Serving: Kansas City Metropolitan Area Kansas and Missouri
Enrollment in this Plan is limited. You must live or work in our
Geographic service area to enroll. See page 6 for requirements.
Enrollment codes for this Plan:
HA1 Self Only
HA2 Self and Family
RI 73-128
For changes
in benefits
see page 7.
A Health Maintenance Organization 1
1
Page 2 3
2002
Coventry Health Care of Kansas, Inc. 2 Table of Contents
Table
of Contents
Introduction…………………………………………………………………......................................................................................
4
Plain
Language..................................................................................................................................................................................
4
Inspector General
Advisory...............................................................................................................................................................
4
Section 1. Facts about this HMO
plan...............................................................................................................................................
6
How we pay providers
.....................................................................................................................................................
6
Your Rights
.....................................................................................................................................................................
6
Service Area
....................................................................................................................................................................
6
Section 2. How we change for 2002
...............................................................................................................................................
7
Program-wide
changes.....................................................................................................................................................
7
Changes to this
Plan.........................................................................................................................................................
7
Section 3. How you get care
............................................................................................................................................................
8
Identification
cards...........................................................................................................................................................
8
Where you get covered care
.............................................................................................................................................
8
Plan
providers............................................................................................................................................................
8
Plan facilities
.............................................................................................................................................................
8
What you must do to get covered
care..............................................................................................................................
8
Primary care
..............................................................................................................................................................
8
Specialty care
............................................................................................................................................................
8
Hospital
care..............................................................................................................................................................
9
Circumstances beyond our control
...................................................................................................................................
9
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................................ 25
(c) Services provided by a
hospital or other facility, and ambulance services
............................................................ 30
(d)
Emergency services/
accidents..............................................................................................................................
34
(e) Mental health and substance abuse benefits
.........................................................................................................
36
(f) Prescription drug benefits
....................................................................................................................................
38
(g) Special features
..................................................................................................................................................
41
24 Hour Nurse Line 2
2 Page 3 4
2002 Coventry
Health Care of Kansas, Inc. 3 Table of Contents
Services for
the deaf and hearing impaired
Transplant Network for transplants/ heart
surgery/ etc.
Flexible benefits option
(h) Dental
benefits.....................................................................................................................................................
42
Section 6. General exclusions --things we don't
cover....................................................................................................................
44
Section 7. Filing a claim for covered services
.................................................................................................................................
45
Section 8. The disputed claims
process...........................................................................................................................................
46
Section 9. Coordinating benefits with other coverage
....................................................................................................................
48
When you have…
Other health coverage
...............................................................................................................................................
49
Original
Medicare.....................................................................................................................................................
49
Medicare managed care plan
....................................................................................................................................
50
TRICARE/ Workers' Compensation/ Medicaid
...............................................................................................................
51
Other Government agencies
...........................................................................................................................................
51
When others are responsible for
injuries.........................................................................................................................
51
Section 10. Definitions of terms we use in this
brochure..................................................................................................................
52
Section 11. FEHB facts
..................................................................................................................................................................
54
Coverage
information...................................................................................................................................................
54
No pre-existing condition limitation
.....................................................................................................................
54
Where you get information about enrolling in the FEHB
Program........................................................................
54
Types of coverage available for you and your
family............................................................................................
54
When benefits and premiums
start........................................................................................................................
55
Your medical and claims records are
confidential.................................................................................................
55
When you
retire...................................................................................................................................................
55
When you lose benefits
................................................................................................................................................
55
When FEHB coverage
ends..................................................................................................................................
55
Spouse equity coverage
.......................................................................................................................................
55
Temporary Continuation of Coverage
(TCC).......................................................................................................
55
Converting to individual
coverage.......................................................................................................................
56
Getting a Certificate of Group Health Plan
Coverage...........................................................................................
56
Long term care insurance is coming later in
2002............................................................................................................................
57
Department of Defense/ FEHB Demonstration Project
.....................................................................................................................
58
Index……….......................................................................................................................
............................................................ 60
Summary of benefits
.......................................................................................................................................................................
61
Rates
.................................................................................................................................................................................
Back cover 3
3 Page
4 5
2002 Coventry Health Care of
Kansas, Inc. 4 Introduction/ Plain Language/ Advisory
Introduction
Coventry Health Care of Kansas, Inc.
1001 E.
101 st Terrace, Suite 300
Kansas City, Missouri 64131-3368
This brochure describes the benefits of Coventry Health Care of Kansas, Inc.,
under our contract (CS 1948) 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 Coventry Health Care
of Kansas, Inc.
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 e-mail 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
Fraud increases the cost of health care
for everyone. If you suspect that a physician,
pharmacy, or hospital has
charged you for services you did not receive, billed you
twice for the same
service, or misrepresented any information, do the following:
Call the provider and ask for an explanation. There may be an error.
If the provider does not resolve the matter, call us at 1-800-969-3343 and
explain the situation.
If we do not resolve the issue, call or write
THE HEALTH CARE FRAUD HOTLINE
202/ 418-3300 The United States
Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room
6400
Washington, DC 20415
Stop health care fraud! 4
4 Page 5 6
2002 Coventry
Health Care of Kansas, Inc. 5 Introduction/ Plain Language/ Advisory
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB
Program benefits can be prosecuted
for fraud. Also, the Inspector General
may investigate anyone who uses an ID card
if the person tries to obtain
services for someone who is not an eligible family
member, or is no longer
enrolled in the Plan and tries to obtain benefits. Your
agency may also take
administrative action against you. 5
5 Page 6 7
2002 Coventry
Health Care of Kansas, Inc. 6 Section 1
Section 1. Facts about
this HMO plan
This Plan is a health maintenance organization (HMO). We
require you to see specific physicians, hospitals, and other providers that
contract with us. These Plan providers coordinate your health care services.
HMOs emphasize preventive care such as routine office visits, physical exams,
well-baby care, and immunizations, in addition to
treatment for illness and
injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit
claim forms or pay bills. You only pay the copayments,
coinsurance, and
deductibles described in this brochure. When you receive emergency services from
non-Plan providers, you may
have to submit claim forms.
You should join an HMO because you prefer the plan's benefits, not because
a particular provider is available. You cannot
change plans because a
provider leaves our Plan. We cannot guarantee that any one physician, hospital,
or other provider will be available and/ or remain under contract with us.
How we pay providers
We contract with individual physicians,
medical groups, and hospitals to provide the benefits in this brochure. These
Plan providers
are paid in a number of ways, including salary, capitation,
per diem rates, case rates, and fee for service. You will also be responsible
for unauthorized care or services not covered under this plan.
Your Rights
OPM requires that all FEHB Plans provide certain
information to their FEHB members. You may get information about us, our
networks, providers, and facilities. OPM's FEHB website (www. opm. gov/
insure) lists the specific types of information that we must
make available
to you. Some of the required information is listed below.
