Enrollment Codes for this Plan:
Florida Service Area Code:
EM1
Self Only
EM2 Self and Family
AVMED Health Plan http: / / www. avmed. org
RI 73-126
For changes
in benefts
see page
7.
This Plan has commendable
accreditation from the NCQA.
See the
2002 Guide for more
information on NCQA.
This Plan has accreditation with
commendation from the JCAHO.
See the
2002 Guide for more
information on JCAHO.
2002 A H E A L T H P L A N D E M
This plan has consolidated the rating areas of Gainesville, code
JF;
Jacksonville, code HW; Orlando, code FP; South Fl, code
EM; and Tampa, code
H5 into one rating area. AvMed enrollees
that choose not to change
enrollment to another participating
plan during Open Enrollment Season will
automatically be
transferred to the enrollment code EM.
Authorized for distribution by the: 1
1 Page 2 3
2002 AvMed Health
Plan 2 Table of Contents
Table of Contents
Introduction
..................................................................................................................................................................................................................
4
Plain
Language..............................................................................................................................................................................................................
4
Inspector General Advisory
........................................................................................................................................................................................
4
Section 1. Facts about this HMO plan
.....................................................................................................................................................................
5
How we pay providers
.............................................................................................................................................................................
5
Your
Rights................................................................................................................................................................................................
5
Service
Area...............................................................................................................................................................................................
5
Section 2. How we change for
2002.........................................................................................................................................................................
7
Program-wide
changes.............................................................................................................................................................................
7
Changes to this Plan
.................................................................................................................................................................................
7
Section 3. How you get care
.....................................................................................................................................................................................
8
Identification
cards...................................................................................................................................................................................
8
Where you get covered
care....................................................................................................................................................................
8
Plan
providers.....................................................................................................................................................................................
8
Plan facilities
......................................................................................................................................................................................
8
What you must do to get covered care
..................................................................................................................................................
8
Primary care
........................................................................................................................................................................................
8
Specialty care
.....................................................................................................................................................................................
8
Hospital care
.....................................................................................................................................................................................
10
Circumstances beyond our
control.......................................................................................................................................................
10
Services requiring our prior
approval..................................................................................................................................................
10
Section 4. Your costs for covered
services............................................................................................................................................................
11
Copayments
......................................................................................................................................................................................
11
Deductible
.........................................................................................................................................................................................
11
Coinsurance......................................................................................................................................................................................
11
Your out-of-pocket
maximum..............................................................................................................................................................
11
Section 5.
Benefits.....................................................................................................................................................................................................
12
Overview..................................................................................................................................................................................................
12
(a) Medical services and supplies provided by physicians and other health
care professionals ......................................... 13
(b) Surgical
and anesthesia services provided by physicians and other health care
professionals ..................................... 21
(c) Services provided
by a hospital or other facility, and ambulance
services.......................................................................
24
(d) Emergency services/ accidents
..................................................................................................................................................
26
(e) Mental health and substance abuse
benefits...........................................................................................................................
28
(f) Prescription drug
benefits..........................................................................................................................................................
29 2
2 Page 3 4
2002 AvMed Health Plan 3 Table of Contents
(g) Special features
..........................................................................................................................................................................
32
Flexible benefits option
24 nurse line
Centers of
Excellence for transplants/ heart surgery etc.
Disease Management
(h)
Dental
benefits.............................................................................................................................................................................
33
(i) Non-FEHB benefits available to Plan members
....................................................................................................................
34
Section 6. General exclusions --things we don't
cover.......................................................................................................................................
35
Section 7. Filing a claim for covered services
......................................................................................................................................................
36
Section 8. The disputed claims
process.................................................................................................................................................................
37
Section 9. Coordinating benefits with other coverage
.......................................................................................................................................
39
When you have…
Other health coverage
......................................................................................................................................................................
39
Original Medicare
.............................................................................................................................................................................
39
Medicare managed care plan
.........................................................................................................................................................
41
TRICARE/ Workers' Compensation/ Medicaid
.................................................................................................................................
41
Other Government
agencies..................................................................................................................................................................
42
When others are responsible for injuries
............................................................................................................................................
42
Section 10. Definitions of terms we use in this brochure
....................................................................................................................................
43
Section 11. FEHB facts
.............................................................................................................................................................................................
44
Coverage
information...........................................................................................................................................................................
44
No pre -existing condition limitation
........................................................................................................................................
44
Where you get information about enrolling in the FEHB
Program....................................................................................
44
Types of coverage available for you and your family
...........................................................................................................
44
When benefits and premiums
start............................................................................................................................................
45
Your medical and claims records are
confidential.................................................................................................................
45
When you
retire...........................................................................................................................................................................
45
When you lose
benefits........................................................................................................................................................................
45
When FEHB coverage
ends.......................................................................................................................................................
45
Spouse equity coverage
.............................................................................................................................................................
45
Temporary Continuation of Coverage
(TCC)........................................................................................................................
45
Converting to individual
coverage...........................................................................................................................................
46
Getting a Certificate of Group Health Plan
Coverage..........................................................................................................
46
Long term care insurance is coming later in 2002
................................................................................................................................................
47
Department of Defense/ FEHB Demonstration Project
........................................................................................................................................
48
Index..............................................................................................................................................................................................................................
50
Summary of benefits
..................................................................................................................................................................................................
51
Rates..............................................................................................................................................................................................................
Back cover 3
3 Page
4 5
2002 AvMed Health Plan 4
Introduction/ Plain Language/ Inspector General Advisory
Introduction
AvMed, Inc.
9400 South Dadeland Boulevard
Miami, FL 33156
This brochure describes the benefits of AvMed Health Plan under our contract
(CS 1955) 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 7. 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 AvMed Health Plan.
We limit acronyms to ones you know. FEHB is the
Federal Employees Health Benefits Program. OPM is the Office of Personnel
Management. If we use others, we tell you what they mean first.
Our
brochure and other FEHB plans' brochures have the same format and similar
descriptions to help you compare plans.
If you have comments or suggestions
about how to improve the structure of this brochure, let us know. Visit OPM's
"Rate Us" feedback area at www. opm. gov/ insure or email us 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 mis represented any information, do the
following:
Call the provider and ask for an explanation. There may be an error. If
the provider does not resolve the matter, call us at 800/ 882-8633 and explain
the situation.
If we do not resolve the issue, call THE HEALTH CARE
FRAUD HOTLINE--202/ 418-3300 or write to: The United States Office of
Personnel
Management, Office of the Inspector General Fraud Hotline, 1900 E Street, NW,
Room 6400, Washington, DC 20415.
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. 4
4 Page 5 6
2002 AvMed Health
Plan 5 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to
see specific physicians, hospitals, and other providers that
contract with
us. These Plan providers coordinate your health care services.
HMOs emphasize preventive care such as routine office visits, physical exams,
well-baby care, and immunizations, in addition to treatment for illness and
injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit
claim forms or pay bills. You only pay the copayments 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.
Your Rights
OPM requires that all FEHB Plans provide certain
information to their FEHB members. You may get information about us, our
networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure)
lists the specific types of information that we must
make available to you.
AvMed Health Plan is an Individual Practice Association organization in
Florida. Member's medical services are provided by a wide array of primary care
doctors and specialists with whom AvMed contracts. AvMed contracts with
approximately nine thousand four
hundred forty-three (9,443) doctors and eighty-five (85) major hospitals in
the area to provide medical care to members.
The first and most important
decision each member must make is the selection of a primary care doctor. The
decision is important since it is through this doctor that all other health
services, particularly those of specialists, are obtained. It is the
responsibility of
your primary care doctor to obtain any necessary authorizations from the Plan
before referring you to a specialist or making
arrangements for
hospitalization. See Specialty Care below for services that you can receive
without a referral from your primary doctor.
If you want more information about us, call 800/ 882-8633, or write to 9400
South Dadeland Blvd., Suite 200, Miami, FL 33156. You may also contact us by fax
at 305/ 671-4710 or visit our website at www. avmed. com.
Service Area
To enroll with us, you must live or work in our
service area. This is where our providers practice. Our service areas are:
Gainesville area:
Service from Plan providers are available in the
following area: Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton,
Levy, Marion, Putnam, Suwannee, and Union Counties.
Jacksonville area:
Services from Plan providers are available in the
following area: Baker, Clay, Duval, Nassau, and St. Johns Counties.
Orlando area: Services from Plan providers are available in the following
area: Orange, Osceola, and Seminole Counties.
