MD-Individual Practice
Association, Inc. http: / / www. mamsi. com
RI 73-100
A Health Maintenance Organization
Serving:
Washington, DC, Maryland, Northern Virginia,
Roanoke, Richmond and
Tidewater areas
Enrollment codes for this Plan:
JP1 Self Only
JP2 Self and Family
Enrollment in this Plan is limited;
see pages 6 and 7 for
requirements.
For changes
in benefits
see page 8.
2002
This Plan has excellent accreditation
from the NCQA. See the 2001
Guide
for more information on NCQA. 1
1
Page 2 3
2002 M. D. IPA 2 Table of Contents
Table of Contents
Introduction…………………………………………………………………………………………………….. 5
Plain Language………………………………………………………………………………………………….
Inspector General Advisory…………………………………………………………………………………….
5
Section 1. Facts about this HMO
plan……………………………………………………………………... 6
How we pay
providers………………………………………………………………………….. 6
Your Rights…………………………………………………………………………………….. 6
Service Area……………………………………………………………………………………. 6
Section 2.
How we change for 2002………………………………………………………………………. 8
Program-wide changes…………………………………………………………………………. 8
Changes to this Plan……………………………………………………………………………. 8
Section 3. How you get
care……………………………………………………………………………….. 9
Identification
cards……………………………………………………………………………... 9
Where you get
covered care……………………………………………………………………. 9
Plan
providers……………………………………………………………………………… 9
Plan facilities………………………………………………………………………………. 9
What you must do to get covered
care.………………………………………………………... 9
Primary
care……………………………………………………………………………….. 9
Specialty
care……………………………………………………………………………… 10
Hospital
care………………………………………………………………………………. 11
Circumstances beyond our control……………………………………………………………..
11
Services requiring our prior
approval………………………………………………………….. 12
Section 4. Your costs for covered
services………………………………………………………………… 13
Copayments……………………………………………………………………………….. 13
Deductible…………………………………………………………………………………. 13
Coinsurance……………………………………………………………………………….. 13
Your out-of-pocket
maximum…………………………………………………………………. 13 2
2 Page 3 4
2002 M. D. IPA 3 Table of Contents
Section 5. Benefits…………………………………………………………………………………………. 14
Overview……………………………………………………………………………………….. 14
(a)
Medical services and supplies provided by physicians and other health care
professionals 15
(b) Surgical and anesthesia services
provided by physicians and other health care…………...
professionals 24
(c) Services provided by a hospital or other facility, and
ambulance services……………….. 27
(d) Emergency services/ accidents……………………………………………………………..
30
(e) Mental health and substance abuse
benefits……………………………………………….. 32
(f) Prescription drug
benefits…………………………………………………………………. 34
(g) Special
features ……………………………………………………………………………
Flexible benefits
options………………………………………………………………
Centers of Excellence
………………………………………………………………...
WeeCall Program …………………………………………………………………….
Plan Publications ……………………………………………………………………..
Health Education and
Disease Management Programs………………………………
36
36
36
36
36
36
(h) Dental benefits…………………………………………………………………………….. 37
(i) Non-FEHB benefits available to Plan
members…………………………………………... 39
Section 6. General
exclusions – things we don't cover……………………………………………………. 40
Section 7. Filing a claim for covered services……………………………………………………………... 41
Section 8. The disputed claims
process……………………………………………………………………. 42
Section 9. Coordinating benefits with other coverage……………………………………………………..
44
When you have….
Other health coverage……………………………………………………………………...
44
Original Medicare…………………………………………………………………………. 44
Medicare managed care plan………………………………………………………………. 46
TRICARE/ Workers' Compensation/
Medicaid………………………………………………… 47
Other Government
agencies……………………………………………………………………. 47
When others are responsible for
injuries……………………………………………………….. 47
Section 10. Definitions of terms we use in this brochure……………………………………………………
48
Section 11. FEHB facts
…………………………………………………………………………………….. 49
Coverage
information…………………………………………………………………………… 49
No pre-existing condition
limitation……………………………………………………… 49
Where you get information about enrolling in the FEHB Program………………………. 49
3
3 Page 4 5
2002 M. D. IPA 4 Table of Contents
When
benefits and premiums start……………………………………………………….. 49
Your medical and claims records are
confidential……………………………………….. 50
When you
retire…………………………………………………………………………...
When you lose
benefits………………………………………………………………………....
50
50
When FEHB coverage ends………………………………………………………………. 50
Spouse equity
coverage…………………………………………………………………...
Temporary Continuation of Coverage
(TCC) ……………………………………………
50
50
Converting to
individual coverage………………………………………………………... 51
Getting a Certificate of
Group Health Plan Coverage……………………………………. 51
Long term
care insurance is coming later in 2002 ……………………………………………………… 52
Department of Defense/ FEHB Demonstration Project
……………………………………………………… 53
Index
………………………………………………………………………………………………….. 55
Summary of
benefits ………………………………………………………………………………………… 56
Rates
………………………………………………………………………………………………….. 58 4
4
Page 5 6
2002 M. D. IPA 5 Introduction/ Plain Language
Introduction
MD-Individual Practice Association, Inc. (MD-IPA)
4 Taft Court
Rockville, MD 20850
This brochure describes the benefits of MD-IPA under our contract (CS 1935)
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 are
summarized on page 8. Rates
are shown at the end of this brochure.
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 MD-IPA.
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
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 301/ 360-8080, or
800-251-0956 and explain the situation.
If we do not resolve the issue,
call
THE HEALTH CARE FRAUD HOTLINE
202/ 418-3300 or write:
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 M. D. IPA 6 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to
see specific physicians, hospitals, and other providers that
contract with
us. These Plan providers coordinate your health care services.
HMOs emphasize preventive care such as routine office visits, physical exams,
well-baby care, and immunizations, in addition to
treatment for illness and
injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit
claim forms or pay bills. You only pay the copayments
and coinsurance
described in this brochure. When you receive emergency services from non-Plan
providers, you may have to submit
claim forms.
You should join an HMO because you prefer the plan's benefits, not because
a particular provider is available. You cannot change plans because a provider
leaves our Plan. We cannot guarantee that any one physician, hospital, or other
provider will
be available and/ or remain under contract with us.
How we
pay providers
We contract with individual physicians, medical groups,
and hospitals to provide the benefits in this brochure. These Plan providers
accept a negotiated payment from us, and you will only be responsible for
your copayments or coinsurance.
Your Rights
OPM requires that all FEHB Plans to 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.
If you want more information about us, call MD-IPA's Member Services Office
at 301/ 360-8080 or at 1-800/ 251-0956 (TTY:
301/ 360-8111 or 1-800/
553-7109), or write to P. O. Box 933, Frederick, and Maryland 21705. You may
also contact us by fax at
301/ 360-8907 or visit our website at www. mamsi. com.
Service Area
To enroll in this Plan, you must live in or work in
our Service Area. This is where our providers practice.