Coventry Health Care of Kansas, Inc., is a for profit domiciled Kansas health
maintenance organization (HMO) with certificates of
authority to operate in
both Kansas and Missouri. Coventry Health Care of Kansas, Inc., has been in
existence since 1961, and has
two unique service areas: Kansas City and
Wichita for a combined total membership of over 170,000. We are dedicated to
providing
quality health care at an affordable price. We offer prepaid
health care benefit plans to employers for employees and their dependents.
We provide our members the security of knowing they are being offered a
health care delivery system supported by a long tradition of
quality and
service.
If you want more information about us, call 816/ 941-3030, or write to
Coventry Health Care of Kansas, Inc., Suite 300, Kansas Cit y,
MO
64131-3368. You may also contact us by fax at 816/ 941-8516 or visit our website
at www. chckansascity. com.
Service Area
To enroll in this Plan, you must live in or work in
our Service Area. This is where our providers practice. Our service area is:
Kansas -Anderson, Atchison, Douglas, Franklin, Jackson, Jefferson, Johnson,
Leavenworth, Linn, Miami, Shawnee, and Wyandotte
Counties
Missouri – Benton, Buchanan, Caldwell, Cass, Clay, Clinton, Daviess, DeKalb,
Henry, Jackson, Johnson, Lafayette, Platte, and Ray
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 are 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 Season to
change plans. Contact your employer or retirement
office. 6
6 Page 7
8
2002 Coventry Health Care of Kansas, Inc. 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 requirements that services must be required to restore functional
speech. (Section 5( a))
Changes to this Plan
Allergy testing is now covered at 50% of
charges. Previously, allergy testing was covered at $10 copay.
Voluntary sterilization is now covered at a $100 copay. Previously, it was
covered at $10 office visit copay.
Skilled nursing facility is now covered
for up to 60 days per calendar year. Previously, skilled nursing facility was
covered at 100 days per calendar year.
Outpatient surgeries are now covered at no charge. Previously, outpatient
surgeries were covered at $50 at a hospital or
ambulatory surgical center.
Durable medical equipment, prosthetic devices and orthopedic devices are
covered at 20% of charges up to a combined
$1,000 maximum per calendar year.
Previously, durable medical equipment, prosthetic devices and orthopedic devices
were covered at nothing up to a $1, 000 maximum per calendar year.
Emergency care at an urgent care center is now covered at $25 per visit.
Previously, emergency care at an urgent care
center was $10 per visit.
Prescription drugs benefit is now covered at a $5 for generic, $15 for
brand name, $45 for non-formulary per a 31-day
supply. Previously,
prescription drugs benefits were covered at $5 per prescription unit or refill
at a 30-day supply.
The out-of-pocket maximum copayments have changed from $2,000 to $1,000 per
person and from $4,500 to $3,000 per
family.
We no longer limit total blood cholesterol tests to certain age groups.
(Section 5( a))
We now cover certain intestinal transplants. (Section 5( b))
We
changed the address for sending disputed claims to OPM.
The expanded
service and enrollment area includes the following entire counties in Kansas:
Anderson, Atchison,
Douglas, Franklin, Jackson, Jefferson, Johnson,
Leavenworth, Linn, Miami, Shawnee and Wyandotte, and the following entire
counties in Missouri: Benton, Buchanan, Caldwell, Cass, Clay, Clinton,
Daviess, DeKalb, Henry, Jackson,
Johnson, Lafeyette, Platte and Ray.
We supply your mail order
prescriptions through Caremark Prescription Mail Service. (Section 5( f))
Your share of the non-Postal premium for Enrollment Code HA will increase by
3.2% for Self Only and by 3.2% for Self and
Family. 7
7 Page
8 9
2002 Coventry Health Care of
Kansas, Inc. 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 1-800-969-3343
or visit our
website at www. chckansascity. com to request a new card.
Where you get covered care You get care from "Plan providers" and
"Plan facilities." You will only pay copayments, deductibles, and/ or
coinsurance, and you will not have to file claims.
Plan providers Plan providers are physicians and other health care
professionals in our service area that
we contract with to provide covered
services to our members. We credential Plan
providers according to national
standards.
We list Plan providers in the provider directory, which we update
periodically. The list is
also on our website www. chckansascity. com
Plan facilities Plan facilities are hospitals and other facilities
in our service area that we contract with to
provide covered services to our
members. We list these in the provider directory, which
we update
periodically.
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.
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. You may choose a primary care physician for the entire family or a
different
primary care physician may be selected for individual family
members.
If you want to change primary care physicians or if your primary care
physician leaves
the Plan, call us or visit our website at www.
chckansascity. com to change your PCP. We
will help you select a new one.
Specialty care Your primary care physician will refer you to a
specialist for a consultation. If after the
consultation, the specialist
requires additional visits, then the specialist must obtain pre-certification
of services that require authorization. Some lab, radiology, and therapy
services may require authorization by our utilization management department.
Your
participating specialist must obtain this authorization. However, you
may see a OB/ Gyn
or a mental health provider without a referral.
Here are other things you should know about specialty care:
If you need
to see a specialist frequently because of a chronic, complex, or serious
medical condition, your primary care physician will develop a treatment plan
that
allows you to see your specialist for a certain number of visits
without additional
referrals. Your primary care physician will use our
criteria when creating your
treatment plan (the physician may have to get an
authorization or approval
beforehand).
What you must do
to get covered care 8
8
Page 9 10
2002
Coventry Health Care of Kansas, Inc. 9 Section 3
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 60 days after
you receive
notice of the change. Contact us or, if we drop out of the
Program, contact your new
plan.
If you are in the second or third trimester of pregnancy and you lose access
to your
specialist based on the above circumstances, you can continue to see
your specialist until
the end of your postpartum care, even if it is beyond
the 60 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. Be sure to tell
the hospital you are a Coventry Health Care HMO member and
remember to
present your identification card when you are admitted. This will ensure we
are notified.
If you are in the hospital when your enrollment in our Plan begins, call our
customer
service department immediately at 1-800-969-3343. 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 effective date of the new plan
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. 9
9
Page 10 11
2002
Coventry Health Care of Kansas, Inc. 10 Section 3
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 prior authorization of services.
Your physician
must obtain authorization for the following services:
hospitalization, referral to a
specialist outside of the network, or
recommendations for follow-up-care.
You are responsible for ensuring that your physician has obtained
authorization for a
planned hospital admission or surgery.
In addition, we may retract or refuse to pay an authorization, referral, or
claim if:
You make a material misrepresentation or omission about your
health condit ion or
the cause for your health condition.
You permit someone else to use your health plan identification card, you
use another
person's card, or you deface the card in order to obtain
services at a higher level of
benefits. Except when the member is unaware
another person is using their
identification card (i. e. lost or stolen
card)
Your group terminates its contract before your health care services are
provided; or
Your coverage under the group agreement terminates before the health care
services
are provided.