South Florida area: Services from Plan providers are available in the
following area: Dade, Broward, and Palm Beach Counties. 5
5 Page 6 7
2002 AvMed Health Plan 6 Section 1
Tampa area:
Services from Plan providers are available in the
following area: Hernando, Hillsborough, Lee, Pasco, Pinellas, Polk, and Sarasota
Counties.
Ordinarily, you must get your care from providers who contract with us. If
you receive care outside our service area, we will pay only
for emergency
care benefits. We will not pay for any other health care services out of our
service area unless the services have prior plan approval.
If you or a covered family member move outside of our service area, you can
enroll in another plan. If your dependents live out of the
area (for
example, if your child goes to college in another state), you should consider
enrolling in a fee-for-service plan or an HMO that has agreements with
affiliates in other areas. If you or a family member move, you do not have to
wait until Open Enrollment
Season to change plans. Contact your employing or retirement office. 6
6 Page 7 8
2002 AvMed Health Plan 7 Section 2
Section 2. How we change for 2002
Do not rely on these change
descriptions; this page is not an official statement of benefits. For that, go
to Section 5 Benefits. Also, we
edited and clarified language throughout the
brochure; any language change not shown here is a clarification that does not
change benefits.
Program-wide changes
We increased speech therapy benefits by
removing the requirement that services must be required to restore functional
speech. (Section 5 (a))
Changes to this Plan
Your share of the non-Postal premium will
increase by 6.6% for Self Only and decrease by 5.6% for Self and Family.
We no longer limit total blood cholesterol tests to certain age groups. (Section
5 (a))
We have included a $100 copay for hospital admission/ surgical
procedure. (Section 5 (c))
We have included a $100 copay for Outpatient
hospital or ambulatory surgical centers (Section 5 (c))
We now have a
3-tier prescription copay; $5 for generic drugs, $10 for preferred brand-name
drugs and $25 for non-preferred brand-name drugs. (Section 5 (f))
We have included a Mail order benefit for maintenance medications (Section
5 (f))
We have included a $75 copay for injectable drug coverage (Section
5 (f))
This plan has consolidated the rating areas of Gainesville, code
JF; Jacksonville, code HW; Orlando, code GP; South Fl, code EM; and Tampa, code
H5 into one rating area. AvMed enrollees that choose not to change enrollment to
another participating
plan during Open Enrollment Season will automatically be transferred to the
enrollment code EM.
We changed the address for sending disputed claims to
OPM. (Section 8)
We now cover certain intestinal transplants. (Section 5
(b)) 7
7 Page 8 9
2002 AvMed Health Plan 8 Section 3
Section 3. How you get care
Identification cards We will send
you an identification (ID) card when you enroll. You should carry your ID card
with you at all times. You must show it whenever you receive services from a
Plan
provider, or fill a prescription at a Plan pharmacy. Until you receive
your ID card, use
your copy of the Health Benefits Election Form, SF-2809,
your health benefits enrollment confirmation (for annuitants), or your Employee
Express confirmation letter.
If you do not receive your ID card within 30 days after the effective date of
your enrollment, or if you need replacement cards, call us at 1-800-882-8633.
Where you get covered care You get care from "Plan providers" and
"Plan facilities." You will only pay copayments and you will not have to file
claims.
Plan providers Plan providers are physicians and other
health care professionals in our service area that we contract with to provide
covered services to our members. We credential Plan
providers according to
national standards. All AvMed physicians are reviewed at the
time of initial
application and every two years following. The vast majority of AvMed physicians
are board certified or board eligible in their specialty.
We list Plan providers in the provider directory, which we update
periodically. The list is also on our website.
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.
What you must do to get covered care It depends on the type of care
you need. First, you and each family member must choose
a primary care
physician. This decision is important since your primary care physician provides
or arranges for most of your health care.
You can select your primary care physician by using AvMed's provider
directory. This directory is available at the time of enrollment or upon your
request by calling the
Member Services Department at 1-800-882-8633. You can
also find out if your doctor
participates with this Plan by calling this
number. If you are interested in receiving care from a specific provider who is
listed in the directory, call the provider to make sure that
he or she still participates with the Plan and is accepting new patients.
Important note:
When you enroll in this Plan, services (except for emergency
benefits) are provided through the Plan's delivery system; the continued
availability and/ or participation of any
one doctor, hospital, or other provider cannot be guaranteed.
If you
decide to enroll, you will be asked to complete a primary care doctor selection
form and send it directly to the Plan, indicating the name of the primary care
doctor( s)
selected for you and each member.
Primary care
Your primary care physician can be a family practitioner, internist or
pediatrician. Your primary care physician will provide most of your health care,
or give you a referral to see
a specialist.
If you want to change
primary care physicians or if your primary care physician leaves the Plan, call
us. We will help you select a new one.
Specialty care Your primary care physician will refer you to a
specialist for needed care. When you receive a referral from your primary care
physician, you must return to the primary care 8
8
Page 9 10
2002
AvMed Health Plan 9 Section 3
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. On referrals, the primary care
physician will
give specific instructions to the consultant about what
services are authorized. If additional services or visits are suggested by the
consultant, you must first check with
your primary care physician. However, you may see certain specialists without
a referral.
Except in a medical emergency, or when a primary care physician
has designated another doctor to see patients when he or she is unavailable, you
must receive a referral from
your primary care physician before seeing any other doctor or obtaining
special services.
Referral to a participating specialist is given at the
primary care physician's discretion; if specialists or consultants are required
beyond those participating in the Plan, the primary
care physician will make arrangements for the appropriate referral. A member
may
obtain covered services from a chiropractor or a podiatrist without a
referral; a woman may see her Plan gynecologist directly once a year for an
annual check-up, with no need
to be referred by her primary care physician; a member may obtain up to 5
office visits
per calendar year to a Plan dermatologis t for covered
services.
The treatment plan will permit you to visit your specialist without the need
to obtain
further referrals. Requests by primary care physicians for
referrals to specialists are evaluated based upon medical information given by
the provider. The authorization for
the referral includes the initial visit as well as the follow-up visits as
determined by the
medical condition. The authorization is good for 90 days.
At the end of 90 days, additional visits can be authorized based on the
patient's medical condition.
Here are other things you should know about specialty care:
If you need
to see a specialist frequently because of a chronic, complex, or serious medical
condition, your primary care physician will work with you and AvMed to
develop a treatment plan that allows you to see your specialist for a
certain number of visits without additional referrals. Your primary care
physician will use our criteria
when creating your treatment plan (the
physician may have to get an authorization or approval beforehand).
If you are seeing a specialist when you enroll 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. 9
9 Page
10 11
2002 AvMed Health Plan 10
Section 3
If you are in the second or third trimester of pregnancy
and you lose access to your
specialist based on the above circumstances, you
can continue to see your specialist until the end of your postpartum care, even
if it is beyond the 90 days.
Hospital care Your Plan primary care physician or specialist will
make necessary hospital arrangements and supervise your care. This includes
admission to a skilled nursing or other type of
facility.
If you are in
the hospital when your enrollment in our Plan begins, call our customer service
department immediately at 1-800-882-8633. 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.
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
preauthorization. Your physician must obtain authorization for the following
services: such as, but not limited to, consultation by
specialists,
hospitalization, Growth hormone therapy (GHT), most laboratory testing, and
other comprehensive diagnostic and treatment services.
AvMed will provide benefits for covered services only when the services are
medically necessary to prevent, diagnose or treat your illness or condition.
Your plan doctor must
obtain the Plan's determination of medical necessity
before you may be hospitalized,
referred for specialty care or obtain
follow-up care from a specialist.
Services requiring our
prior approval 10
10 Page 11 12
2002 AvMed Health Plan 11 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 $100 per
admission.
Deductible We do not have a deductible.
Coinsurance
We do not usually charge coinsurance; however, if you choose a non-Plan
Physician for a second medical opinion, you will be responsible for 40% of the
reasonable and customary
charges.
After you pay $1,500 in copayments for Self Only enrollment, or $2,500 for
Self and Family enrollment, you do not have to make any further payments for
certain services for
the rest of the year. This is called an out-of-pocket
limit. However, copayments for your prescription drugs, dental services, and
voluntary family planning services do not count
toward these limits, and you
must continue to make these payments.
Be sure to keep accurate records of
your copayments since you are responsible for informing us when you reach the
maximum.
Your catastrophic protection out-of-pocket maximum for
deductibles,
coinsurance and
copayments 11
11 Page 12 13
2002 AvMed
Health Plan 12 Section 5
Section 5. Benefits --OVERVIEW
(See page 7 for how our benefits changed this year and page 51 for
a benefits summary.)