Our service area is:
Washington, D. C.;
Maryland (the entire state)
Virginia
Cities of: Alexandria, Charlottesville, Chesapeake, Clifton Forge,
Colonial Heights, Covington, Emporia, Fairfax, Falls
Church, Franklin,
Fredericksburg, Hampton, Hopewell, Manassas, Manassas Park, Newport News,
Norfolk,
Petersburg, Poquoson, Portsmouth, Radford, Richmond, Roanoke,
Salem, Staunton, Suffolk, Virginia Beach,
Waynesboro and Williamsburg
Counties of: Accomack, Albemarle, Alleghany, Amelia, Arlington,
Augusta, Bath, Bedford, Bland, Botetourt, Buchanan,
Buckingham, Caroline,
Charles City, Chesterfield, Clarke, Craig, Cumberland, Dinwiddie, Fairfax,
Fauquier, Floyd,
Franklin, Giles, Goochland, Gloucester, Greensville,
Hanover, Henrico, Isle of Wight, James City, King George,
King William, King
and Queen, Loudoun, Louisa, Mathews, Middlesex, Montgomery, Nelson, New Kent,
Northampton, Nottoway, Orange, Page, Patrick, Powhatan, Prince George,
Prince William, Pulaski, Rappahannock,
Roanoke, Russell, Southampton,
Spotsylvania, Stafford, Surry, Sussex, Tazewell, Westmoreland, Wythe, and York.
6
6 Page 7 8
2002 M. D. IPA 7 Section 1
Ordinarily, you
must get your care from providers who contract with us. If you receive care
outside our service area, we will pay only
for emergency care 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 moves outside of our service area, you can
enroll in another plan. If your dependents live out of
the area (for
example, if your child goes to college in another state), you should consider
enrolling in a fee-for-service plan or an
HMO that has agreements with
affiliates in other areas. If you or a family member moves, you do not have to
wait until Open Season
to change plans. Contact your employing or retirement
office. 7
7 Page 8
9
2002 M. D. IPA 8 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 now cover certain intestinal
transplants. (Section 5( b))
Changes to this Plan
Your share of the non-Postal premium will
be increase by 10.7% for Self Only coverage, or by 10.3% for Self and Family
coverage.
You pay a $20 specialist copayment per office visit.
You pay a $25
urgent care center copayment or $50 a hospital copayment for emergency care.
You pay a $50 outpatient copayment for products, services, and/ or test at
hospital outpatient departments or ambulatory surgical centers.
You pay $15 for brand name drugs in our formulary or $30 for non-formulary
drugs.
Hearing aids for children under 19 years old are covered with a 50%
copayment up to $1,400 per ear every 36 months.
We clarified Chiropractic
services to show coverage is up to a maximum of $500.
We changed
the speech therapy benefit to combine both rehabilitative and habilitative
services. Habilitative speech therapy no longer has an age limit. All speech
therapy is limited to two months or sixty (60) days, whichever is greater.
(Section 5 (a))
We have changed the age at which members can get routine vaccines for
influenza from age 65 to age 50. 8
8 Page 9 10
2002 M. D. IPA 9 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card. You
should carry your ID card with you at all times. You must show it whenever you
receive
services from a Plan provider, or fill a prescription at a Plan
pharmacy.
Until you receive your ID card, use your copy of the Health
Benefits
Election Form, SF-2809, your health benefits enrollment
confirmation
(for annuitants), or your Employee Express confirmation letter.
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 301/
360-
8080 or 1-800/ 251-0956.
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.
All of our physicians are credentialed in
accordance with the standards
set by the National Committee for Quality
Assurance (NCQA). For
further information on our credentialing procedures,
please contact our
Member Services Department 301/ 360-8080 or 1-800/
251-0956.
We list Plan providers in the provider directory, which we update
periodically. The list is also on our website, www. mamsi. com.
Information in the
directory is subject to change. For this reason, we
recommend that you
access our website to look up the most up-to-date
information.
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, www. mamsi. com. Information in the directory is
subject to change. For this reason, we recommend that you access our
website to look up the most up-to-date information.
What you must do to get covered care It depends on the type of care
you need. First, you and each family member must choose a primary care
physician. This decision is
important since your primary care physician
provides or arranges for
most of your health care. To choose a Primary Care
Physician, select
the PCP of your choice either from the provider directory,
or from our
website. You may call the Member Services Department at 301/
360-
8080 or 1-800/ 251-0956 and we will make the change for you over the
phone. Or, if you wish, you may complete the "Federal Information
Form"
included in your open season information packet and mail it to us
at P. O.
Box 943, Frederick, Maryland 21705.
Primary care Your primary care physician can be an internist, an
obstetrician/ gynecologist for a woman, a pediatrician for a child, or a
general/ family practitioner for any member of the family. 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. 9
9 Page 10 11
2002 M. D. IPA 10 Section 3
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,
female members
may see a participating obstetrician or gynecologist, or
a participating
Certified Nurse Midwife, for obstetrical and
gynecological care without a
referral. Obstetrical and gynecological
services include routine care and
follow-up services, as well as
medically necessary services. Eye refractions
and dental care are also
available from Plan providers without a referral.
Here are other things you should know about specialty care:
If you need
to see a specialist frequently because of a chronic, complex, or serious medical
condition, your primary care
physician will develop a treatment plan that allows you to see your
specialist for a certain number of visits without additional
referrals.
Your primary care physician will use our criteria when
creating your
treatment plan (the physician may have to get an
authorization or approval
beforehand).
If you are seeing a specialist when you enroll in our Plan, talk to your
primary care physician. Your primary care physician will
decide what
treatment you need. If he or she decides to refer you
to a specialist, ask
if you can see your current specialist. If your
current specialist does not
participate with us, you must receive
treatment from a specialist who does.
Generally, we will not pay
for you to see a specialist who does not
participate with our Plan.
If you are seeing a specialist and your specialist leaves the Plan, call
your primary care physician, who will arrange for you to see
another
specialist. You may receive services from your current
specialist until we
can make arrangements for you to see someone
else.
If you have a chronic or disabling condition and lose access to your
specialist because we:
-terminate our contract with your specialist for other than
cause; or
-drop out of the Federal Employees Health Benefits (FEHB)
Program
and you enroll in another FEHB Plan; or
-reduce our service area and you enroll in another FEHB Plan,
You
may be able to continue seeing your specialist for up to 90
days after you
receive notice of the change. Contact us or if we
drop out of the Program,
contact your new plan.
If you are in the second or third trimester of pregnancy and you lose
access to your specialist based on the above circumstances, you can
continue to see your specialist until the end of your postpartum care,
even if it is beyond the 90 days. 10
10 Page 11 12
2002 M. D. IPA
11 Section 3
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 Member Services Department immediately at 301/ 360-8080 or
1-800/
251-0956. 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 M. D. IPA 12 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 some services such as, but not
limited to
the following:
Acupuncture
Biofeedback
Breast Reconstruction/ Breast Reduction
Reconstructive surgery
Growth Hormone Therapy (GHT)
Infertility
Services
Morbid Obesity Surgery
Rhinoplasty
Therapies
(Physical Therapy, Occupational Therapy and Speech Therapy) for members under
the age of ten (10)
Temporomandibular Joint (TMJ) Pain Dysfunction and/ or related
Myofascial Pain Dysfunction (MPD) treatment
Transplants
Uvulopalatopharyngoplasty
Most Durable Medical Equipment, Orthopedic and
Prosthetic Devices
In addition, your admitting physician and facility must also preauthorize
any elective inpatient stays.
It is your primary care physician or specialist's responsibility to
obtain precertification for the procedures listed above before performing
them. If the PCP/ specialist does not do this, you will not be liable for
the
cost of covered services.
We will decide whether or not to precertify a procedure within two
working days of the receipt of the information we need to make a
decision.
If we deny the request or if you wish to extend the number of authorized
visits, your primary care physician or specialist may ask us to reevaluate
our decision or extend the number of authorized visits at any time. A
decision will be made within one working day of receiving all of the
information we need to make the decision.