Services requiring our
prior approval 10
10 Page 11 12
2002 Coventry Health Care of Kansas, Inc. 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.
Deductible We do not have a deductible.
Coinsurance Coinsurance is the percentage of our negotiated fee
that you must pay for your care.
Example: In our Plan, you pay 50% of our allowance for infertility services
and allergy
testing.
After your copayments and coinsurance total $1,000 per person or $3,000 per
family
enrollment in any calendar year, you do not have to pay any more for
covered services.
However, copayments or coinsurance for the following
services do not count toward your
out-of-pocket maximum, and you must
continue to pay copayments or coinsurance for
these services:
Extended care services
Durable medical equipment
External
prostheses and braces
Chiropractic services
Dental care services
Prescription Drugs
Be sure to keep accurate records of your copayments or coinsurance since you
are
responsible for informing us when you reach the maximum.
Your out-of-pocket maximum for copayments and
coinsurance 11
11 Page 12 13
2002 Coventry Health Care of Kansas, Inc. 12
Section 5
Section 5. Benefits --OVERVIEW
(See page 7
for how our benefits changed this year and page 60 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 1-800-969-3343 or
at our website at www.
chckansascity. com.
(a) Medical services and supplies provided by physicians and other health
care professionals...................................................... 13-24
Diagnostic and treatment services
Lab, X-ray, and other diagnostic
tests
Preventive care, adult
Preventive care, children
Maternity care
Family planning
Infertility services
Allergy
care
Treatment therapies
Physical 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 ............................................... 25-29
Surgical procedures
Reconstructive surgery
Oral and maxillofacial
surgery
Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services
............................................................................
30-33
Inpatient hospital
Outpatient hospital or ambulatory surgical
center
Extended care benefits/ skilled nursing care facility benefits
Hospice care
Ambulance
(d) Emergency services/ accidents
.............................................................................................................................................
34-35
Medical emergency Ambulance
(e) Mental health and substance abuse benefits
.........................................................................................................................
36-37
(f) Prescription drug
benefits....................................................................................................................................................
38-40
(g) Special features
........................................................................................................................................................................
41
24 Hour Nurse Line
Services for the deaf and hearing impaired
Transplant Network for transplants/ heart surgery/ etc.
Flexible
Benefits Option
(h) Dental benefits
........................................................................................................................................................................
42
Summary of benefits
.......................................................................................................................................................................
61 12
12 Page 13
14
2002 Coventry Health Care of Kansas, Inc. 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.
Be sure to read Section 4,
Your costs for covered services, for valuable information about how cost
sharing works. Also
read Section 9 about coordinating benefits with other
coverage, including with Medicare.
I M
P O
R T
A N
T
Benefit Description You pay
After the calendar year deductible…
Diagnostic and treatment services
Professional services of
physicians
In physician's office
In an urgent care center
Office medical consultations
Second
surgical opinion
$10 per office visit
Professional services of physicians
During a hospital stay
In a skilled nursing facility
Nothing
At home Nothing
Diagnostic and treatment services --continued on next
page 13
13 Page
14 15
2002 Coventry Health Care of
Kansas, Inc. 14 Section 5( a)
Lab, X-ray and other diagnostic
tests
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG
Nothing if you receive these services
during your office visit;
otherwise, $10 per
office visit
Preventive care, adult
Routine screenings, such as:
Total
Blood Cholesterol – once every three years
Chlamydial Infection
Colorectal Cancer Screening, including
-Fecal occult blood test
-Sigmoidoscopy screening – every five years
starting at age 50
$10 per office visit
Prostate Specific Antigen (PSA test) – one annually for men age 40 and older
$10 per office visit
Routine pap 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
Preventive Care -Adult --continued on next page 14
14 Page 15 16
2002 Coventry Health Care of Kansas, Inc. 15
Section 5( a)
Preventive care, adult (continued) You
pay
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 49, one every two consecutive calendar years
At
age 50 and older, one every calendar year
Note: In addition to routine screening, we cover mammograms when
medically necessary to diagnose or treat your illness.
$10 per office visit
Not covered: Physical exams required for obtaining or continuing
employment or insurance, attending schools or camp, or travel.
All
charges.
Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster –
once every 10 years, ages 19 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
Nothing
Well-child care charges for routine examinations, immunizations and
care (through age 22)
Examinations, such as:
Eye exams through age 17 to determine the
need for vision
correction.
Ear exams through age 17 to determine the need for
hearing
correction
Examinations done on the day of immunizations ( through age 22)
$10 per office visit 15
15 Page 16 17
2002 Coventry
Health Care of Kansas, Inc. 16 Section 5( a)
Maternity care
You pay
Complete maternity (obstetrical) care, such as:
Prenatal
care
Delivery
Postnatal care
Physician ordered sonograms
Note: Here are some things to keep in mind:
You do not need to
precertify your normal delivery; see page 34 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).
$10 per office visit
Not covered: Routine sonograms to determine fetal age, size or sex All
charges.
Family planning
A broad range of voluntary family
planning services, limited to:
Family planning and counseling
Injectable contraceptive drugs (such as Depo Provera)
Intrauterine
devices (IUDs)
Diaphragms
NOTE: We cover oral contraceptives under the prescription drug
benefit.
$10 per office visit
Voluntary sterilization $100 per procedure
Not covered: reversal of
voluntary surgical sterilization, genetic
counseling,
All charges.
16
16 Page 17
18
2002 Coventry Health Care of Kansas, Inc. 17
Section 5( a)
Infertility services You pay
Diagnosis and
treatment of infertility, such as:
Outpatient lab and x-rays
Artificial insemination:
intravaginal insemination (IVI)
intracervical insemination (ICI)
intrauterine
insemination (IUI)
50% of our allowance per procedure
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
Drugs
and supplies for the treatment of infertility
All charges.
Allergy care
Testing and treatment
Allergy injection
50% of our allowance per visit
Allergy serum Nothing
Not covered: provocative food testing and
sublingual allergy
desensitization
All charges. 17
17 Page 18 19
2002 Coventry Health Care of Kansas, Inc. 18
Section 5( a)
Treatment therapies You pay
Chemotherapy
and radiation therapy
Note: High dose chemotherapy in association with autologous bone
marrow
transplants are limited to those transplants listed under
Organ/ Tissue
Transplants on page 31.
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 pre-authorize the treatment.
Call
1-800-969-3343 for preauthorization. We will ask you to submit
information
that establishes that the GHT is medically necessary. Ask
us to authorize
GHT before you begin treatment; otherwise, we will only
cover GHT services
from the date you submit the information. 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
Not covered:
Any treatment, procedure, facility, equipment,
drug, device, or
supply that We determine is not accepted as standard
medical
treatment for the condition being treated. Any treatment that We
consider to be experimental or investigational.