NOTE: This benefits section is divided into subsections. Please read
the important things you should keep in mind at the beginning of each
subsection. Also read the General Exclusions in Section 6; they apply to the
benefits in the following subsections. To obtain
claims forms, claims filing
advice, or more information about our benefits, contact us at 1-800-882-8633 or
at our website at
www. avmed. com.
(a) Medical services and supplies provided by physicians and other health
care professionals
............................................................... 13-20
Diagnostic and treatment services Lab, X-ray, and other diagnostic tests
Preventive care, adult Preventive care, children
Maternity care
Family planning Infertility services
Allergy care
Treatment therapies Physical and occupational
therapies
Speech therapy Hearing services (testing, treatment, and 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
(b) Surgical and anesthesia services provided by physicians and other health
care professionals ....................................................... 21-23
Surgical procedures
Reconstructive surgery
Oral and
maxillofacial surgery
Organ/ tissue transplants Anesthesia
(c) Services provided by a hospital or other facility, and ambulance
services.........................................................................................
24-25
Inpatient hospital
Outpatient hospital or ambulatory surgical
center
Extended care benefits/ skilled nursing care facility benefits
Hospice care Ambulance
(d) Emergency services/ accidents
....................................................................................................................................................................
26-27
Medical emergency Ambulance
(e) Mental health and substance
abuse
benefits...................................................................................................................................................
28
(f) Prescription drug
benefits............................................................................................................................................................................
29-31
(g) Special features
..................................................................................................................................................................................................
32
Flexible benefits option
24 Hour Nurse line
Disease Management
Centers of Excellence
(h) Dental
benefits.....................................................................................................................................................................................................
33
(i) Non-FEHB benefits available to Plan members
............................................................................................................................................
34
Summary of benefits
..................................................................................................................................................................................................
51 12
12 Page 13
14
2002 AvMed Health Plan 13 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.
Besuretoread Section4,Yourcosts
forcoveredservices,for valuableinformationabouthow costsharingworks.Also
readSection9about coordinatingbenefitswithother coverage,includingwithMedicare.
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
$10 pervisittoyour primarycarephysicianor participatingspecialist
Professional services of physicians
In an urgent care center
During a hospital stay
In a skilled nursing facility
Office medical
consultations
No separate physician charge in addition to the applicable facility charge
Second surgical opinion $10 per office visit – Plan physician
If the
Member chooses a non-Plan Physician, the Member will be responsible for 40% of
the amount of
reasonable and customary charges for the second medical
opinion
At home Nothing
Not covered:
Injuries received in connection with
the commission of a felony
All charges. 13
13
Page 14 15
2002
AvMed Health Plan 14 Section 5( a)
Lab, X-ray and other
diagnostic tests You pay
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Nothing if you receive these services during your office visit; otherwise,
$10 per office
visit
Prior authorization is required for the following:
CAT Scans/ MRI
Ultrasound
Electrocardiogram
EEG
Nothing if you receive these services during your office vis it; otherwise,
$10 per office
visit
Preventive care, adult
Routine screenings, such as:
Total
Blood Cholesterol – once every three years
Colorectal Cancer Screening,
including
--Fecal occult blood test
--Sigmoidoscopy, screening –
every five years starting at age 50
Nothing if you receive these services during
your office visit;
otherwise, $10 per visit
Prostate Specific Antigen (PSA test) – one annually for men age 40 and older
Nothing if you receive these services during your office visit; otherwise $10
per visit
Cervical pap smear test
Note: The office visit is covered if
pap test is received on the same day; see Diagnosis and Treatment, above.
$10 per office visit
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
Not covered: Physical exams required for obtaining or continuing
employment or insurance, attending schools or camp, or travel. All charges.
Preventive care, adult – Continued on next page 14
14 Page 15 16
2002 AvMed Health Plan 15 Section 5( a)
Preventive care, adult (continued) You pay
Routine immunizations limited to:
Tetanus-diphtheria (Td) booster
– once every 10 years, ages19 and over (except as provided for under Childhood
immunizations)
Influenza/ Pneumococcal vaccines, annually, age 65 and over
$10 per office visit
Preventive care, children
Childhood immunizations recommended by
the American Academy of Pediatrics $10 per office visit
Well-child care charges for routine examinations, immunizations and care
(under age 22)
Examinations, such as:
--Eye exams through age
17 to determine the need for vision correction.
--Ear exams through age 17 to determine the need for hearing
correction
--Examinations done on the day of immunizations (under age
22)
$10 per office visit
Maternity care
Complete maternity (obstetrical) care, such as:
Prenatal care
Postnatal care
Copayments are waived for maternity care.
Delivery
Note: Here are some things to keep in mind:
You do not
need to precertify your normal delivery; see page 10 for other circumstances,
such as extended stays for you or your baby.
You may remain in the hospital up to 48 hours after a regular delivery and
96 hours after a cesarean delivery. We will extend your
inpatient stay if
medically necessary.
We cover routine nursery care of the newborn child
during the covered portion of the mother's maternity stay. We will cover other
care of an infant who requires non-routine treatment only if we
cover the
infant under a Self and Family enrollment.
We pay hospitalization and surgeon services (delivery) the same as for
illness and injury. See Hospital benefits (Section 5c) and Surgery
benefits (Section 5b).
$100 per admission
Not covered: No more than one routine sonogram during pregnancy All
charges. 15
15 Page
16 17
2002 AvMed Health Plan 16
Section 5( a)
Family planning You pay
A broad range of
voluntary family planning services, limited to:
Voluntary sterilization
$100 per hospital admission
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. See
page 30.
$10 per office visit
Not covered: reversal of voluntary surgical sterilization, genetic
counseling
All charges.
Infertility services
Diagnosis and treatment of infertility, such
as:
Artificial insemination:
--intravaginal insemination
(IVI) --intracervical insemination (ICI)
--intrauterine insemination (IUI)
$20 per office visit
Surgery for the enhancement of fertility $100 for physician
$500 for
facility
Not covered:
Assisted reproductive technology (ART)
procedures, such as:
--in vitro fertilization
--embryo transfer, gamete GIFT and zygote ZIFT
--Zygote transfer
Services and supplies related to
excluded ART procedures
Cost of donor sperm
Cost of
donor egg
Fertility drugs
All charges.
Allergy care
Testing and treatment $50 per course of testing
Allergy injection $10 per office visit
Allergy serum Nothing
Not
covered: provocative food testing and sublingual allergy desensitization All
charges. 16
16 Page
17 18
2002 AvMed Health Plan 17
Section 5( a)
Treatment therapies You pay
Chemotherapy
and radiation therapy
Note: High dose chemotherapy in association with
autologous bone marrow transplants are limited to those transplants listed under
Organ/ Tissue Transplants on page 23.
Respiratory and inhalation
therapy
Dialysis – Hemodialysis and peritoneal dialysis
Intravenous
(IV)/ Infusion Therapy – Home IV and antibiotic therapy
Growth hormone therapy (GHT)
Note: Growth hormone is covered under the
prescription drug benefit.
Note: – We will only cover GHT when we
preauthorize the treatment. Call 1-800-816-5465 for preauthorization. We will
ask your AvMed
physician to submit information that establishes that the GHT is
medically necessary. Be sure your AvMed physician obtains approval before
you begin treatment; otherwise, we will only cover GHT services
from the date you get approval. If you do not ask or if we determine
GHT
is not medically necessary, we will not cover the GHT or related services and
supplies. See Services requiring our prior approval in
Section 3.
$10 per office visit
Physical and occupational therapies
60 visits per condition for
the services of each of the following:
--qualified physical
therapists and --occupational therapists. $10 per office visit
Not covered:
exercise programs
Cardiac
rehabilitation
All charges.
Speech therapy
60 visits per condition $10 per office visit
Hearing services (testing, treatment, and supplies)
Hearing
testing for children through age 17 (see Preventive care, children) $10
per office visit
Not covered:
all other hearing testing
hearing
aids, testing and examinations for them
All charges. 17
17 Page 18 19
2002 AvMed
Health Plan 18 Section 5( a)
Vision services (testing,
treatment, and supplies) You pay
Annual eye refractions to determine
the need for vision correction for children through age 17 (see preventive care)
Diagnosis and treatment of diseases of the eye
$10 per office visit
Not covered:
All other vision testing (eye examinations and
refractions)
Eyeglasses or contact lenses (including replacement of
lenses provided during the same calendar year)
External lenses following cataract surgery
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. $10 per office
visit
Not covered:
Cutting, trimming or removal of corns, calluses,
or the free edge of toenails, and similar routine treatment of conditions of the
foot,
except as stated above
Treatment of weak, strained or flat
feet or bunions or spurs; and of any instability, imbalance or subluxation of
the foot (unless the
treatment is by open cutting surgery)
Podiatric shoe inserts
or foot orthotics
All charges.