If you are not satisfied with our decision, you, or your primary care
physician or specialist on your behalf, may appeal the decision. 12
12 Page 13 14
2002 M. D. IPA 13 Section 4
Section 4.
Your costs for covered services
You must share the cost of some
services. You are responsible for:
Copayments A copayment is a
fixed amount of money you pay to the provider, facility, pharmacy, etc. when you
receive services.
Example: When you see your primary care physician you pay
a
copayment of $10 per office visit and when you go in the hospital, you
pay nothing per admission.
Deductible We do not have a deductible.
Coinsurance Coinsurance is the percentage of our negotiated fee that
you must pay for your care.
Example: In our Plan, you pay 50% of our
allowance for infertility
services and durable medical equipment.
Your catastrophic protection out-of-pocket maximum
for coinsurance and copayments
After your copayments and/ or coinsurance total $1,800 per person or
$4,800 per family enrollment in any calendar year, you do not have to
pay any more for covered services. However, copayments and
coinsurance
for the following services do not count toward your out-of-pocket
maximum,
and you must continue to pay copayments and
coinsurance for these services:
Prescription drugs
Dental Services
Eyeglasses or contact lenses
In-vitro fertilization
Be sure to keep accurate records of your copayments and coinsurance
since
you are responsible for informing us when you reach the maximum. 13
13 Page 14 15
2002 M. D. IPA 14 Section 5
Section 5. Benefits – OVERVIEW
(See page 8 for how our benefits changed this year and page 56 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
subsections. To obtain claims forms, claims filing advice,
or more information about our benefits, contact us at
301/ 360-8080 or
1-800/ 251-0956 or at our website at www. mamsi.
com.
1. Medical services and supplies provided by physicians and other health care
professionals…………………. 15-24
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, cardiac
and occupational therapies
Speech therapy
Habilitative therapies
Hearing services
(testing, treatment, and supplies)
Vision services (testing, treatment,
and supplies)
Foot care
Orthopedic and prosthetic devices
Durable medical equipment (DME)
Home health services
Chiropractic
Alternative treatments
Educational classes and programs
2. Surgical and anesthesia services provided by physicians and other health
care professionals………………. 25-27
Surgical procedures
Reconstruction surgery
Oral and
maxillofacial surgery
Organ/ tissue transplants
Anesthesia
3. Services provided by a hospital or other facility, and ambulance
services…………………………………... 28-30
Inpatient hospital
Outpatient
hospital or ambulatory surgical center
Extended care benefits/ skilled
nursing care facility benefits
Hospice care
Ambulance
4. Emergency services/ accidents………………………………………………………………………………... 31-32
Medical emergency Ambulance
5. Mental health and substance abuse
benefits...……………………………………………………………...… 33-34
6. Prescription drug
benefits…………………………………………………………………………………..… 35-36
7. Special
features…………………………………………………………………………………………………... 37
Flexible benefits
option
Diabetic self-management classes
Childbirth Education Classes
(h) Dental benefits……………………………………………………………………………………………...…. 38-39
(i)
Non-FEHB benefits available to Plan members………………………………………………………………….. 40
Summary of benefits………………………………………………………………………………………………..… 57 14
14 Page 15 16
2002 M. D. IPA 15 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
In physician's office
Office medical consultations
Second surgical opinion
$10 per office visit to your primary
care physician
$20 per office visit to a specialist
Professional services of physicians
In an urgent care center
During a hospital stay
In a skilled nursing facility
Nothing
At home $10 per visit from your primary care
physician
$20 per visit from a specialist
Lab, X-ray and other diagnostic tests
Tests, such as:
Blood
tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG
Nothing if you receive these services
during your office visit;
otherwise,
$20 per office visit to a specialist
$50 per outpatient hospital visit 15
15 Page 16 17
2002 M. D. IPA 16 Section 5( a)
Preventive care, adult 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
$10 per office visit to your primary
care physician
$20 per office visit to a specialist
Prostate Specific Antigen (PSA test) – one annually for men age 40 and older
$10 per office visit to your primary
care physician
$20 per office visit to a specialist
Routine pap test
Note: The office visit is covered if pap test is
received on the same day; see
Diagnostic and Treatment services,
above.
$10 per office visit to your primary
care physician
$20 per office visit to a specialist
Nothing per visit to a Certified
Nurse
Midwife
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
$10 per office visit to your primary
care physician
$20 per office visit to a specialist
$50 per outpatient hospital visit
Not covered: Physical exams and immunizations 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, ages 19 and over (except as provided for under Childhood
immunizations.)
Influenza vaccine, annually, age 50 and over
Pneumococcal vaccine,
once after age 65 or older
$10 per office visit to your primary
care physician
$20 per office visit to a specialist
Preventive care, children
Childhood immunizations recommended by
the American Academy of Pediatrics (AAP), American Academy of Family Physicians
(AAFP), and
the Advisory Committee on Immunization Practices (ACIP)
$10 per office
visit to your primary
care physician
$20 per office visit to a specialist
Examinations, such as:
-Ear exams to determine the need for
hearing correction
-Examinations done on the day of immunizations (up
to age 22)
Well-child care for routine examinations, immunizations and
care (up to age 22)
$10 per office visit to your primary
care physician
$20 per office visit to a specialist
Eye exams to determine the need for vision correction $25 per office visit
to a specialist 16
16 Page
17 18
2002 M. D. IPA 17 Section 5( a)
Maternity Care You pay
Complete maternity (obstetrical) care,
such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:
Office visit copays for
routine obstetrical care are waived after the first maternity care visit.
Routine care includes office visits, one office sonogram (as part of
prenatal care) and lab work.
You do not have to obtain a referral to see a
participating obstetrician or gynecologist, or a participating Certified Nurse
Midwife, for obstetrical
and gynecological care. Obstetrical and
gynecological services include
routine care and follow-up services, as well
as medically necessary
services. A participating obstetrician/ gynecologist
may issue referrals for
pregnancy-related illnesses through the postpartum
period.
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.
Circumcisions are covered 100% during newborn stay.
We pay
hospitalization and surgeon services (delivery) the same as for illness and
injury. See Hospital benefits (Section 5c) and Surgery benefits
(Section
5b).
$10 per office visit to your primary
care physician
$20 per office visit to a specialist
Nothing per visit to a Certified
Nurse
Midwife
Family planning
A broad range of voluntary family planning
services, limited to:
Voluntary sterilization
Surgically implanted
contraceptives (such as Norplant)
Injectable contraceptive drugs (such as
Depo provera)
Intrauterine devices (IUDs)
Diaphragms
NOTE: We cover oral contraceptives under the prescription drug benefit.
$10 per office visit to your primary
care physician
$20 per office visit to a specialist
$50 per outpatient hospital visit
Not covered: reversal of voluntary surgical sterilization All charges
17
17 Page 18
19
2002 M. D. IPA 18 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)
In-vitro fertilization when the following criteria is met:
-your
oocytes are fertilized with your spouse's sperm
-you and your spouse have a history of infertility of at least 2
years,
or
-your infertility is associated with endometriosis, or exposure
in-utero
to diethylstilbestrol (DES), or blockage of, or surgical
removal of one or both fallopian tubes, or abnormal male factors,
including oligospermia, contributing to the infertility
-you have been unable to attain a successful pregnancy through a
less costly treatment that is covered by the Plan
In-vitro fertilization is limited to three (3) in-vitro attempts per live
birth and a maximum lifetime benefit of $100,000, except drugs.