All charges. 18
18 Page 19 20
2002 Coventry
Health Care of Kansas, Inc. 19 Section 5( a)
Physical and
occupational therapies You pay
32 visits per condition for the services
of each of the following:
qualified physical therapists and
occupational therapists.
Note: We only cover therapy to restore bodily function when there has
been a total or partial loss of bodily function due to illness or injury.
Cardiac rehabilitation following a heart transplant, bypass surgery or a
myocardial infarction, is provided for up to 32 sessions
$10 per office visit
Nothing per visit during covered inpatient
admission
Not covered:
long-term rehabilitative therapy
All
charges.
Speech therapy
32 visits per condition $10 per office visit
Hearing services (testing, treatment, and supplies) You pay
First hearing aid and testing only when necessitated by accidental
injury
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.
Vision services (testing, treatment, and supplies)
One pair of
eyeglasses or contact lenses to correct an impairment directly
caused by
accidental ocular injury or intraocular surgery (such as for
cataracts)
$10 per office visit
Eye exam to determine the need for vision correction for children
through age 17 (see Preventive care, children)
Annual eye refractions
Note: See Preventive care, children for eye
exams for children
$10 per office visit
Not covered:
Eyeglasses or contact lenses and, after age 17,
examinations for
them
Eye exercises and orthoptics
Radial keratotomy and other refractive surgery
All charges. 19
19 Page 20 21
2002 Coventry
Health Care of Kansas, Inc. 20 Section 5( a)
Foot care You pay
Routine foot care when you are under active treatment for a metabolic
or peripheral vascular disease, such as diabetes.
See orthopedic and prosthetic devices for information on podiatric shoe
inserts.
$10 per office visit
Not covered:
Cutting, trimming or removal of corns, calluses,
or the free edge of
toenails, and similar routine treatment of conditions of
the foot,
except as stated above
Treatment of weak, strained or flat feet or bunions or spurs; and of
any instability, imbalance or subluxation of the foot (unless the
treatment is by open cutting surgery)
All charges.
Orthopedic and prosthetic devices
Artificial limbs and eyes;
stump hose
Externally worn breast prostheses and surgical bras, including
necessary replacements, following a mastectomy
Internal prosthetic
devices, such as artificial joints, pacemakers, and
surgically implanted
breast implant following mastectomy. Note:
See 5( b) for coverage of the
surgery to insert the device.
Note: External devices are limited to one each per member per lifetime,
except if a bilateral mastectomy is performed.
20% of our allowance per device
$1,000 maximum per calendar year
20
20 Page 21
22
2002 Coventry Health Care of Kansas, Inc. 21
Section 5( a)
Orthopedic and prosthetic devices (Continued)
You pay
Not covered:
orthopedic and corrective
shoes
arch supports
ankle foot orthotics or podiatric orthotics
heel pads and heel cups
lumbosacral supports
corsets, trusses, elastic stockings, support hose, and other supportive
devices
Dental braces, devices, and appliances
Braces for aid in sports activities
Experimental and
research braces
Internally implanted devices, equipment, and
prosthetics related to
treatment of sexual dysfunction
Repair and replacement of orthopedic and prosthetic devices, unless
necessitated by normal growth
All charges. 21
21 Page 22 23
2002 Coventry
Health Care of Kansas, Inc. 22 Section 5( a)
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;
wheelchairs;
crutches;
walkers;
Ostomy and urological supplies;
Prosthetic and orthotic supplies;
blood glucose monitors; and
insulin pumps, and syringes for insulin pumps
Apnea monitor
Cane;
Orthopedic braces for scoliosis;
Pads, wires, tubing, electrodes, and masks
Equipment required as a part of
acute primary care such as back braces,
rib belts, slings, and hard cervical
collars;
Replacement due to anatomical growth;
Repair and replacement of DME determined to be medically necessary.
Note: Call us at 1-800-969-3343 as soon as your Plan physician prescribes
this equipment. We will arrange with a health care provider to rent or sell
you durable medical equipment at discounted rates and will tell you more
about this service when you call.
20% of our allowance per item
$1,000 maximum per calendar year
Not covered:
Motorized wheel chairs
Comfort, convenience, or luxury items or features
Electric monitors of bodily functions, except for apnea monitors
Devices to perform medical testing of bodily fluids, excretions, or
substances
Disposable supplies
Replacement of lost equipment
Repair, adjustment, or
replacement necessitated by wear, tear, or
misuse
More than one piece of durable medical equipment serving
essentially
the same function, except for replacement due to
anatomical growth; spare
equipment or alternate use equipment is
not provided
All charges. 22
22 Page 23 24
2002 Coventry
Health Care of Kansas, Inc. 23 Section 5( a)
Home health
services You pay
Part-time or intermittent services:
Home health
care ordered by a Plan physician and approved by the
primary care physician
provided by a registered nurse (R. N.), licensed
practical nurse (L. P. N.),
licensed vocational nurse (L. V. N.), physical
therapist, speech therapist,
occupational therapist, or home health aide.
The agency rendering services is Medicare certified and licensed by
the
state of location
Services are a substitute or alternative to hospitalization
Services include intravenous therapy and medications.
Other services include:
Drugs, supplies, and supplements
Home IV and antibiotic therapy
Nothing
Not covered:
Nursing care requested by, or for the
convenience of, the patient or
the patient's family
Services primarily for hygiene, feeding, exercising, moving the
patient, homemaking, companionship or giving oral medication
Nursing care that could appropriately be rendered in a Plan
medical
office, affiliated hospital, or skilled nursing facility
Nursing care that can be performed safely and effectively by people
whom, in order to provide the care do not require medical licenses
or
certificates, or the presence of a supervising licensed nurse
Services outside our service area
All charges.
Chiropractic
Chiropractic services -up to 20 visits per calendar
year. Covered services
include:
Evaluation
Laboratory and x-ray
Manipulation of the spine and extremities
Adjunctive procedures such as ultrasound, electrical muscle
stimulation,
vibratory therapy, and cold pack application
$15 per office visit 23
23 Page 24 25
2002 Coventry
Health Care of Kansas, Inc. 24 Section 5( a)
Chiropractic
(continued)
Not covered:
Non-neuroskelatal
disorders
Vocational rehabilitation services
Thermography
Transporation costs including ambulance
Prescription drugs
Vitamins and minerals
Nutritional supplements or other
similar type products
MRI or other type of diagnostic radiology
All charges.
Alternative treatments You pay
No benefit
Acupuncture
Biofeedback
Hypnotherapy
Naturopathic services
All charges
Educational classes and programs
When provided as part of a
primary physician's office visit, or other
participating providers office
visit. Health education services include
instructions on achieving and
maintaining physical well being. Learning
how to control, and identify
warning signs of asthma or diabetes. How
to use medication and treat
symptoms. Please call Customer Service at
1-800-969-3343 for assistance.