Orthopedic and prosthetic devices
Artificial limbs and eyes;
stump hose
Externally worn breast prostheses and surgical bras, including
necessary replacements, following a mastectomy
Internal prosthetic devices, such as artificial joints, pacemakers, and
surgically implanted breast implant following mastectomy. Note:
See 5( b)
for coverage of the surgery to insert the device.
$10 per office visit
Orthopedic and prosthetic devices-Continued on next page 18
18 Page 19 20
2002 AvMed Health Plan 19 Section 5( a)
Orthopedic and prosthetic devices (Continued) You pay
Not covered:
orthopedic and corrective shoes
arch supports
cochlear implants
foot orthotics
non orthopedic brace
heel pads and heel cups
lumbosacral supports
corsets, trusses, elastic stockings,
support hose, and other supportive devices
penile implants
prosthetic replacements provided less than
3 years after the last one we covered
All charges.
Durable medical equipment (DME)
Rental or purchase, at our option,
including repair and adjustment, of
durable medical equipment prescribed by
your Plan physician, such as oxygen and dialysis equipment. Under this benefit,
we also cover:
hospital beds;
standard wheelchairs; and
crutches;
infusion pumps
Coverage for orthotic appliances is limited to leg, arm,
back, and neck custom-made braces when related to a surgical procedure or when
used in
an attempt to avoid surgery and are necessary to carry out normal activities
of daily living, excluding sports activities. Coverage is limited to the
first such item; repair and replacement is not covered.
Note: In the treatment of diabetes, coverage for an infusion pump will
apply towards the annual maximum limitation but shall not be subject to the
DME benefit limitation.
$50 per episode of illness
Benefits are limited to a maximum of $500 per
contract year. You pay anything above that amount.
Not covered:
Medical supplies such as corsets which do not
require a prescription
Motorized wheelchairs
Non-standard wheelchairs
All other orthotic appliances
All charges. 19
19 Page 20 21
2002 AvMed
Health Plan 20 Section 5( a)
Home health services You pay
Home health services of nurses and health aides when prescribed by
your Plan doctor, who will periodically review the program for
continuing appropriateness and need.
Services include oxygen therapy,
intravenous therapy and medications.
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.
All charges.
Chiropractic
Manipulation of the spine and extremities
Adjunctive procedures such as ultrasound, electrical muscle stimulation,
vibratory therapy, and cold pack application
$10 per office visit
Not covered: As alternative treatment All charges.
Alternative
treatments
Not covered:
naturopathic services
hypnotherapy
biofeedback Acupuncture
Homeopath services
All charges.
Educational classes and programs
Coverage is limited to:
Smoking Cessation – Up to $100 for one smoking cessation program per member per
lifetime, including all related expenses
such as prescription drugs.
Diabetes self-management
$10 per office visit
Not Covered: Over the counter products All charges 20
20 Page 21 22
2002 AvMed Health Plan 21 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by
physicians and other health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
We have no
calendar year deductible.
Be sure to read Section 4, Your costs for
covered services, for valuable information about how cost sharing works.
Also read Section 9 about coordinating benefits with other coverage, including
with Medicare.
The amounts listed below are for the charges billed by a physician or other
health care professional for your surgical care. Look in Section 5( c) for
charges associated with the facility (i. e. hospital, surgical center, etc.).
YOUR PHYSICIAN MUST GET PREAUTHORIZATION OF SOME SURGICAL PROCEDURES.
Please refer to the preauthorization information shown in Section 3 to be sure
which services require preauthorization and
identify which surgeries require
preauthorization.
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 procedures
Biopsy
procedures Removal of tumors and cysts
Correction of congenital
anomalies (see reconstructive surgery)
Surgical treatment of morbid
obesity --a condition in which an individual weighs 100 pounds or 100% over his
or her normal
weight according to current underwriting standards; eligible
members must
be age 18 or over
Insertion of internal prosthetic devices. See 5( a) – Orthopedic and
prosthetic devices for device coverage information.
$10 per office visit
Voluntary sterilization
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.
$100 per procedure
Not covered:
Reversal of voluntary sterilization
Routine treatment of conditions of the foot; see Foot care.
All charges. 21
21 Page 22 23
2002 AvMed
Health Plan 22 Section 5( b)
Reconstructive surgery You pay
Surgery to correct a functional defect
Surgery to correct a
condition caused by injury or illness if:
--the condition produced a major effect on the member's appearance and
--the condition can reasonably be expected to be corrected by such
surgery
Surgery to correct a condition that existed at or from birth and
is a significant deviation from the common form or norm. Examples of
congenital anomalies are: protruding ear deformities; cleft lip; cleft
palate; birth marks; webbed fingers; and webbed toes.
All stages of breast reconstruction surgery following a mastectomy, such
as:
--surgery to produce a symmetrical appearance on the other breast;
--treatment of any physical complications, such as lymphedemas;
--breast prostheses and surgical bras and replacements (see
Prosthetic devices)
Note: If you need a mastectomy, you may choose to
have the procedure performed on an inpatient basis and remain in the hospital
up to 48 hours after the procedure.
$10 per office 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;
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 vis it
Not covered:
Oral/ dental implants and transplants
Procedures that involve the teeth or their supporting structures (such as
the periodontal membrane, gingiva, and alveolar bone)
Impacted wisdom teeth
All charges. 22
22 Page 23 24
2002 AvMed
Health Plan 23 Section 5( b)
Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Kidney
Liver
Allogeneic (donor) bone marrow transplants
Autologous bone marrow
transplants (autologous stem cell and peripheral stem cell support) for the
following conditions: acute
lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's
lymphoma;
advanced non-Hodgkin's lymphoma; advanced neuroblastoma; breast cancer; multiple
myeloma; epithelial ovarian
cancer; and testicular, mediastinal, retroperitoneal and ovarian germ
cell tumors
Intestinal transplants (small intestine) and the small
intestine with the liver or small intestine with multiple organs such as the
liver, stomach,
and pancreas
Limited Benefits -Treatment for breast cancer, multiple myeloma, and
epithelial ovarian cancer may be provided in an NCI-or NIH-approved
clinical
trial at a Plan-designated center of excellence and if approved
by the
Plan's medical director in accordance with the Plan's protocols.
Note: We cover related medical and hospital expenses of the donor when we
cover the recipient.
Nothing
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 charges.
Anesthesia
Professional services provided in –
Hospital
(inpatient)
Covered under Hospital admission copay 23
23 Page 24 25
2002 AvMed Health Plan 24 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and
ambulance services
I M
P O
R T
A N
T
Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions, limitations,
and exclusions in this brochure and are payable only when we determine they are
medically necessary.
Plan physicians must provide or arrange your care and you must be
hospitalized in a Plan facility.
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 the facility (i. e., hospital or surgical center) or ambulance service
for your surgery or care. Any costs associated with the professional charge
(i. e., physicians, etc.) are covered in Sections 5( a) or (b).
YOUR
PHYSICIAN MUST GET PREAUTHORIZATION OF HOSPITAL STAYS. Please refer to
Section 3 to be sure which services require preauthorization.
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 per day charge above the
semiprivate room rate,
in addition to the admission charge.
$100 per admission
Other hospital services and supplies, such as:
Operating, recovery,
maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Administration of blood and blood products
Blood or blood plasma,
only if donated or replaced Dressings, splints, casts, and sterile tray
services
Medical supplies and equipment, including oxygen Anesthetics, including
nurse anesthetist services
Take-home items Medical supplies, appliances, medical equipment, and any
covered
items billed by a hospital for use at home.
Nothing
Not covered:
Custodial care Non-covered facilities,
such as nursing homes, schools
Personal comfort items, such as telephone, television, barber services,
guest meals and beds
Private nursing care Blood and blood derivatives not replaced
by the member
All charges. 24
24 Page 25 26
2002 AvMed
Health Plan 25 Section 5( c)
Outpatienthospital
orambulatorysurgicalcenter 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 and
blood plasma, only if donated or replaced
Pre-surgical testing
Dressings, casts, and sterile tray services
Medical supplies, including
oxygen
Anesthetics and anesthesia service
NOTE: – We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment. We do not
cover the dental procedures.