Note: We cover injectables and oral fertility drugs for in-vitro
fertilization, and
Clomid (clomiphene) for artificial insemination under the
prescription drug
benefit.
$10 per office visit to your primary
care physician
50% per office visit to other plan
providers
Not covered:
Assisted reproductive technology (ART)
procedures, such as:
-embryo transplant, gamete intrafallopian transfer (GIFT), zygote
intrafallopian transfer (ZIFT), sex selection, surrogacy, gene
therapy,
and cryopreservation
Other services and supplies related to ART procedures
Cost
of donor sperm, donor eggs, and related costs
Infertility services
after reversal of voluntary sterilization
All charges
Allergy care
Testing and treatment
Allergy injections
$10
per office visit to your primary
care physician
$20 per office visit to a specialist
Allergy serum Nothing
Not covered: provocative food testing and
sublingual allergy desensitization. All charges 18
18 Page 19 20
2002 M. D. IPA 19 Section 5( a)
Treatment therapies You pay
Chemotherapy and radiation
therapy
Note: High dose chemotherapy in association with autologous bone
marrow
transplants is limited to those transplants listed under Organ/
Tissue Transplants
on page 26.
Respiratory and inhalation therapy
Dialysis – Hemodialysis and
peritoneal dialysis
Intravenous (IV)/ Infusion Therapy – Home IV and
antibiotic therapy
Growth hormone therapy (GHT)
Notes: Growth hormone is covered under the prescription drug benefit. We will
only cover GHT when we precertify the treatment. See Services requiring
our
prior approval in Section 3.
$10 per office visit to your primary
care physician
$20 per office visit to a specialist
$50 per outpatient hospital visit
Physical, cardiac and occupational therapies
Up to two months or
60 visits (whichever is more) per condition, for the services 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, is provided for up to two months or 60 visits
(whichever is more) per condition.
$20 per office visit to a specialist
$50 per outpatient hospital visit
Nothing per visit during covered
inpatient admission
Not covered:
long-term rehabilitative therapy
exercise programs, gym or pool memberships
All charges
Speech therapy
Up to two months or 60 visits (whichever is more)
per condition $20 per office visit to a specialist
$50 per outpatient hospital visit
Nothing per visit during covered
inpatient admission
Habilitative Therapies
Habilitative services for children under
age 19 with congenital or genetic birth
defects. Treatment is provided to
enhance the child's ability to function.
Services include:
Occupational therapy, and
Physical therapy;
Notes: No day or visit limits apply to these services. A congenital disorder
means a significant structural or functional abnormality that was present
from
birth.
$20 per office visit to a specialist
$50 per outpatient hospital visit 19
19 Page 20 21
2002 M. D. IPA 20 Section 5( a)
Hearing
services (testing, treatment, and supplies) You Pay
Hearing testing
Hearing aid examinations for children under 19; hearing aids covered under
Durable Medical Equipment.
$10 per office visit to your primary
care physician
$20 per office visit to a specialist
Not covered:
Hearing aids, except as covered for children
under age 19 under Durable Medical Equipment in this section
All charges
Vision services (testing, treatment, and supplies)
Diagnosis and
treatment of diseases of the eye $10 per office visit to your primary care
physician
$20 per office visit to a specialist
One pair of eyeglasses or contact lenses to correct an impairment directly
caused by accidental ocular injury or intraocular surgery (such as for
cataracts)
50% of charges
Annual eye refractions to provide a written lens prescription
You do
not have to obtain a referral from your Primary Care Physician for this
service
$25 per office visit to a specialist
Not covered:
Eyeglasses or contact lenses
Eye
exercises and orthoptics
Radial keratotomy and other refractive
surgery
All charges
Foot Care
Routine foot care when you are under active treatment
for a metabolic or
peripheral vascular disease, such as diabetes.
See orthopedic and prosthetic devices for information on podiatric shoe
inserts.
$10 per office visit to your primary
care physician
$20 per office visit to a specialist
$50 per outpatient hospital 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.
All charges 20
20 Page 21 22
2002 M. D. IPA
21 Section 5( a)
Orthopedic and prosthetic devices
Orthopedic
devices, such as:
Artificial limbs and eyes; stump hose
External lenses following cataract removal
Externally worn breast
prostheses and surgical bras, including necessary replacements, following a
mastectomy
Enteral equipment and supplies for covered tube feedings
Ostomy
supplies except deodorants, filters, lubricants, tape, appliance cleaners,
adhesive and adhesive removers
Orthotic braces and splints not available over-the-counter
Surgical
dressings not available over-the-counter; (see Durable Medical Equipment)
A hair prosthesis for hair loss resulting from chemotherapy or radiation
treatment for cancer. There is a limit of one hair prosthesis per lifetime,
with a maximum cost of $350.
Corrective orthopedic appliances for
non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.
Internal prosthetic devices, such as artificial joints, pacemakers,
cochlear implants, and surgically implanted breast implants following
mastectomy.
Note: We pay internal prosthetic devices as hospital benefits;
see Section 5( c)
for payment information. See 5( b) for coverage of the
surgery to insert the
device.
50% of charges
Not covered:
orthopedic and corrective shoes
shoes and foot orthotics, including heel pads, heel cups and arch supports
lumbosacral supports
corsets trusses, elastic
stockings, support hose, and other supportive devices
prosthetic replacements provided less than 5 years after the last one we
covered (except as needed to accommodate growth in children or for
socket
replacement for members with significant residual limb volume or
weight
changes)
external penile devices
speech prosthetics (except
electrolarynx)
All charges 21
21 Page 22 23
2002 M. D. IPA
22 Section 5( a)
Durable medical equipment (DME) You pay
Rental or purchase, at our option, including repair and adjustment, of
durable
medical equipment prescribed by your Plan physician, such as oxygen
and
dialysis equipment. Under this benefit, we also cover:
hospital beds;
wheelchairs;
crutches;
walkers;
blood glucose monitors;
and
insulin pumps.
surgical dressings not available over-the-counter
Note: Call us at 301/ 360-8080 or 1-800/ 251-0956 if your Plan physician
prescribes this equipment and you need assistance locating a health care
provider to rent or sell you durable medical equipment. You may also call us
to
see if a certain piece of equipment is covered. Most durable medical
equipment
must be preauthorized.
50% of charges
Hearing aids for children under age 19, prescribed, fitted and dispensed by a
licensed audiologist
50% of charges up to $1,400 per ear
every 36
months
Not covered:
Power-operated vehicles
Duplicate
or backup equipment
Parts and labor costs for supplies and
accessories replaced due to wear and tear such as wheelchair tires and tubes
Educational, vocational, or environmental equipment
Deluxe
or upgraded equipment and supplies
Home or vehicle modifications,
seat lifts
Over-the-counter medical equipment and supplies
Activities of daily living aids (such as grab bars and utensil
holders)
Personal hygiene equipment
Paraffin baths,
whirlpools, and cold therapy
Augmentative communication devices
Infertility monitors
Physical fitness equipment
Hearing aids for those over 19 years old
Continuous
pulse oximetry unless skilled nursing is involved in home care and it is part of
their medically necessary equipment
All charges 22
22 Page 23 24
2002 M. D. IPA
23 Section 5( a)
Home health services You pay
Home health
care ordered by a Plan physician and provided by a registered nurse (R. N.),
licensed practical nurse (L. P. N.), licensed
vocational nurse (L. V. N.),
or home health aide.
Services include oxygen therapy, intravenous therapy
and medications.