Coverage is limited to:
Asthma education (Telephonic – No charge)
Diabetes self-management
$10 per office visit 24
24 Page 25 26
2002 Coventry
Health Care of Kansas, Inc. 25 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 informat ion about how cost
sharing
works. Also read Section 9 about coordinating benefits wit h 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.).
YOU MUST GET PRECERTIFICATION
OF SOME SURGICAL PROCEDURES. Please refer to the
precertification information shown in Section 3.
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)
Insertion of internal prosthetic devices. See 5( a) – Orthopedic
and
prosthetic devices for device coverage information.
Treatment of burns
$10 per office visit
Nothing in a hospital
Surgical procedures continued on next page. 25
25 Page 26 27
2002 Coventry Health Care of Kansas, Inc. 26
Section 5( b)
Surgical procedures (continued) You
pay
Voluntary sterilization $100 per procedure
Not covered:
Reversal of voluntary sterilization
Routine treatment of conditions of the foot; see Foot care.
All charges.
Reconstructive surgery
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
the
condition produced a major effect on the member's
appearance and
the condition can reasonably be expected to be
corrected by
such surgery
Surgery to correct a condition that existed at or from
birth and is a
significant deviation from the common form or norm. Examples
of
congenital anomalies are: 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. 26
26 Page 27 28
2002 Coventry
Health Care of Kansas, Inc. 27 Section 5( b)
Oral and
maxillofacial surgery
Oral surgical procedures, when medically
necessary, 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.
$10 per office visit
Nothing in a hospital
Not covered:
Oral implants and transplants
Procedures that involve the teeth or their supporting structures (such as
the periodontal membrane, gingiva, and alveolar bone)
Other procedures that involve the teeth or intra-oral areas surrounding
the teeth, including shortening of the mandible or maxillae for cosmetic
purposes
Correction of malocclusion
All charges. 27
27 Page 28 29
2002 Coventry
Health Care of Kansas, Inc. 28 Section 5( b)
Organ/ tissue
transplants You pay
Limited to:
Cornea
Heart
Heart/
lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single –Double
Pancreas
Allogeneic (donor) bone marrow transplants
Autologous
bone marrow transplants (autologous stem cell and
peripheral stem cell
support) for the following conditions: acute
lymphocytic or non-lymphocytic
leukemia; advanced Hodgkin's
lymphoma; advanced non-Hodgkin's lymphoma;
advanced
neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian
cancer; and testicular, mediastinal, retroperitoneal and ovarian germ
cell tumors
Intestinal transplants (small intestine) and the small intestine with the
liver or small intestine with multiple organs such as the liver, stomach,
and pancreas
Note: We cover related medical and hospital expenses of the donor when we
cover the recipient provided the recipient is a plan member. After referral
to
a transplant facility, the following will apply:
If our Medical Director or the referral facility decides you do not satisfy
criteria for a transplant, we only pay for covered services you receive
before that decision is made
We, and the plan providers are not responsible for finding, furnishing, or
ensuring the availability of a bone marrow or organ donor
We cover
reasonable medical and hospital expenses as long as the
expenses are
directly related to a covered transplant of the donor or an
individual
identified as a potential donor, even if a member
Unless otherwise authorized by our Medical Director, we provide
transplants only at approved Transplant Network facilities.
Nothing
Not covered:
Donor screening tests and donor search expenses,
except those
performed for the actual donor
Any related
conditions or complications for a member who is
donating an organ or tissue
when the recipient is not a member
Outpatient immunosuppressive
agents
Any transplant procedure that is performed in a facility
that has not
been designated by the Medical Director as a approved
transplant
facility
Implants of non-human or artificial organs
Transplants not listed as covered
All charges. 28
28 Page 29 30
2002 Coventry
Health Care of Kansas, Inc. 29 Section 5( b)
Anesthesia You
pay
Professional services provided in:
Hospital (inpatient)
Nothing
Professional services provided in –
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office
$10 per office visit 29
29 Page 30 31
2002 Coventry
Health Care of Kansas, Inc. 30 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 PRECERTIFICATION OF HOSPITAL STAYS. Please
refer to Section 3 to be sure which services require precertification. If
hospitalization is required,
your primary physician will arrange admission
to one of our participating hospitals. Either your
primary care physician
will admit you or you will be referred to a participating provider who will
manage your inpatient coordination with your primary care physician. Your
admitting physician
will give you instructions about which hospital to go
to, including the date and time you should
arrive. Before the arrangements
are made, please remind your primary care physician or
participating
physician that you need to go to a participating hospital.
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: When it is medically necessary, a plan physician may prescribe
private accommodations. If you want a private room when it is not
medically necessary, you pay the additional charge above the
semiprivate
room rate.
Nothing
Inpatient hospital continued on next page. 30
30 Page 31 32
2002 Coventry Health Care of Kansas, Inc. 31
Section 5( c)
Inpatient hospital (continued) You pay
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, if not donated or replaced
Dressings, splints, casts, and sterile tray services
Medical
supplies and equipment, including oxygen
Anesthetics, including nurse
anesthetist services
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 not medically necessary
Inpatient dental procedures( except for children or incapacitated
adult)
All charges.
Outpatient hospital or ambulatory surgical center
Operating,
recovery, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services
Administration
of blood, blood plasma, and other biologicals
Blood and blood plasma, if
not donated or replaced
Pre-surgical testing
Dressings, casts, and
sterile tray services
Medical supplies, including oxygen
Anesthetics
and anesthesia service
NOTE: – We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment. We
do
not cover the dental procedures.
Nothing
Not covered: blood and blood derivatives not replaced by the member All
charges.
Extended care benefits/ skilled nursing care facility
benefits You pay
Up to 60 days per member per calendar year when:
Full-time skilled
nursing care is necessary
Confinement in a skilled nursing facility is medically necessary
Nothing 31
31 Page
32 33
2002 Coventry Health Care of
Kansas, Inc. 32 Section 5( c)
Extended care benefits/ skilled
nursing care facility benefits
(continued)
You pay
Services include:
Bed, board, and general nursing
Prescribed drugs and their administration
Biologicals
Supplies
Durable medical equipment ordinarily furnished by the facility
Nothing
Not covered: custodial care or care in an intermediate care facility All
charges.
Hospice care
Supportive and palliative care for a terminally ill member:
You must
reside in the service area
Services are provided in the home
Services are provided in a Plan
approved hospice facility
Note: Services include inpatient care, outpatient care, and family
counseling (except financial, legal or spiritual counseling provided by a
volunteer). A plan physician must certify that you have a terminal
illness, with a life expectancy of approximately six months or less.