$100 per procedure
Not covered: blood and blood derivatives not replaced by the member All
charges.
Extendedcarebenefits/ skilled nursingcarefacilitybenefits
Extended care benefit: We provide a comprehensive range of benefits for
up to 30 post-hospital days per calendar year when full-time skilled nursing
care is necessary and confinement in a skilled nursing facility is
medically appropriate as determined by a Plan doctor, and approved by
the
Plan. All necessary services are covered, including:
Bed, board, and general nursing care; Drugs, biologicals, supplies, and
equipment ordinarily
provided or arranged by the skilled nursing facility when prescribed by a
Plan doctor.
Nothing
Not covered:
Custodial care Residential treatment
facilities
All charges.
Hospice care
We provide supportive and palliative care for a
terminally ill member in the home or hospice facility. Services included:
Inpatient and outpatient care;
Family counseling These services are
provided under the direction of a Plan doctor who
certifies that the patient is in the terminal stages of illness, with a life
expectancy of approximately six months or less.
Nothing
Not covered:
Independent nursing
Homemaker
services
All charges.
Ambulance
Local professional ambulance service when medically
appropriate and ordered or authorized by a Plan doctor. Nothing 25
25 Page 26 27
2002 AvMed Health Plan 26 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations,
and exclusions in this brochure.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
I M
P O
R T
A N
T
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or
an injury that you believe endangers your life or could result in serious injury
or disability, and requires immediate medical or surgical care. Some problems
are emergencies
because, if not treated promptly, they might become more serious; examples
include deep cuts and broken bones. Others are emergencies because they are
potentially life-threatening, such as heart attacks, strokes, poisonings,
gunshot wounds, or
sudden inability to breathe. There are many other acute
conditions that we may determine are medical emergencies – what
they all
have in common is the need for quick action.
What to do in case of emergency:
Emergencies within our service area: If you are in an emergency
situation, please call your primary care doctor. In extreme emergencies, if you
are unable to
contact your doctor, contact the local emergency room. Be sure
to tell the emergency room personnel that you are an AvMed member so they can
notify AvMed. You or a family member must notify AvMed within 48 hours unless it
was not
reasonably possible to do so. It is your responsibility to make sure
that AvMed 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
admission,
unless is was not reasonably possible to notify AvMed within that
time. If you are hospitalized in non-Plan facilities and Plan doctors believe
care can be better provided in a Plan Hospital, you will be transferred when
medically feasible with any
ambulance charges covered in full. Benefits are available for care for
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.
Emergencies outside our service area:
If you need to be
hospitalized, AvMed must be notified within 48 hours or on the first working day
following your
admission, unless it was not reasonably possible to notify
AvMed within that time. If you are hospitalized in non-Plan facilities and Plan
doctors believe care can be better provided in a Plan hospital, you will be
transferred when medically
feasible with any ambulance charges covered in full.
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. 26
26
Page 27 28
2002
AvMed Health Plan 27 Section 5( d)
Benefit Description You pay
Emergency within our service area
Emergency care at a
participating doctor's office $10 per visit
Emergency care at an urgent care center $30 per visit
Emergency care
at a non-participating urgent care center or non-participating hospital
emergency room $50 per visit
Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area
Emergency care at a
doctor's office Emergency care at an urgent care center
Emergency care as an outpatient or inpatient at a hospital, including
doctors' services
$50 per visit
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 amb ulance service when medically
appropriate.
Air ambulance, when medically necessary and preauthorization by
Medical Director or Chief Medical Officer
See 5( c) for non-emergency service.
Nothing 27
27 Page
28 29
2002 AvMed Health Plan 28
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.
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
$10 per visit
Diagnostic tests $10 per visit
Services provided by a hospital or
other facility $100 per admission
Services in approved alternative care
settings such as partial
hospitalization, half-way house, residential
treatment, full-day
hospitalization, facility based intensive outpatient
treatment
$10 per visit
Not covered: Services we have not approved.
Note: OPM will base its
review of disputes about treatment plans on the
treatment plan's clinical
appropriateness. OPM will generally not order us to pay or provide one
clinically appropriate treatment plan in favor
of another.
All charges.
Preauthorization To be eligible to receive these benefits you must
follow your treatment plan and all the following authorization processes:
Pre-Authorization is required for most scheduled diagnostic tests/
procedures and all scheduled inpatient/ outpatient surgical procedures. It is
the responsibility of the
requesting physician to obtain authorization prior
to scheduling services. In order to
check on a referral, call AvMed Link
Line at 1-800-806-3623.
Limitation We may limit your benefits if you do not obtain a treatment
plan. 28
28 Page
29 30
2002 AvMed Health Plan 29
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
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 must write the prescription.
Where you can
obtain them. You must fill the prescription at a plan pharmacy, or by mail
for a maintenance medication.
We use a formulary. Drugs are prescribed by Plan doctors and
dispensed in accordance with the Plan's Drug Formulary. The Drug Formulary is a
list of commonly prescribed medications that have been chosen
by the
Pharmacy and Therapeutic Committee based on a drug's effectiveness and cost. The
Pharmacy and
Therapeutic Committee will evaluate any needed additions or
deletions to the formulary. Upon a participating provider's request, specific
medications can be evaluated on a case by case basis to be added to
the formulary. Non-formulary drugs will be covered when prescribed by a Plan
doctor. It is the prescribing
doctor's responsibility to obtain
authorization for on-formulary drugs before they are dispensed.
These are the dispensing limitations. Prescription drugs prescribed
by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed
for up to a 30-day supply (or 100 unit dosage, whichever is
less); 240 milliliters of liquid (8 oz.); 60 grams of ointment, creams or
topical preparation; or one commercially prepared unit (e. g. one inhaler, one
vial ophthalmic medication or insulin).
Why use generic drugs? The active ingredient that makes a drug work
is the medicine. All drugs, Brand and Generic, have this same active ingredient
inside. Brand drugs have a patent for the name, shape and
color. Generic
drugs used by AvMed have the same ingredients as the Brand drug, they just look
different
on the outside.
When you have to file a claim. If you need a prescription before you
receive your Membership card, you can fill the prescription at a participating
pharmacy and submit the receipt and a copy of the prescription to
AvMed for reimbursement. The copayment amount will be subtracted from the
reimbursement. Please indicate your Social Security Number on the receipt. See
Section 7 for specific information.
Prescription drug benefits begin on the next page. 29
29 Page 30 31
2002 AvMed Health Plan 30 Section 5( f)
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan
physician and obtained from a Plan pharmacy or through our mail order
program:
Drugs and medicines that by Federal law of the United States require a
physician's prescription for their purchase, except those listed as
Not
covered.
Insulin Disposable needles and syringes for the
administration of covered
medications
Drugs for sexual dysfunction (see Prior authorization
below) Coverage is limited; contact AvMed for dose limits. You pay the
drug copayment up to the dosage limit and all charges above that.
Contraceptive drugs and devices
Retail Drugs
$ 5 Generic Drugs
$ 10 Preferred Brand Name Drug
$
25 Non-Preferred Brand Name Drugs
Mail service is a benefit option for maintenance medications needed for
chronic or long-term health conditions. It's best to get an initial
prescription filled at your retail pharmacy. Ask your physician for an
additional prescription for up to a 90-day supply of your medication to be
ordered through mail service. Up to 3 refills are allowed per prescription.
Pay the following copayment (as well as the Brand Additional Charge if
you or your physician choose a Brand name product when a Generic is
available).
Mail Order Drugs
$ 10 Generic Drugs
$ 20 Preferred Brand Name Drugs
$ 50 Non-Preferred Brand Name Drugs
Your injectable drug prescription coverage includes the quantity sufficient
to treat the acute phase of an illness or established by the manufacturers
packaging guidelines but not more than a 30 day supply per copayment or
actual cost, whichever is less.
$75 Generic Drugs
Here are some things to keep in mind about our prescription drug program:
A Generic equivalent will be dispensed if it is available, unless your
physician specifically requires a name brand. If you receive a
name brand drug when a Federally-approved generic drug is
available, and
your physician has not specified Dispense as Written for the name brand drug,
you have to pay the difference in
cost between the name brand drug and the generic.
We have an open
formulary. If your physician believes a name brand product is necessary or there
is no generic available, your
physician may prescribe a name brand drug from a formulary list.
This
list of name brand drugs is a preferred list of drugs that we selected to meet
patient needs at a lower cost.