Medical foods prescribed by a physician when determined
to be your sole source of nutrition
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;
foods that you can obtain without a prescription, even if
prescribed by your physician or determined to be your sole source of nutrition.
All charges
Chiropractic
Chiropractic services are covered up to a maximum
benefit of $500 50% of charges up to the maximum benefit and all charges
thereafter.
Alternative treatments
Acupuncture – up to twelve (12) visits
per calendar year for postoperative and chemotherapy nausea and vomiting, nausea
of pregnancy,
postoperative dental pain and as part of a comprehensive
treatment
program for chronic pain
Biofeedback – for pain management, migraine treatment, bowel training and
pelvic floor training for urinary incontinence
$20 per office visit to a specialist
$50 per outpatient hospital visit
Not covered:
naturopathic services hypnotherapy
massage therapy
herbal medicine
homeopathy
All charges
Educational classes and programs
Coverage is limited to:
Diabetes self-management classes
Childbirth education classes. We will
reimburse you up to $50.
Smoking cessation program. We will reimburse you
up to $100.
When you complete the Childbirth education class or Smoking
cessation
program submit a copy of the certificate of completion with the
dates attended,
as well as a copy of your canceled check or receipt to P. O.
Box 948, Frederick,
Maryland 21705. 23
23
Page 24 25
2002
M. D. IPA 24 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.
YOUR PHYSICIAN MUST GET PRECERTIFICATION OF SOME SURGICAL
PROCEDURES. Please refer to the precertification information shown in Section 3
to be
sure which services 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
Normal pre-and
post-operative care by the surgeon
Correction of amblyopia and strabismus
Endoscopy procedure
Biopsy procedure
Removal of tumors and
cysts
Correction of congenital anomalies (see Reconstructive surgery)
Surgical treatment of morbid obesity – a condition in which an
individual's Body Mass Index (BMI) is greater than 40. Eligible members
must be age 18 or over. The member's PCP must submit recent records
documenting: a one year supervised weight loss program, comorbidities,
and a BMI greater than 40.
Insertion of internal prosthetic devices. See 5( a) – Orthopedic and
prosthetic devices for device coverage information.
Voluntary sterilization
Norplant (a surgically implanted
contraceptive) and intrauterine devices (IUDs). Note: Devices are covered under
5( a).
Treatment of burns
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.
$10 per office visit to your primary
care physician
$20 per office visit to a specialist
$50 per outpatient hospital visit
Not Covered:
Reversal of voluntary sterilization
All
charges 24
24 Page
25 26
2002 M. D. IPA 25 Section 5( b)
Reconstructive surgery You pay
Surgery to correct a
functional defect
Surgery to correct a condition caused by injury or
illness if:
-the condition produced a major effect on the member's
appearance, and
-the condition can reasonably be expected to be corrected by such
surgery
Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form or norm. Examples of
congenital
anomalies are: protruding ear deformities; cleft lip; cleft palate;
birth
marks; webbed fingers; and webbed toes. Your physician must
precertify
repair of congenital anomalies.
All stages of breast reconstruction surgery following a mastectomy, such
as:
-surgery to produce a symmetrical appearance on the other breast;
-treatment of any physical complications, such as lymphedemas;
-breast prostheses and surgical bras and replacements (see
Prosthetic devices)
Note: If you need a mastectomy, you may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to 48 hours
after
the procedure.
$10 per office visit to your primary
care physician
$20 per office visit to a specialist
$50 per outpatient hospital visit
Not covered:
Cosmetic surgery – any surgical procedure (or
any portion of a procedure) performed primarily to improve physical appearance
through change in
bodily form, except repair of accidental injury
Surgeries
related to sex transformation
All charges
Oral and maxillofacial surgery
Oral surgical procedures, limited
to:
Reduction of fractures of the jaws or facial bones;
Surgical correction of cleft lip, cleft palate or severe functional
malocclusion; facial defects due to congenital syndromes such as cleft
lip/ cleft palate, Crouzon's and Pierre-Robin's.
Removal of stones from
salivary ducts;
Excision of leukoplakia or malignancies;
Excision of
cysts and incision of abscesses when done as independent procedures; and
Other surgical procedures that do not involve the teeth or their supporting
structures
$10 per office visit to your primary
care physician
$20 per office visit to a specialist
$50 per outpatient hospital visit
Not covered:
Oral implants and transplants
Procedures that involve the teeth or their supporting structures (such as the
periodontal membrane, gingiva, and alveolar bone)
All charges 25
25 Page 26 27
2002 M. D. IPA
26 Section 5( b)
Organ/ tissue transplants You pay
Limited
to:
Cornea
Heart
Heart/ lung
Kidney
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 Hodgkins 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
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.
$10 per office visit to your primary
care physician
$20 per office visit to a specialist
$50 per outpatient hospital visit
Not covered;
Donor screening tests and donor search expenses,
except those performed for the actual donor
Implants of artificial organs
Transplants not listed as
covered
All services related to non-covered transplants
All charges
Anesthesia
Professional services provided in-
Hospital
(inpatient)
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office
Nothing 26
26 Page
27 28
2002 M. D. IPA 27 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 keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care and you must be
hospitalized in a Plan facility
Be sure to read Section 4, Your costs
for covered services, for valuable information about how cost sharing works.
Also, read Section 9 about coordinating benefits with other
coverage,
including 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 ATTENDING PHYSICIAN MUST GET PREAUTHORIZATION FOR ELECTIVE
HOSPITAL STAYS.
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; and
Meals and special diets.
NOTE: If you want a private room when it is not medically necessary, you pay
the additional charge above the semiprivate room rate.
Other hospital services and supplies, such as:
Operating, recovery,
maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Administration of blood and blood
products
Blood products, derivatives and components, artificial blood
products and biological serum. Blood products include any product created from a
component of blood such as, but not limited to, plasma, packed red blood
cells, platelets, albumin, Factor VIII, immunoglobulin, and prolastin.
Dressings, splints, casts, and sterile tray services
Medical supplies
and equipment, including oxygen
Anesthetics, including nurse anesthetist
services
Take-home items
Medical supplies, appliances, medical
equipment, and any covered items billed by a hospital for use at home
Nothing
Not covered:
Custodial care
Non-covered facilities, such as nursing homes and schools
Personal comfort items, such as telephone, television, barber services, guest
meals and beds
Private nursing care
Whole blood and concentrated red blood
cells not replaced by the member
All charges 27
27 Page 28 29
2002 M. D. IPA
28 Section 5( c)
Outpatient hospital or ambulatory surgical center
You pay
Operating, recovery, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and
pathology services
Administration of blood, blood plasma, and other
biologicals
Blood products, derivatives and components, artificial blood
products and biological serum.
Pre-surgical testing
Dressings, casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia
services
NOTE: We cover hospital services and supplies related to dental procedures
when necessitated by a non-dental physical impairment.
$50 per visit
Not covered: Whole blood and concentrated red blood cells blood and blood
derivatives not replaced by the member
All charges
Extended care benefits/ skilled nursing care facility benefits
Extended care benefits:
All necessary services provided for up to 60
days per calendar year in a skilled
nursing facility when full-time nursing
care is necessary and confinement in a
skilled nursing facility is medically
appropriate as determined by a Plan doctor
and approved by the Plan.
Services include:
Bed, board and general nursing care
Drugs, biologicals, supplies and equipment ordinarily provided or arranged
by the skilled nursing facility when prescribed by a Plan doctor
Nothing
Not covered:
custodial care
rest cures,
domiciliary or convalescent care
personal comfort items, such as
telephone, television, barber services, guest meals and beds
All charges 28
28 Page 29 30
2002 M. D. IPA
29 Section 5( c)
Hospice Care You pay
Supportive or
palliative care for a terminally ill member in the home or hospice
facility.