Note: Hospice is a program for caring for the terminally ill that
emphasizes supportive services, such as home care and pain control,
rather than curative care of the terminal illness. A person who is
terminally ill may elect to receive hospice benefits. These palliative
and supportive services include nursing care, medical social services,
physician services, and short-term inpatient care for pain control and
acute chronic symptom management. We also provide services for
symptom
control to enable the person to continue life with as little
disruption as
possible.
Nothing 32
32 Page
33 34
2002 Coventry Health Care of
Kansas, Inc. 33 Section 5( c)
Hospice care (continued)
Not covered:
Medical equipment or supplies that are not
included in the physician's
recommended plan of treatment
Services in the member's home outside of the service area
Financial and legal counseling
Any service for which the
hospice does not customarily charge the
member, or his or her family
Reimbursement for volunteer or spiritual counseling
Independent nursing, homemaker services
All charges.
Ambulance
Local professional ambulance service to the nearest
hospital
equipped to handle your medical condition when medically
appropriate
We will authorize air ambulance if ground transportation is not
medically appropriate
$50 per transport
Not covered: All charges 33
33 Page 34 35
2002 Coventry
Health Care of Kansas, Inc. 34 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 deduct ible
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:
In a life-threatening emergency,
call the local emergency system (e. g., the local 911 telephone system), or go
to the nearest
emergency facility. If an ambulance comes, tell the
paramedics that the person who needs help is a Coventry Health Care of
Kansas member.
Emergencies within our service area:
If you are admitted to a
non-participating facility, call Customer Service at (800) 969-3343. You must
notify us about your
medical emergency within a reasonable time period as
dictated by the circumstances. If you are hospitalized in a non-participating
hospital and plan physicians believe your care can be provided in one of our
participating hospitals, we will
transfer you when medically feasible.
Follow-up services will normally be performed by your primary care physician.
Benefits are available for care from non-participating providers in a medical
emergency only if delay in reaching a
participating facility would result in
death, disability, or significant jeopardy to your condition.
If your symptoms are not life-threatening, contact your primary care
physician who is on call 24 hours a day, seven days a
week. After hours or
weekends, your physician may use an answering service. Your physician or a
covering physician will
generally return your call within 30 minutes. We
also provide First Help, which is available to our members 24 hours a
day,
seven days a week by calling (800) 622-9528. With this service
registered nurses are available to help direct you to the
appropriate level
of care or provide medical advice.
We also provide several Urgent Care centers which are open on evenings,
weekends, and holidays and are designed to give
our members fast, effective
quality care for non-emergent conditions such as: sprains, influenza, sore
throats, ear infections,
minor lacerations, and upper respiratory
infections.
Emergencies outside our service area:
If you are hospitalized, We
must be notified about your medical emergency within a reasonable time period as
dictated by
the circumstances. If a participating physician believes your
care can be provided in one of our participating hospitals, we
will transfer
you when medically feasible.
First Help is available to our members 24 hours day, seven days a week
by calling (800) 622-9528. With this service
registered nurses are
available to help direct you to the appropriate level of care or provide medical
advice. If a medical
condition requires urgent care, please go to the
nearest urgent care facility, physician's office or other provider for
treatment. 34
34 Page
35 36
2002 Coventry Health of Kansas,
Inc. 35 Section 5( d)
Benefit Description You pay
Emergency within our service area
Emergency care at a doctor's
office
Emergency care at an urgent care center
$10 per visit
$25 per visit
Emergency care as an outpatient or inpatient at a
hospital,
including doctors' services
Note: We waive the copay if you are admitted to the hospital, or First Help
authorized you to go.
$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
Nothing
Not covered:
Elective care or non-emergency care
Emergency care provided outside the service area if the need for
care could have been foreseen before leaving the service area
Medical and hospital costs resulting from a normal full-term
delivery of a baby outside the service area {If you cover full-term
deliveries outside the service area delete this exclusion}
All charges.
Ambulance (within or outside of service area)
Local professional
ambulance service to the nearest hospital equipped
to handle you medical
condition when medically appropriate
We will authorize air ambulance if ground transportation is not
medically appropriate
See 5( c) for non-emergency service.
$50 per transport
Not covered: Transports we determine are not medically necessary All
charges. 35
35 Page
36 37
2002 Coventry Health Care of
Kansas, Inc. 36 Section 5( e)
Section 5 (e). Mental health and
substance abuse benefits
I M
P O
R T
A N
T
When you get our approval for services and follow a treatment plan we
approve, cost-sharing and limitations
for Plan mental health and substance
abuse benefits will be no greater than for similar benefits for other
illnesses and conditions.
Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and
exclusions in this brochure.
We have not calendar year deductible
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost
sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with
Medicare.
YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the
instructions after the
benefits description below.
I M
P O
R T
A N
T
Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider
and contained in a treatment plan that we approve. The treatment plan
may include services, drugs, and supplies described elsewhere in this
brochure.
Note: Plan benefits are payable only when we determine the care is
clinically appropriate to treat your condition and only when you receive
the care as part of a treatment plan that we approve.
Your cost sharing responsibilities are no
greater than for other illness
or conditions.
Diagnostic and treatment of psychiatric conditions, mental illness and
mental disorders. Services include:
Diagnostic evaluation
Professional services, including individual or group therapy by
providers such as psychiatrists, psychologists, or clinical social
workers
Crisis intervention and stabilization for acute episodes
Psychological testing necessary to determine the appropriate treatment
Medication evaluation and management
$10 per visit
Mental health and substance abuse benefits -continued on next page 36
36 Page 37 38
2002 Coventry Health Care of Kansas, Inc. 37
Section 5( e)
Mental health and substance abuse benefits
(continued) You pay
Diagnosis and treatment of alcoholism
and drug abuse. Services include:
Detoxification (medical management of
withdrawal from the substance)
Treatment and counseling (including individual and group therapy visits)
Rehabilitation
Note: Your mental health or substance abuse provider will develop a
treatment plan to assist you in improving or maintaining your condition and
functional level, or to prevent relapse.
Note: You may see an outpatient mental health or substance abuse provider
without referral from your primary care physician. However, before you see
a mental health provider you must obtain authorization for the visit from
APS
Healthcare, Inc., at 800-752-7242. They can be reached for routine
referrals
between 8 a. m. and 6 p. m. CT Monday through Friday, or for
emergency
services 24 hours a day. Your mental health provider will obtain
subsequent
authorizations for treatment.
$10 per visit
Inpatient psychiatric care
Services in approved alternative care
settings such as partial
hospitalization, half-way house, residential
treatment, full-day
hospitalization, facility based intensive outpatient
treatment
Inpatient substance abuse care
Inpatient detoxification
Nothing
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:
APS Healthcare, Inc., is contracted by Coventry Health Care of Kansas, Inc., to
provide a network of providers who offer a
variety of therapeutic services
on an inpatient and outpatient basis.