Covered medications and supplies -continued on next page 30
30 Page 31 32
2002 AvMed Health Plan 31 Section 5( f)
Covered medications and supplies You pay
Not covered:
Drugs and supplies for cosmetic purposes
Vitamins,
nutrients and food supplements even if a physician prescribes or administers
them
Nonprescription medicines or medicines for which there is a
nonprescription equivalent
Drugs obtained at a non-Plan pharmacy;
except for out-of-area emergencies
Medical supplies such as
dressing and antiseptics
Drugs to enhance athletic performance
Fertility drugs
All charges. 31
31 Page 32 33
2002 AvMed
Health Plan 32 Section 5( g)
Section 5 (g). Special features
Feature Description
Flexible benefits option Under the flexible benefits option, we
determine the most effective way to provide services.
We may identify
medically appropriate alternatives to traditional care and coordinate other
benefits as a less costly alternative benefit.
Alternative benefits are subject to our ongoing review.
By approving
an alternative benefit, we cannot guarantee you will get it in the future.
The decision to offer an alternative benefit is solely ours, and we may
withdraw it at any time and resume regular contract benefits.
Our decision
to offer or withdraw alternative benefits is not subject to OPM review under the
disputed claims process.
24 hour nurse line For any of your health concerns, 24 hours a day, 7
days a week, you may call 1-888-866-5432 and talk with a registered nurse who
will discuss treatment
options and answer your health questions.
Centers of Excellence for transplants/ heart
surgery/ etc.
Consult Member Services at 1-800-882-8633 to obtain a complete list of
centers.
Disease Management Call 1-800-972-8633 for information and help with
the following: Healthy Hearts – congestive heart failure
E-Z Breath'n –
asthma
Healthy Expectations – high risk pregnancy 32
32 Page 33 34
2002 AvMed Health Plan 33 Section 5( h)
Section 5 (h). Dental benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan dentists must provide or arrange your care.
We have no calendar
year deductible.
We cover hospitalization for dental procedures only when
a non-dental physical impairment exists which makes hospitalization necessary to
safeguard the health of the patient; we do not cover the dental procedure unless
it is
described below.
Be sure to read Section 4, Your costs for covered
services, for valuable information about how cost sharing works. Also read
Section 9 about coordinating benefits with other coverage, including with
Medicare.
I M
P O
R T
A N
T
Accidental injury benefit You pay
We cover restorative services
and supplies necessary to promptly repair
(but not replace) sound natural
teeth. The need for these services must result from an accidental injury.
Nothing
Dental benefits
We cover the following dental services when
provided by participating Plan dentists to children through age 11.
Service You pay
Preventive and Diagnostic
Oral examinations
X-rays as necessary
Prophylaxis (cleaning)
Nothing
Nothing
Nothing
Topical application of fluoride $10 per application 33
33 Page 34 35
2002 AvMed Health Plan 34 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.
Expanded dental benefits AvMed is making available dental services
through American Dental Plan (ADP) to Federal employees for an additional
premium.
ADP's benefits include NO CHARGE services for the following:
Topical fluoride Oral examinations
X-rays Cleaning (semi-annual)
Local anesthesia
For more information on how to enroll in the Dental Plan,
please call ADP at
(352) 371-2811 or 1-800-342-5209.
Expanded vision care Discounts on vision services are available to
AvMed members. Services include:
Eye exams
Eyeglasses Contact
lenses
Designer glasses, sunglasses, etc.
For details on specific services and
discounts in your Service Area, please call your Plan's Membership Services
Office listed on page 8 of the brochure.
Additional value added services include Weight Watchers and Smokenders.
Medicare prepaid plan enrollment – This Plan offers Medicare recipients the
opportunity to enroll in the Plan through Medicare. As indicated in Section 9,
annuitants and former spouses with FEHB coverage and Medicare Part B may
elect to drop their FEHB coverage and enroll in a Medicare prepaid plan when
one is available in their area. They may then later re-enroll in the FEHB
program. Most Federal annuitants have Medicare Part A. Those without
Medicare Part A may join this Medicare prepaid plan but will probably have
to pay for hospital coverage in addition to the Part B premium. Before you join
the plan, ask whether the plan covers hospital benefits and, if so, what you
will have to pay. Contact your retirement system for information on changing
your FEHB enrollment and changing
to Medicare prepaid plan. Contact us at
1-800-535-9355 for information on the Medicare prepaid plan and the cost of that
enrollment.
If you are Medicare eligible and are interested in enrolling in a Medicare
HMO sponsored by this Plan without dropping your enrollment in this Plan's FEHB
Plan, call 1-800-535-9355 for information on the benefits available
under
the Medicare HMO. 34
34 Page
35 36
2002 AvMed Health Plan 35
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 10.
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. 35
35 Page
36 37
2002 AvMed Health Plan 36
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.
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 1-800-882-8633.
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:
9400 South Dadeland Blvd., Suite 200, Miami, FL 33156
Prescription drugs
Submit your claims to: 9400 South Dadeland
Blvd., Suite 200, Miami, FL 33156
Deadline for filing your claim Send us all of the documents for your
claim as soon as possible (remember to keep copies). 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. 36
36 Page
37 38
2002 AvMed Health Plan 37
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. Yo u must: (a)
Write to us within 6 months from the date of our decision; and
(b) Send your
request to us at: AvMed Member Relations, P. O. Box 749, Gainesville, FL
32602-0749; and
(c) Include a statement about why you believe our initial
decision was wrong, based on specific benefit provisions in this
brochure;
and
(d) Include copies of documents that support your claim, such as physicians'
letters, operative reports, bills, medical records, and explanation of benefits
(EOB) forms.
2 We have 30 days from the date we receive your request to: (a) Pay
the claim (or, if applicable, arrange for the health care provider to give you
the care); or
(b) Write to you and maintain our denial --go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider,
we will send you a copy of our request— go to step 3.
3 You or your provider must send the information so that we receive it
within 60 days of our request. We will then decide within 30 more days.
If
we do not receive the information within 60 days, we will decide within 30 days
of the date the information was due. We will base our decision on the
information we already have.
We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
90 days after the date of our letter
upholding our initial decision; or
120 days after you first wrote to us
--if we did not answer that request in some way within 30 days; or
120
days after we asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance
Programs, Contracts Division 3, 1900 E Street, NW,
Washington, DC
20415-3630. 37
37 Page
38 39
2002 AvMed Health Plan 38
Section 8
The Disputed Claims process (Continued)
Send OPM the following information:
A statement about why you
believe our decis ion was wrong, based on specific benefit provisions in this
brochure;
Copies of documents that support your claim, such as physicians'
letters, operative reports, bills, medical records, and explanation of benefits
(EOB) forms;
Copies of all letters you sent to us about the claim;
Copies of all
letters we sent to you about the claim; and
Your daytime phone number and
the best time to call.
Note: If you want OPM to review different claims, you must clearly identify
which documents apply to which claim.
Note: You are the only person who has
a right to file a disputed claim with OPM. Parties acting as your
representative, such
as medical providers, must include a copy of your
specific written consent with the review request.
Note: The above deadlines may be extended if you show that you were unable to
meet the deadline because of reasons beyond your control.
5 OPM will review your disputed claim request and will use the
information it collects from you and us to decide whether our decision is
correct. OPM will send you a final decision within 60 days. There are no other
administrative appeals.
6 If you do not agree with OPM's decision,
your only recourse is to sue. If you decide to sue, you must file the suit
against OPM in Federal court by December 31 of the third year after the year in
which you received the disputed services, drugs, or supplies or from the year in
which you were denied preauthorization. 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 1-800-882-8633
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/ 606-0755
between 8 a. m. and 5 p. m. eastern time. 38
38
Page 39 40
2002
AvMed Health Plan 39 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. If we are the
secondary payer, we may be entitled to receive payment from your primary plan.
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 the term used to describe the various
health plan choices available to
Medicare beneficiaries. The information in
the next few pages shows how we coordinate benefits with Medicare, depending on
the type of Medicare managed care plan you have.
The Original Medicare Plan (Original Medicare) is a Medicare+ Choice 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.
(Primary payer chart begins on next page.)
The Original Medicare Plan
(Part A or Part B) 39
39 Page 40 41
2002 AvMed Health Plan 40 Section 9
The following chart illustrates whether the Original Medicare Plan
or this Plan should be the primary payer for you according to your
employment status and other factors determined by Medicare. It is critical that
you tell us if you or a covered family member
has Medicare coverage so we
can administer these requirements correctly.