These services are provided under the direction of a Plan doctor who
certifies that you are in the terminal stages of illness, with a life
expectancy of
approximately six (6) months or less.
Services include:
Inpatient and outpatient care
Family counseling
Nothing
Not covered: Independent nursing, private duty nursing, homemaker services
All charges
Ambulance
Professional ambulance service when
medically appropriate Nothing 29
29 Page 30 31
2002 M. D. IPA
30 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 and are payable only when we
determine they are medically necessary.
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, 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 or outside our
service area:
If you are in an emergency situation, please call your
primary care physician. In extreme emergencies, if you are unable
to contact
your doctor, contact the local emergency system (e. g., the 911 telephone
system) or go to the nearest hospital
emergency room. Be sure to tell the
emergency room personnel that you are a Plan member so they can notify the Plan.
You or a family member should notify the Plan within 48 hours, unless it was
not reasonably possible to notify us within
that time. It is your
responsibility to ensure that the Plan has been timely notified.
If you need to be hospitalized, the Plan must be notified within 48 hours or
on the first working day following your
admission, unless it was not
reasonably possible to notify us within that time. If you are hospitalized in a
non-Plan
facility and Plan doctors believe care can be better provided in a
Plan hospital, you will be transferred when medically
feasible with any
ambulance charges covered in full. Benefits are available for care from non-Plan
providers in a
medical emergency only if delay in reaching a Plan provider
would result in death, disability or significant jeopardy to
your condition.
To be covered by this Plan, any follow-up care recommended by non-Plan providers
must be approved
by the Plan or provided by Plan providers.
Benefit Description You pay
Emergency within or outside our service
area
Emergency care at a doctor's office $10 per office visit to your
primary
care physician
$20 per office visit to a specialist
Emergency care at an urgent care center $25 per visit 30
30 Page 31 32
2002 M. D. IPA 31 Section 5( d)
Emergency within or outside our service area (continued)
You pay
Emergency care at an emergency room. $50 per visit,
waived if the emergency results in an admission to a hospital
Not covered:
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care
could have been foreseen before leaving the service area
Medical and hospital costs resulting from a normal full-term delivery of
a baby outside the service area.
All charges
Ambulance
Professional ambulance service, including air ambulance,
when medically
appropriate.
See 5( c) for non-emergency service.
Nothing 31
31 Page
32 33
2002 M. D. IPA 32 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 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.
YOU 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 illness
or
conditions
Professional services, including individual or group therapy by providers
such as psychiatrists, psychologists, or clinical social workers
Medication management
$20 per office visit to a specialist
$50 per
outpatient hospital visit
Diagnostic tests $20 per office visit to a specialist
$50 per
outpatient hospital visit
Services provided by a hospital or other facility while an inpatient
Nothing
Services provided by a hospital or other facility while an outpatient. This
includes partial hospitalization and facility based intensive outpatient
treatment.
$20 per office visit
$50 per outpatient hospital visit
Services in approved alternative care settings such as half-way house and
residential treatment.
Note: The services covered in approved alternative settings are limited to
those
provided by participating licensed professionals according to a
treatment plan
that has been approved by a Plan psychiatrist and Primary
Care Physician.
$20 per office visit 32
32 Page 33 34
2002 M. D. IPA 33 Section 5( e)
Mental health and substance
abuse benefits (continued) You pay
Not covered:
Services we have not approved
Psychiatric evaluation
or therapy on court order or as a condition of parole or probation, unless
determined by a Plan doctor to be necessary
and appropriate
All charges
Preauthorization To be eligible to receive these benefits you must
follow your treatment plan and
all the following authorization processes:
Once you have been referred for mental health services, you must be
evaluated by a Psychiatric Physician. This physician will discuss with
you a recommended course of treatment at the appropriate provider level.
We list mental health and substance abuse providers in the provider
directory, which we update periodically. The list is also on our website,
www. mamsi. com. Information in the
directory is subject to change; for
this reason, we recommend that you
access our website to look up the most
up-to-date information.
Limitation We may limit your benefits if you do not obtain a treatment
plan. 33
33 Page
34 35
2002 M. D. IPA 34 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 the next page.
All benefits are subject to the definitions,
limitations and exclusions in this brochure and are payable only when we
determine they are medically necessary.
We have no calendar year
deductible.
Certain drugs require your doctor to get prior authorization
from us before they can be prescribed under the plan. The Plan requires prior
authorization for these drugs to
make sure that they are being prescribed and consumed according to FDA
approved
indications and dosing schedules. If your pharmacist tells you that
your prescription
drug requires prior authorization, ask your pharmacist or
doctor to call Pharmacy
Services at 1-800/ 205-3636 for further
instructions.
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 licensed physician or licensed
dentist must write the prescription
Where you can obtain them. You
must fill the prescription at a plan pharmacy. You may fill prescriptions for
maintenance medications either by mail or at a retail pharmacy. Maintenance
medications are those drugs used on a continual basis, for six
months or longer, for the treatment of chronic health conditions such as high
blood pressure, asthma, or diabetes. To locate the
name of a participating
pharmacy near you, refer to your Directory, call our Member Services Department
at 301/ 360-8080 or 1-
800/ 251-0956, or visit our website at www. mamsi. com.
We use a formulary. A formulary is a listing of prescription drugs
that are preferred by the Plan for use. All generic drugs are on the formulary,
as well as certain name brand drugs. Drugs that are on the formulary are
selected based on safety, efficacy and
cost. This listing is periodically reviewed and updated by a team of doctors
and pharmacists. M. D. IPA uses an open formulary.
This means you are
covered for all prescription medications written in accordance with FDA
guidelines for a particular
therapeutic indication whether or not the
medication appears on the formulary, except for prescription drugs or classes of
drugs
listed under "Not Covered" in this section of the brochure. However
drugs not specifically listed on our formulary are subject to a
non-formulary copay. Drugs requiring prior authorization will be covered
once reviewed and approved by the Plan.
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 copy of the formulary, call Member Services at 301/ 360-8080 or
1-
800/ 251-0956.
These are the dispensing limitations. You may obtain up to a 34-day
supply of non-maintenance prescription drugs at a Plan pharmacy or by mail
order. Prescriptions for covered maintenance medications may be filled or
refilled at a Plan retail pharmacy,
or through the mail by Merck-Medco Rx Services. You may obtain up to a
consecutive 90-day supply of maintenance
prescription medications, with one
copay for each month's supply. For more information on mail order benefits, you
can reach
Merck-Medco Rx Services at 1-800-711-3813. A prescription can be
refilled when you have used 75% of the medication. For
example, a
prescription that was filled for a 34-day supply could be refilled after 26
days.
We follow FDA dispensing guidelines. Generic drugs will be dispensed when
substitution is permissible for prescriptions filled at a retail pharmacy or
through mail order. If generic substitution is permissible (i. e., a generic
drug is available and the
prescribing doctor does not require the use of a name brand drug), but you
request the name brand drug, you pay the name brand
copay plus the cost
difference between the generic and the name brand drug. If you fill a
prescription for a name brand drug and
there is no generic available, you
will be responsible for either the formulary or non-formulary name brand copay.
