM does not contribute to your Medicare
managed care plan
premium.) For information on suspending your FEHB enrollment, contact your
retirement office. If you later want to re-enroll
in the FEHB Program,
generally you may do so only at the next open season unless you involuntarily
lose coverage or move out of the
Medicare managed care plan's service area.
If you do not enroll in Medicare Part A or
Part B
If you do
not have one or both Parts of Medicare, you can still be covered under the FEHB
Program. We will not require you to enroll in
Medicare Part B and, if you
can't get premium-free Part A, we will not ask you to enroll in it. 49
49 Page 50 51
2002 Health Maintenance Plan 49 Section 9
TRICARE TRICARE is the health care program for eligible
dependents of military persons and retirees of the military. TRICARE includes
the CHAMPUS
program. If both TRICARE and this Plan cover you, we pay first.
See your TRICARE Health Benefits Advisor if you have questions about
TRICARE
coverage.
Workers' Compensation We do not cover services that:
You need
because of a workplace-related illness or injury that the Office of Workers'
Compensation Programs (OWCP) or a similar
Federal or State agency determines
they must provide; or
OWCP or a similar agency pays for through a third
party injury settlement or other similar proceeding that is based on a claim you
filed under OWCP or similar laws.
Once OWCP or similar agency pays its
maximum benefits for your treatment, we will cover your care. You must use our
providers.
Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies are responsible for your care We do
not cover services and supplies when a local, State, or Federal Government
agency directly or indirectly pays for them.
When others are responsible for injuries When you receive money to
compensate you for medical or hospital care for injuries or illness caused by
another person, you must reimburse us for
any expenses we paid. However, we
will cover the cost of treatment that exceeds the amount you received in the
settlement
If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our subrogation
procedures. 50
50 Page
51 52
2002 Health Maintenance Plan 50
Section 10
Section 10. Definitionsof terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new
enrollees, the calendar year begins on the effective date of their enrollment
and ends on
December 31 of the same year.
Coinsurance Coinsurance is the percentage of our allowance that you
must pay for your care. See page 12.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services. See page 12.
Covered services Care we
provide benefits for, as described in this brochure.
Custodial care
Treatment or services, regardless of who recommends them or where they are
provided, that could be rendered safely and reasonably by a
person not
medically skilled, or that are designed mainly to help the patient with daily
living activities. These activities include, but are not
limited to:
Personal care such as help in walking, getting in and out of
bed, bathing, eating by spoon, tube or gastrostomy, exercising or
dressing Homemaking such as preparing meals or special diets
Moving the
patient Acting as a companion or sitter
Supervising medication that can
usually be self administered Treatment services that any person may be able to
perform with
minimal instruction, including, but not limited to, recording
temperature, pulse and respirations or administration and
monitoring of
feeding systems
We determine which services are custodial.
Experimental or investigational services A drug, device, or biological
product is experimental or investigational if the drug, device, or biological
product cannot be lawfully marketed
without approval of the U. S. Food and
Drug Administration (FDA) and approval for marketing has not been given at the
time it is furnished.
Approval means all forms of acceptance by the FDA.
A medical treatment or
procedure, or biological product is experimental or investigational if 1)
reliable evidence shows that it is the subject of
ongoing phase I, II or III
clinical trials or under study to determine its maximum tolerated dose, its
toxicity, its safety, its efficacy, or its
efficacy as compared with the
standard means of treatment or diagnosis; or 2) reliable evidence shows that the
consensus of opinion among
experts regarding the drug, device, or biological
product or medical treatment or procedure is that further studies or clinical
trials are
necessary to determine its maximum tolerated dose, its toxicity,
its safety, its efficacy, or its efficacy as compared with the standard means
of treatment or diagnosis.
Reliable evidence shall mean only published
reports and articles in the authoritative medical and scientific literature; the
written protocol or
protocols used by the treating facility or the protocol(
s) of another facility studying substantially the same drug, device, or medical
treatment or procedure; or the written informed consent used by the 51
51 Page 52 53
2002 Health Maintenance Plan 51 Section 10
treating facility or by another facility studying substantially the same
drug, device, or medical treatment or procedure.
Group health coverage
Health care coverage that a member is eligible for because of employment,
membership in, or connection with, a particular
organization or group that
provides payment for hospital, medical, or other health care services or
supplies, or that pays a specific amount for
each day or period of hospitalization.
Medical necessity Services, drugs, supplies or equipment provided by a
hospital or covered provider of the health care services that the Carrier
determines:
Are appropriate to diagnose or treat the patient's condition,
illness or injury
Are consistent with standards of good medical practice in
the United States
Are not primarily for the personal comfort of the patient,
the family or the provider
Are not a part of or associated with the
scholastic education or vocational training of the patient and
In the case
of inpatient care, cannot be provided safely on an outpatient basis
The fact that a covered provider has prescribed, recommended or approved a
service, supply, drug or equipment does not, in itself, make
it medically
necessary.
Our allowance Our allowance is the amount we use to determine our
payment and your coinsurance for covered services. Plans determine their
allowances in
different ways. We determine our allowance as follows:
Amounts charged by other providers for the same or similar service Any
unusual medical circumstances requiring additional time, skill
or experience and Other factors we determine are relevant, including, but not
limited
to, a resource based relative value scale
Us/ We Us and we refer to Health