Primary Payer Chart
Then the primary payer is… A. When either you --or
your covered spouse --are age 65 or over and …
OriginalMedicare This Plan
1) Are anactiveemployeewith
theFederalgovernment(including whenyouora familymemberare
eligibleforMedicaresolely becauseofadisability),
2) Are an annuitant,
3) Are a reemployed annuitant with the Federal government when…
a)
The position is excluded from FEHB, or
b) The position is not excluded from FEHB
(Ask your employing office
which of these applies to you.)
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,
(exceptforclaims
relatedtoWorkers'
Compensation.)
B. When you --or a covered family member --have Medicare based on end
stage renal disease (ESRD)
and…
1) Are within the first 30 months of eligibility to receive
Part A benefits
solely because of ESRD,
2) Have completed the 30-month ESRD coordination period and are still
eligible for Medicare due to ESRD,
3) Become eligible for Medicare due to ESRD after Medicare became primary for
you under another provision,
C. When you or a covered family member have FEHB
and…
1) Are eligible for Medicare based on disability, and
a) Are an
annuitant, or
b) Are an active employee, or
c) Are a former spouse of an annuitant, or
d) Are a former spouse of an
active employee 40
40 Page
41 42
2002 AvMed Health Plan 41
Section 9
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 our Medicare managed care plan: You may enroll in our
Medicare managed care plan and also remain enrolled in our FEHB plan. In this
case, we do not
waive any of our copayments for your FEHB coverage.
This Plan and another plan's Medicare managed care plan: You may
enroll in another plan's Medicare managed care plan and also remain enrolled in
our FEHB plan.
We will still provide benefits when your Medicare managed
care plan is primary, even
out of the managed care plan's network and/ or
service area (if you use our Plan providers), but we will not waive any of our
copayments. 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 to
enroll in a Medicare managed care plan, eliminating your FEHB premium. (OPM does
not contribute to your
Medicare managed care plan premium.) For information on suspending your FEHB
enrollment, contact your retirement office. If you later want to re-enroll
in the FEHB Program, generally you may do so only at the next open enrollment
season unless you
involuntarily lose coverage or move out of the Medicare managed care plan's
service
area.
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 have questions about TRICARE coverage.
Workers' Compensation We do not cover services that:
you need
because of a workplace-related illness or injury that the Office of Workers'
Compensation Programs (OWCP) or a similar Federal or State agency determines
they
must provide; or
OWCP or a similar agency pays for through a third
party injury settlement or other similar proceeding that is based on a claim you
filed under OWCP or similar laws.
Once OWCP or similar agency pays its maximum benefits for your treatment, we
will cover your care. You must use our providers.
If you do not enroll in
Medicare Part A or
Part B 41
41 Page 42 43
2002 AvMed Health Plan 42 Section 9
Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies
are responsible for your care We
do not cover services and supplies when a local, State, or Federal Government
agency directly or indirectly pays for them.
When others are responsible for injuries When you receive money to
compensate you for medical or hospital care for injuries or
illness caused
by another person, you must reimburse us for any expenses we paid.
However,
we will cover the cost of treatment that exceeds the amount you received in the
settlement.
If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our subrogation
procedures. 42
42 Page
43 44
2002 AvMed Health Plan 43
Section 10
Section 10. Definitions of terms we use in this
brochure
Calendar year January 1 through December 31 of the same year.
For new enrollees, the calendar year begins on the effective date of their
enrollment and ends on December 31 of the same
year.
Coinsurance See page 11.
Copayment A copayment is a fixed
amount of money you pay when you receive covered services. See page 11.
Covered services Care we provide benefits for, as described in this
brochure.
Custodial care Services and supplies that are furnished
mainly to train or assist in the activities of daily living, such as bathing,
feeding, dressing, walking, and taking oral medicines. "Custodial
Care" also
means services and supplies that can be safely and adequately provided by
persons other than licensed health care professionals, such as dressing
changes and catheter care or that of ambulatory patients customarily provide for
themselves, such as
ostomy care, measuring and recording urine and blood sugar levels, and
administering
insulin.
Deductible See page 11.
The Plan's experimental/ investigational
determination process is based on authoritative information from medical
literature, medical consensus bodies, FDA approval, clinical
trials, and
health care professionals with specialty expertise in the subject.
Group health coverage The form of health insurance covering groups of
persons under a master group health insurance policy issues to any one group.
Medical necessity The use of any appropriate medical treatment,
service, equipment, and/ or supply as provided by a hospital, skilled nursing
facility, physician, or other provider which is
necessary for the diagnosis,
care, and/ or treatment of a Member's illness or injury.
Us/ We Us and we refer to AvMed Health Plan.
You You refers
to the enrollee and each covered family member.
Experimental or
investigational services 43
43 Page 44 45
2002 AvMed Health Plan 44 Section 11
Section 11. FEHB facts
No pre-existing condition
limitation
We will not refuse to cover the treatment of a condition that you had before
you enrolled in this Plan solely because you had the condition before you
enrolled.
Where you can get information about enrolling in the
FEHB Program
See www. opm. gov/ insure. Also, your employing or retirement office can
answer your questions, and give you a Guide to Federal Employees Health
Benefits Plans, brochures
for other plans, and other materials you need
to make an informed decision about:
When you may change your enrollment;
How you can cover your family members;
What happens when you
transfer to another Federal agency, go on leave without pay, enter military
service, or retire;
When your enrollment ends; and
When the next open enrollment season
begins.
We don't determine who is eligible for coverage and, in most cases,
cannot change your
enrollment status without information from your employing
or retirement office.
Types of coverage available for you and your family Self Only coverage
is for you alone. Self and Family coverage is for you, your spouse,
and your
unmarried dependent children under age 22, including any foster children or
stepchildren your employing or retirement office authorizes coverage for.
Under certain circumstances, you may also continue coverage for a disabled child
22 years of age or
older who is incapable of self-support.
If you have a Self Only
enrollment, you may change to a Self and Family enrollment if you marry, give
birth, or add a child to your family. You may change your enrollment 31
days
before to 60 days after that event. The Self and Family enrollment begins on the
first day of the pay period in which the child is born or becomes an eligible
family member.
When you change to Self and Family because you marry, the
change is effective on the
first day of the pay period that begins after
your employing office receives your enrollment form; benefits will not be
available to your spouse until you marry.
Your employing or retirement office will not notify you when a family
member is no longer eligible to receive health benefits, nor will we. Please
tell us immediately when
you add or remove family members from your coverage
for any reason, including
divorce, or when your child under age 22 marries
or turns 22.
If you or one of your family members is enrolled in one FEHB plan, that
person may not
be enrolled in or covered as a family member by another FEHB
plan. 44
44 Page
45 46
2002 AvMed Health Plan 45
Section 11
When benefits and The benefits in this brochure are
effective on January 1. If you joined this Plan during
premiums start
Open Enrollment Season, your coverage begins on the first day of your first
pay period that starts on or after January 1. Annuitants' coverage and premiums
begin on January 1.
If you joined at any other time during the year, your employing office will
tell you the effective date of coverage.
Your medical and claims We will keep your medical and claims
information confidential. Only the following records are confidential
will have access to it:
OPM, this Plan, and subcontractors when they
administer this contract;
This Plan and appropriate third parties, such as
other insurance plans and the Office of Workers' Compensation Programs (OWCP),
when coordinating benefit payments and
subrogating claims;
Law enforcement officials when investigating and/
or prosecuting alleged civil or criminal actions;
OPM and the General Accounting Office when conducting audits;
Individuals involved in bona fide medical research or education that does not
disclose your identity; or
OPM, when reviewing a disputed claim or defending litigation about a claim.
When you retire When you retire, you can usually stay in the FEHB
Program. Generally, you must have been enrolled in the FEHB Program for the last
five years of your Federal service. If you
do not meet this requirement, you
may be eligible for other forms of coverage, such as temporary continuation of
coverage (TCC).
When you lose benefits
When FEHB coverage ends You will
receive an additional 31 days of coverage, for no additional premium, when:
Your enrollment ends, unless you cancel your enrollment, or
You are
a family member no longer eligible for coverage.
You may be eligible for
spouse equity coverage or Temporary Continuation of Coverage.
Spouse
equity
coverage If you are divorced from a Federal employee or
annuitant, you may not continue to get benefits under your former spouse's
enrollment. But, you may be eligible for your own
FEHB coverage under the spouse equity law. If you are recently divorced or
are
anticipating a divorce, contact your ex-spouse's employing or retirement
office to get RI 70-5, the Guide to Federal Employees Health Benefits Plans
for Temporary Continuation
of Coverage and Former Spouse Enrollees, or other information about
your coverage
choices.