34
34 Page 35 36
2002 M. D. IPA 35 Section 5( f)
Why
use generic drugs? Generic drugs are lower-priced drugs that are the
therapeutic equivalent to more expensive brand-name drugs. They must contain the
same active ingredients and must be equivalent in strength and dosage to the
original brand-name
product. Generics cost less than the equivalent
brand-name 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 brand-name 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.
When you have to file a claim. Usually, there are no claim forms to
fill out when you fill a prescription at a Plan pharmacy. In some cases,
however, you may pay out-of-pocket, such as when you are outside the service
area in a medical emergency. If this
happens, send the following information
to P. O. Box 948, Frederick, Maryland 21705.
-your receipt
-the drug NDC number
-the pharmacy's NABP number, and
-the prescribing doctor or dentist's DEA number
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 require a
physician's prescription for their purchase, except those listed as Not
covered.
Insulin, with a copay charge applied to each vial
Diabetic supplies, including insulin syringes, needles, glucose test tablets and
test tape, Benedict's solution or equivalent, and acetone test tablets.
Disposable needles and syringes for the administration of covered,
prescribed medications
Oral contraceptive drugs (you may obtain up to
three cycles of oral contraceptive drugs at one time with a copay charge applied
to each cycle);
contraceptive devices.
$ 5 per generic drug
$ 15 per name brand drug in the Plan's formulary
$ 30 per name brand drug not in the Plan's formulary
20% up to $50 for
injectable drugs, except for insulin.
Note: If there is no generic
equivalent available, you will
still have to pay the brand name copay.
Limited Benefits
Drugs to treat sexual dysfunction are limited.
Contact the Plan for dosage limits.
Not covered:
Drugs and supplies for cosmetic purposes,
including drugs for weight loss or control
Nonprescription medicines
Vitamins and nutritional
substances that can be purchased without a prescription
Medical supplies such as dressings and antiseptics
Fertility drugs except Clomid (clomiphene) for artificial insemination (oral
and injectable drugs are covered for in-vitro fertilization)
Drugs to enhance athletic performance
Drugs obtained at a
non-Plan pharmacy; except for out-of-area emergencies
Replacement
Prescription Drug Products resulting from loss, theft, spoilage, or breakage of
original product
All charges 35
35 Page 36 37
2002 M. D. IPA
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.
Centers of Excellence We use specific institutions called Centers of
Excellence that offer "best practices" to treat certain conditions or to perform
specific procedures. We have
Centers of Excellence for cardiac care,
transplants and joint replacement. A list
of our Centers of Excellence can
be found in the provider directory, or you can
call the Member Services
Department at 301/ 360-8080 or 1-800/ 251-0956 for an
up-to-date listing.
WeeCall Programs Our maternity programs offer women support and
education throughout pregnancy. We will mail you educational materials, and
obstetrical nurses are
available to talk to you on the telephone at no cost.
Call the Member Services
Department at 301/ 360-8080 or 1-800/ 251-0956 for
more information about our
maternity programs.
Plan Publications There are several publications that are available to
you at no cost. They include:
Advance Directives
HealthLine
(immunization and preventive health check-up schedule)
HealthSense
Member Newsletter
Healthy Living Series
HomeCall Hospice Services,
Inc.
Provider Directory
Wee Call Pregnancy Education
Vaccination Facts
Call the Member Services Department at 301/ 360-8080 or 1-800/ 251-0956 to
request a copy of any of these items.
Health Education and Disease
Management Programs Healthwise
Knowledgebase – on-line source for members to research health questions
Diabetes care
Behavioral Health/ Depression care
Asthma
Disease
Management
Cardiovascular Prevention
Breast Cancer Prevention 36
36 Page 37 38
2002 M. D. IPA 37 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
This plan is a discount program. 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
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 (but not replace) sound
natural
teeth. The need for these services must result from an accidental injury. You
must
request treatment within seventy-two (72) hours after the accident
occurs. If your injury cannot
be reasonably treated within seventy-two (72)
hours (example: if you have sustained medical
injuries to such an extent to
render dental treatment during this time period impossible), an
extension
may be granted if you make the request within sixty (60) days of the date of
injury.
Dental treatment for accidental injury is a limited benefit intended to
stabilize your dental
condition and includes only the following:
Emergency examination
Periapical and panoral radiographs
Root canal therapy
Emergency, temporary splinting of the teeth
Prefabricated post and core
Simple, minimal restorative procedures
(fillings)
Emergency extractions
Post-traumatic crowns are covered
if it is the only treatment available
Note: Injury as a result of chewing, biting or poor dental hygiene is not
covered
$20 per visit.
Dental Discount benefits
The following list summarizes the fees
for dental services provided by a participating PLAN GENERAL DENTIST
ONLY.
All services rendered by a Plan dental specialist are provided at a 25%
reduction of costs; the copays listed
below do not reflect the payment to a
Plan dental specialist. You do not have to obtain a referral from your primary
care
physician to obtain the following dental care services. For a complete
list of fees, or a list of participating dentists,
contact us at 301/
360-8080 or 1-800/ 251-0956. The list is also on our website, www. mamsi. com. 37
37
Page 38 39
2002 M. D. IPA 38 Section 5( h)
Service You pay Type I
Diagnostic and Preventive Services
D1203 Topical Application of Fluoride
(Prophylaxis not Included) – Child N/ C
D0120 Periodic Oral Examination
$17.00
D0150 Comprehensive Oral Evaluation $25.00
D1110 Prophylaxis –
Adult $30.00
D1120 Prophylaxis – Child $23.00
Radiological Services
D0210 Intraoral – Complete Series (including bitewings) $47.00
D0220
Intraoral – Periapical – First Film $10.00
D0272 Bitewings – 2 Films $18.00
D0330 Panoramic Film $45.00
Type II Basic Dental Services, Silver
Restorations and All Other Services
Amalgam Restorations – Adult
D2150
Amalgam – 2 Surfaces, Permanent $51.00
Amalgam Restorations – Child
D1351 Sealant – Per Tooth $19.00
D2120 Amalgam – 2 Surfaces, Primary
$46.00
Composite Restorations (White Filling)
D2331 Resin – 2 Surfaces,
Anterior $58.00
D2381 Resin – 2 Surfaces, Posterior – Primary $62.00
D2386 Resin – 2 Surfaces, Posterior – Permanent $72.00
D2920 Recement
Crown $32.00
D2950 Core Buildup, Including Any Pins $60.00
Type III
Major Dental Services
Crown and Inlay
D2530 Inlay – Metallic – 3 or more
Surfaces $340.00
D2752 Crown – Porcelain Fused to Noble Metal $460.00
D2952 Cast Post and Core In Addition to Crown $135.00
D2954
Prefabricated Post and Core In Addition to Crown $110.00
Bridge Services
D6242 Bridge Pontic (Porcelain Fused to Noble Metal) $460.00
D6752 Crown
– Abutment (Porcelain Fused to High Noble Metal) $475.00
Cosmetic and
Esthetic Services
D2961 Labial Veneer (Resin Laminate) – Laboratory $272.00
Endodontic Services
D3110 Pulp Cap – Direct (Excluding Final
Restoration) $ 23.00
D3310 Anterior (Excluding Final Restoration) $295.00
D3330 Molar (Excluding Final Restoration) $441.00
Periodontics Services
D4341 Periodontal Scaling and Root Planing – Per Quadrant $ 76.00
Prosthodontics – Removable
D5110 Complete Denture – Maxillary $509.00
D5213 Maxillary Partial Denture – Cast Metal Framework with Resin Denture
Bases
(Including any Conventional Clasps, Rest and Teeth)
$562.00
D5650 Add Tooth to Existing Partial Denture $ 30.00*
D5730 Reline
Complete Maxillary Denture (Chairside) $110.00
D5750 Reline Complete
Maxillary Denture (Laboratory_) $160.00*
*Plus invoice lab costs
Oral
Surgery Services
D7110 Single Tooth $ 60.00
D7210 Surgical Removal of
Erupted Tooth Requiring Evaluation of Mucoperiosteal Flap
And Removal of
Bone and/ or Section of Tooth
$ 81.00
D7230 Removal of Impacted Tooth – Partially Bony $175.00
D7240 Removal of
Impacted Tooth – Completely Bony $210.00
For all services performed by a
Dental Specialist (including Orthodontic Services) and any services not listed
above, you
pay a fee of 75% Of the Dentist's Usual and Customary fee. 38
38 Page 39 40
2002 M. D. IPA 39 Section 5( i)
Section 5 (i). Non-FEHB
benefits available to Plan members
The benefits on this page are not
part of the FEHB contract or premium, and you cannot file an FEHB disputed
claim about them.