All inpatient and outpatient treatment must be authorized through APS
Healthcare, Inc., at 800-752-7242.
Limitation We may limit your benefits if you do not follow your
treatment plan. 37
37 Page
38 39
2002 Coventry Health Care of
Kansas, Inc. 38 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 informat ion about how cost sharing
works. Also read Section 9
about coordinat ing benefits wit h other coverage, including with Medicare.
I M
P O
R T
A N
T
There are important features you
should be aware of. These include:
Who can write your prescription.
A plan physician, referral physician or oral surgeon must write the
prescription.
Where you can obtain them. You must fill the
prescription at a participating pharmacy. You may obtain
maintenance
medication through Caremark, our mail order prescription drug program.
Caremark's
Customer Service number is (800) 378-7040.
We use a formulary. A formulary is a list of specific generic and
brand name prescription drugs authorized
by the Health Plan, and subject to
periodic review and modification. Since there may be more than one brand
name of a prescription drug, not all brands of the same prescription drug
(e. g., different manufacturers) may
be included in the Formulary. If you
would like information on whether a specific drug is included in our
drug
formulary, please call Customer Service at 800-969-3343.
If your plan physician specifically prescribes a non-formulary drug because
it is medically necessary, you will
receive the non-formulary drug at the
Plan non-formulary copayment. If you request a non-formulary drug
when your
physician has prescribed a substitution, we will not provide the non-formulary
drug. However,
you may purchase the non-formulary drug from a Plan pharmacy
at our allowance.
These are the dispensing limitations. Prescription Drugs will be dispensed
in the quantity determined by the
Prescribing Provider. The following also
apply:
One (1) copayment is due each time a prescription is filled or refilled up
to a thirty-one (31) days supply.
Insulin and diabetic supplies (insulin syringes, with or without needles,
needles, blood and urine glucose test
strips, lancets and devices, ketone
test strips and tabs), up to a ninety-three (93) days supply, may be
dispensed with one (1) generic level copayment for each prescription up to a
thirty-one (31) days supply.
Maintenance Drugs obtained through a pharmacy designated by the Health
Plan, maybe dispensed with two
(2) copayment( s) for a ninety-three (93)
days supply.
Generic oral contraceptives, up to a maximum of three (3)
cycles maybe dispensed with one (1) generic level
copayment for each cycle.
Brand name contraceptives will be dispensed up to a maximum of three (3)
cycles may be dispensed with one
(1) brand level copayment per cycle. The
Ancillary charge does not apply to brand name contraceptives.
If a brand
name Prescription Drug is dispensed, and an equivalent generic Prescription Drug
is available, the
Member shall pay an Ancillary Charge in addition to the
formulary brand name copayment. The Ancillary
Charge will be due regardless
of whether or not the Prescribing Provider indicates that the pharmacy is to
"Dispense as Written." The Ancillary Charge is the difference between the
average wholesale price of the
brand name and the maximum allowable cost
price of the generic prescription. Copayments and Ancillary
Charges do not
apply to the Out-of-Pocket Maximum. 38
38 Page 39 40
2002 Coventry
Health Care of Kansas, Inc. 39 Section 5( f)
Generic drugs are
a lower-priced drugs that are the therapeutic equivalent to more expensive
brand-name
drugs. They must contain the same active ingredients and must be
equivalent in strength and dosage to the
original brand-name product.
Generics cost less than the equivalent brand-name product. The U. S. Food and
Drug Administration sets quality standards for generic drugs to ensure that
these drugs meet the same
standards of quality and strength as brand-name
drugs. Generic drugs are indicated on the formulary listing
of prescription
drugs.
When you have to file a claim. When you receive drugs from a Plan
pharmacy, you do not have to file a
claim. For a covered out-of-area
emergency, you will need to file a claim when you receive drugs from a no-Plan
pharmacy.
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 (per vial) and lancets
Glucose test strips
Oral Contraceptive drugs
Injectable
contraceptive drugs (such as Depo Provera)
$5 per prescription or refill (Formulary
generic and brand name insulin)
$15 per prescription or refill (Formulary
brand name)
$45 per prescription or refill (Non-formulary)
Note: If there is no generic equivalent
available, you will still have to
pay the
brand name copay.
Disposable needles and syringes for the administration of covered
medications
Any equipment necessary to use a prescribed drug
Immunosuppressant drugs required after a covered transplant
Nothing
Covered medications and supplies --continued on next page 39
39 Page 40 41
2002 Coventry Health Care of Kansas, Inc. 40
Section 5( f)
Covered medications and supplies (continued)
You pay
Drugs to treat sexual dysfunction
Note: These drugs have dispensing limitations. Contact the Plan for details.
50% of our allowance
Not covered:
Drugs and supplies for cosmetic purposes
Medical supplies such as dressings and antiseptics
Smoking
Cessation drugs, and devices including nicotine gum
Drugs to
enhance athletic performance
Fertility drugs
Drugs
obtained at a non-Plan pharmacy; except for out-of-area
emergencies
Vitamins, nutrients and food supplements even if a physician
prescribes or administers them
Drugs available without a prescription or for which there is a
non-prescription
equivalent
Prescription drugs for a non-covered service
Drugs used for hair restoration
Dietary supplements,
appetite suppressants, and other drugs used to
treat obesity or assist in
weight reduction
All charges. 40
40 Page 41 42
2002 Coventry
Health Care of Kansas, Inc. 41 Section 5( g)
Section 5 (g).
Special features
Feature Description
24 hour nurse line Call First Help anytime you or a family member
experience health symptoms that need attention. Nurses are available to you and
your family 24 a day, 7 days a
week and are trained to handle your
questions. Any member who visits an
emergency room or urgent care center as
a result of advice from First Help will
automatically have associated claims
approved. With First Help authorization, you
will know in advance if medical
services will be covered. You may call 1-800-
622-9528 or for the hearing
impaired call 1-800-735-2966.
Services for deaf and hearing impaired The Missouri TDD relay number
is 1-800-735-2966.
Transplant Network In order to provide members requiring a transplant
the opportunity for the best outcomes and experiences, We have contracted with
United Resource Networks
for access to a network of transplant programs with
proven expertise. United
Resource Networks evaluates transplant programs
throughout the United States,
and has built a nationally-recognized network
of programs called the United
Resource Networks Transplant Network.
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. 41
41 Page 42 43
2002 Coventry Health Care of Kansas, Inc. 42
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 dentally necessary.
Members may
contact CompDent toll free at (800) 456-5500 or visit their website at www.
compdent. com.
We have no calendar year deductible. There are no out-of-network benefits.
The member must pay the dentist the listed copay at the time of service.
The member is not limited to a specific
number of visits per year. Member
does not have to be assigned to a certain provider office. Member may visit any
dentist in the plan. A plan dentist must provide or arrange your care.