Temporary continuation
of coverage (TCC) If you leave Federal
service, or if you lose coverage because you no longer qualify as a family
member, you may be eligible for Temporary Continuation of Coverage (TCC).
For example, you can receive TCC if you are not able to continue your FEHB
enrollment
after you retire, if you lose your job, if you are a covered
dependent child and you turn 22 or marry, etc.
You may not elect TCC if you are fired from your Federal job due to gross
misconduct.
Enrolling in TCC. Get the RI 79-27, which describes TCC,
and the RI 70-5, the Guide
to Federal Employees Health Benefits Plans for
Temporary Continuation of Coverage 45
45
Page 46 47
2002
AvMed Health Plan 46 Section 11
and Former Spouse Enrollees, from
your employing or retirement office or from
www. opm. gov/ insure. It
explains what you have to do to enroll.
Converting to You may convert to a non-FEHB individual policy if:
individual coverage
Your coverage under TCC or the spouse equity
law ends (If you canceled your coverage or did not pay your premium, you cannot
convert);
You decided not to receive coverage under TCC or the spouse equity law; or
You are not eligible for coverage under TCC or the spouse equity law.
If you leave Federal service, your employing office will notify you of your
right to convert. You must apply in writing to us within 31 days after you
receive this notice.
However, if you are a family member who is losing coverage, the employing or
retirement office will
not notify you. Yo u must apply in writing to
us within 31 days after you are no longer eligible for coverage.
Your benefits and rates will differ from those under the FEHB Program;
however, you will not have to answer questions about your health, and we will
not impose a waiting
period or limit your coverage due to pre-existing
conditions.
Getting a Certificate of You may be entitled to continued coverage
through the Health Insurance Portability and Group Health Plan Coverage
Accountability Act of 1996 (HIPAA). This Federal law offers limited Federal
protections
for health coverage availability and continuity to people who
lose employer group coverage. If you leave the FEHB Program, we will give you a
Certificate of Group
Health Plan Coverage that indicates how long you have
been enrolled with us. You can
use this certificate when getting health
insurance or other health care coverage. Your new plan must reduce or eliminate
waiting periods, limitations, or exclusions for health related
conditions based on the information in the certificate, as long as you enroll
within 63
days of losing coverage under this Plan.
If you have been enrolled with us for less than 12 months, but were
previously enrolled in other FEHB plans, you may also request a certificate from
those plans.
Get OPM pamphlet RI 79-27, Temporary Continuation of Coverage (TCC) under the
FEHB Program. It highlights HIPAA rules, such as the requirement that Federal
employees must exhaust any TCC eligibility as one condition for guaranteed
access to
individual health coverage under HIPAA, and it has information
about Federal and State agencies you can contact for more information. 46
46 Page 47 48
2002 AvMed Health Plan 47 Long Term Care
Insurance
Long Term Care Insurance Is Coming Later in 2002!
The Office of Personnel Management (OPM) will sponsor a high-quality
long term care insurance program effective in October 2002. As part of its
educational effort, OPM asks you to consider these questions:
It's
insurance to help pay for long term care services you may need if you can't take
care of yourself because of an extended illness or injury, or an age-related
disease
such as Alzheimer's.
LTC insurance can provide broad, flexible
benefits for nursing home care, care in an assisted living facility, care in
your home, adult day care, hospice care, and more.
LTC insurance can supplement care provided by family members, reducing the
burden you place on them.
Welcome to the club!
76% of Americans believe they will never need
long term care, but the facts are that about half of them will. And it's not
just the old folks. About 40% of people needing
long term care are under age 65. They may need chronic care due to a serious
accident, a stroke, or developing multiple sclerosis, etc.
We hope you will never need long term care, but everyone should have a plan
just in case. Many people now consider long term care insurance to be vital to
their
financial and retirement planning.
Yes, it can be very expensive. A
year in a nursing home can exceed $50,000. Home care for only three 8-hour
shifts a week can exceed $20,000 a year. And that's before
inflation!
Long term care can easily exhaust your savings. Long term care insurance can
protect your savings.
Not FEHB. Look at the "Not covered" blocks in sections 5( a) and 5(
c) of your FEHB brochure. Health plans don't cover custodial care or a stay in
an assisted
living facility or a continuing need for a home health aide to
help you get in and out of bed and with other activities of daily living.
Limited stays in skilled nursing
facilities can be covered in some
circumstances.
Medicare only covers skilled nursing home care (the highest
level of nursing care) after a hospitalization for those who are blind, age 65
or older or fully disabled. It
also has a 100 day limit.
Medicaid covers long term care for those who
meet their state's poverty guidelines, but has restrictions on covered services
and where they can be received. Long term
care insurance can provide choices of care and preserve your independence.
Employees will get more information from their agencies during the LTC open
enrollment period in the late summer/ early fall of 2002.
Retirees will
receive information at home.
Our toll-free teleservice center will begin in mid-2002. In the meantime,
you can learn more about the program on our web site at www. opm. gov/ insure/
ltc.
Many FEHB enrollees think that their health plan and/ or Medicare will
cover their long-term care needs. Unfortunately, they are WRONG!
How are YOU planning to pay for the future custodial or chronic care you may
need? You should consider buying long-term care insurance.
What is long term care
(LTC) insurance?
I'm healthy. I won't need
long term care. Or, will I?
Is long term care
expensive?
But won't my FEHB plan, Medicare or Medicaid cover
my long term care?
When will I get more information on how to
apply for this new
insurance coverage?
How can I find out more
about the program
NOW? 47
47 Page 48 49
2002 AvMed Health Plan 48 DoD/ FEHB
Demonstration Project
Department of Defense/ FEHB Demonstration
Project
What is it? The Department of Defense/ FEHB Demonstration
Project allows some active and retired uniformed service members and their
dependents to enroll in the FEHB Program. The
demonstration will last for
three years and began with the 1999 open enrollment season for the year 2000.
Open enrollment season will be for an effective date of January 1, 2002. DoD and
OPM have set up some special procedures to implement the Demonstration
Project, noted below. Otherwise, the provisions described in this brochure
apply.
Who is eligible DoD determines who is eligible to enroll in the FEHB
Program. Generally, you may enroll if:
You are an active or retired
uniformed service member and are eligible for Medicare;
You are a
dependent of an active or retired uniformed service member and are eligible for
Medicare;
You are a qualified former spouse of an active or retired uniformed service
member and you have not remarried; or
You are a survivor dependent of a
deceased active or retired uniformed service member; and
You live in one
of the geographic demonstration areas.
If you are eligible to enroll in a plan under the regular Federal Employees
Health Benefits
Program, you are not eligible to enroll under the DoD/ FEHBP
Demonstration Project.
The demonstration areas Dover AFB, DE Commonwealth of Puerto Rico
Fort Knox, KY Greensboro/ Winston Salem/ High Point, NC
Dallas, TX
Humboldt County, CA area New Orleans, LA Naval Hospital, Camp Pendleton, CA
Adair County, IA area Coffee County, GA area
When you can join
You may enroll under the FEHB/ DoD Demonstration Project during the 2001
open enrollment season, November 12, 2001, though December 10, 2001. Your
coverage will begin January 1,
2002. DoD has set-up an Information
Processing Center (IPC) in Iowa to provide you with
information about how to
enroll. IPC staff will verify your eligibility and provide you with FEHB Program
information, plan brochures, enrollment instructions and forms. The toll-free
phone
number for the IPC is 1-877/ DOD-FEHB (1-877/ 363-3342).
You may select
coverage for yourself (Self Only) or for you and your family (Self and Family)
during open enrollment season. Your coverage will begin January 1, 2002. If you
become eligible
for the DoD/ FEHB Demonstration Project outside of open
enrollment season, contact the IPC to find out how to enroll and when your
coverage will begin.
DoD has a web site devoted to the Demonstration Project. You can view
information such as their Marketing/ Beneficiary Education Plan, Frequently
Asked Questions, demonstration area locations
and zip code lists at www.
tricare. osd. mil/ fehbp. You can also view information about the
demonstration project, including "The 2002 Guide to Federal Employees Health
Benefits Plans Participating in the DoD/ FEHB Demonstration Project," on the OPM
web site at www. opm. gov.
Temporary Continuation Of Coverage (TCC) See Section 11, FEHB Facts; it explains temporary continuation of coverage