Fees you pay for these services do not count toward
FEHB deductibles or out-of-pocket maximums.
PPO DENTAL PLAN
In addition to the Dental Discount benefit
described in Section 5 (h) of this brochure, M. D. IPA provides a PPO dental
Plan to all 2002
Federal members. There is no additional premium for this
benefit and enrollment is automatic when you enroll in M. D IPA's FEHB
health Plan (JN) for 2002.
Members may go to the dentist of their choice; however, the benefit is
usually better when you visit a dentist who participates in the
PPO. The
benefit provides reimbursement of up to $1,000 per contract year for covered
dental procedures. The PPO dental Plan
covers diagnostic (e. g., x-rays),
preventive (e. g., exams, cleanings), basic (e. g., fillings), and major
procedures (e. g., .root canals,
crowns).
Members will get a separate I. D. card for this benefit in their enrollment
kit. It is issued by MAMSI Life and Health insurance
Company (MLH), who
provides and administers this benefit.
Look for important details about this Plan, its usage, as well as a listing
of participating dentists, in the 2002 Dental Benefits Guide.
This Guide is
in the enrollment packet, or can be obtained by calling Member Services at
1-800/ 251-0956, or 301/ 360-8080. You can
also find information about the
dental Program on our website (www. mamsi. com/ federal).
TLC LASER VISION CORRECTION DISCOUNT
TLC Laser Eye Centers offer
M. D. IPA members a preferred savings of 25% to a maximum of $1,800 per eye for
laser vision
correction. For more information on this benefit, please
contact TLC toll-free at 1-877-PLAN TLC.
ASHN COMPLEMENTARY HEALTH CARE ACCESS PROGRAM
As a member with M.
D IPA, you will receive a 25% discount on services rendered by an American
Specialty Health Networks
(ASHN) participating chiropractor, acupuncturist
or massage therapist that are not reimbursed under your FEHB benefits. For more
information about the ASHN Access Program, please call ASHN at
1-877-327-2746, or select the Healthyroads. com link on our
website (www. mamsi. com).
OPTICAL SERVICES
Discounts are available on eyewear and related
services at participating optical centers listed in the Plan's Provider
Directory.
Members simply show their member identification card at a
participating center to receive a discount on eyeglasses, including single,
multifocal or designer, and other optical services.
Contact lenses may also be available at a discount. Please contact Member
Services for the names of participating practitioners.
NATIONAL FITNESS NETWORK DISCOUNT The National Fitness Network offers
discounts at area health and fitness clubs of up to 30% to M. D. IPA members.
For more
information or for questions regarding registration, call National
Fitness Network at 1-800-811-5454, or visit their website at
www. nationalfitnessnetwork. com.
39
39 Page 40 41
2002 M. D. IPA 40 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
and we agree, as discussed under What Services
Require Our Prior Approval on page 12.
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. 40
40 Page
41 42
2002 M. D. IPA 41 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 301/ 360-8080 or at 1-800/ 251-0956.
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: P. O.
Box 948, Frederick, MD 21705
Prescription drugs Usually, there are no claim forms to fill out when
you fill a prescription at a Plan pharmacy. In some cases, however, you may pay
out-of-pocket,
such as when you are outside the service area in a medical
emergency. If this happens, send the following information to P. O.
Box
948, Frederick, Maryland 21705:
-your receipt
-the drug NDC number
-the pharmacy's NABP number, and
-the prescribing doctor or dentist's DEA number
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. 41
41 Page
42 43
2002 M. D. IPA 42 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: Customer Support, P. O. Box 933, Frederick, MD 21705
(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 your 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 3, 1900
E Street, NW, Washington, DC
20415-3630.
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 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. 42
42 Page 43 44
2002 M. D. IPA 43 Section 8
Disputed
Claims process (Continued)
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 301/ 360-
8080 or 1-800/
251-0956, 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 3 at 202/ 606-0737 between
8 a. m. and 5 p. m. eastern time 43
43 Page 44 45
2002 M. D. IPA
44 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 1-800-MEDICARE 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 + Choice is a 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) Plan that 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. 44
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2002 M. D. IPA 45 Section 9
The following chart illustrates whether Original Medicare or this Plan
should be the primary payer for you according to your
employment status and
other factors determined by Medicare. It is critical that you tell us if you or
a covered family member has
Medicare coverage so we can administer these
requirements correctly.
Primary Payer Chart
A. When either you – or your covered spouse – are
age 65 or over and… Then the primary payer is..
Original Medicare This Plan
1) Are an active employee with the Federal government (including when
you or a family member are eligible for Medicare solely because of a
disability),
2) Are an annuitant,
3) Are a reemployed annuitant with the
Federal government when..
a) The position is excluded from FEHB, or
b) The position is not excluded from FEHB
(Ask your employing office
which of these applies to you.)
4) Are a Federal judge who retired under title 28, U. S. C., or a Tax Court
judge who retired under Section 7447 of title 26, U. S. C. (or if your
covered spouse is this type of judge),
5) Are enrolled in Part B only, regardless of your employment status,
(for Part B services)
(for other
services)
6) Are a former Federal employee receiving Workers' Compensation and
the
Office of Workers' Compensation Programs has determined 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 ESRC 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
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Claims process when you have the
Original Medicare Plan – You
probably will never have to file a claim
form 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 and we will pay
the balance of covered charges.
You will not need to do anything. To find
out if you need to do
something about filing your claims, call us at 301/
360-8080 or 1-
800/ 251-0956
We waive some costs when you have the Original Medicare Plan. When
Original Medicare is the primary payer, we will waive some out-of-
pocket
costs until you meet your Medicare Part B deductible. All
copayment and
coinsurance amounts will be applied. Once the
Medicare Part B deductible has
been met, all copayments and
coinsurance are waived. We will pay all amounts
identified as "patient
responsibility" on the Medicare Explanation of
Benefits as long as the
service rendered is a covered benefit. We will pay
the Inpatient
Medicare deductible.
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 1-800-MEDICARE (1-800-633-4227) or at
www. medicare. gov.
If you enroll in a Medicare managed care plan, the following options are
available to you:
This Plan and another plan's Medicare 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, but we will not waive any
of our copayments,
coinsurance, or deductibles. If you enroll in a
Medicare managed care plan,
tell us. We will need to know whether
you are in the Original Medicare 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
and 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. 46
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2002 M. D. IPA 47 Section 9
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.
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