Be sure to read Section 4, Yourcostsfor 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 emergency restorative
services and supplies necessary to
promptly repair (but not replace) sound
natural teeth. The need for these
services must result from an accidental
injury.
You will receive a 20% reduction of
participating specialist fees
Dental Benefits
Service You pay
General dentist (you pay
restorative services)
Amalgam (fillings silver, plastic or composite)
Inlay/ Onlay
Crowns (Stainless steel, cast or porcelain/ metal)
$28 – 52
$188 – 278
$120 – 340
Periodontic services
Root planning (per quadrant)
Occlusal adjustment
$55 – 210
$21 – 278
Orthodontic services
Standard fully banded case (available to
members age 19 and under)
You will receive a 20% reduction of
participating specialist fees
Endodontic services
Root canals $190 – 370
Oral surgery
Simple extraction
Extractions (each additional
tooth)
Surgical removal of erupted tooth
$32
$31
$62
Prosthetic services
Dentures (complete
upper or lower)
Partial dentures
Denture relines
$410 – 445
$350 – 440
$75 – 115 42
42
Page 43 44
2002
Coventry Health Care of Kansas, Inc. 43 Section 5( h)
Dental
benefits (continued) You pay
Any treatment provided by a
participating specialist (advanced
degree) will be charged at a 20%
reduction of participating
specialist fees for that particular case.
Note: Some specialists may require a consultation visit before treatment is
initiated.
You will receive a 20% reduction of
participating specialist fees
Not covered:
Services for injuries or conditions that are
covered under
Workman's Compensation or Employer Liability Laws.
Cost of dental care which is covered under automobile medical, no
fault, or similar type insurance.
General anesthesia, IV sedation, hospitalization or hospital medical
charges of any kind.
Osseointegrated implants
Member's dental fees apply only when treatment is performed at a
participating dental office. If the services of a non-participating
specialist or non-participating general dentist are required, these
dental fees do not apply, and the patient will be responsible for the
non-participating dentist's usual, customary and reasonable fee.
Reduced fees will not be honored if the dental treatment is already
in progress or if the patient's membership is no longer valid.
Any member accepted for orthodontics must remain a member of the
dental plan for the full duration of their treatment or risk additional
charges from their participating Orthodontist.
A patient's existing dental or medical condition may necessitate
extra precautionary procedures and require additional charges.
Please discuss all fees with the dentist prior to treatment.
All charges. 43
43 Page 44 45
2002 Coventry
Health Care of Kansas, Inc. 44 Section 6
Section 6. General
exclusions --things we don't cover
The exclusions in this section apply
to all benefits. Although we may list a specific service as a benefit, we
will not cover it
unless your Plan doctor determines it is medically
necessary to prevent, diagnose, or treat your illness, disease, injury, or
condition.
We do not cover the following:
Care by non-Plan providers except for
authorized referrals or emergencies (see Emergency Benefits);
Services, drugs, or supplies you receive while you are not enrolled in this
Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of
medical, dental, or psychiatric practice;
Experimental or investigational
procedures, treatments, drugs or devices;
Services, drugs, or supplies
related to abortions, except when the life of the mother would be endangered if
the fetus
were carried to term or when the pregnancy is the result of an act
of rape or incest;
Services, drugs, or supplies related to sex
transformations;
Services required when the Member is incarcerated in a local, state or
federal facility;
Services, drugs, or supplies you receive from a provider
or facility barred from the FEHB Program. 44
44
Page 45 46
2002
Coventry Health Care of Kansas, Inc. 45 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, coinsurance.
You will only need to file a claim when you receive emergency services from
non-plan providers. Sometimes these providers bill us
directly. Check with
the provider. If you need to file the claim, here is the process:
Medical, hospital, and drug In most cases, providers and facilities
file claims for you. Physicians must file on the benefits form HCFA-1500,
Health Insurance Claim Form. Facilities will file on the UB-92 form.
For
claims questions and assistance, call us at 1-800-969-3343.
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:
Coventry Health Care of Kansas, Inc.
P.
O. Box 7109
London, KY 40742
Deadline for filing your claim Send us all of the documents for your
claim as soon as possible. You must submit the claim by December 31 of the year
after the year you received the service, unless timely
filing was prevented
by administrative operations of Government or legal incapacity,
provided the
claim was submitted as soon as reasonably possible.
When we need more information Please reply promptly when we ask for
additional information. We may delay processing or deny your claim if you do not
respond. 45
45 Page
46 47
2002 Coventry Health Care of
Kansas, Inc. 46 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
Ask us in writing to reconsider our initial decision. You must:
(a)
Write to us within 90 days from the date of our decision; and
(b) Send your request to us at: Coventry Health Care of Kansas, Inc., Attn:
Member Appeals, 1001 East 101 st Terrace, Suite
300, Kansas City, MO 64131;
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.
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.
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.
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. 46
46 Page
47 48
2002 Coventry Health Care of
Kansas, Inc. 47 Section 8
The Disputed Claims process
(Continued)
Send OPM the following information:
A
statement about why you believe our decision was wrong, based on specific
benefit provisions in this brochure;
Copies of documents that support your claim, such as physicians' letters,
operative reports, bills, medical records, and
explanation of benefits (EOB)
forms;
Copies of all letters you sent to us about the claim;
Copies of all letters we sent to you about the claim; and
Your
daytime phone number and the best time to call.
Note: If you want OPM to review different claims, you must clearly identify
which documents apply to which claim.
Note: You are the only person who has
a right to file a disputed claim with OPM. Parties acting as your
representative, such
as medical providers, must include a copy of your
specific written consent with the review request.
Note: The above deadlines may be extended if you show that you were unable to
meet the deadline because of reasons
beyond your control.
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.
If you do not agree with OPM's decision, your only recourse is to sue. If
you decide to sue, you must file the suit against OPM in Federal court by
December 31 of the third year after the year in which you received the disputed
services, drugs, or
supplies or from the year in which you were denied
precertification or prior approval. This is the only deadline that may not
be extended.
OPM may disclose the information it collects during the review process to
support their disputed claim decision. This
information will become part of
the court record.
You may not sue until you have completed the disputed claims process.
Further, Federal law governs your lawsuit, benefits,
and payment of
benefits. The Federal court will base its review on the record that was before
OPM when OPM decided to
uphold or overturn our decision. You may recover
only the amount of benefits in dispute.
NOTE: If you have a serious or life threatening condition (one that
may cause permanent loss of bodily functions or death if not treated as soon as
possible), and
(a) We haven't responded yet to your initial request for care
or preauthorization/ prior approval, then call us at 1-800-969-3343
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. 47
47
Page 48 49
2002
Coventry Health Care of Kansas, Inc. 48 Section 9
Section 9.
Coordinating benefits with other coverage
When you have other health
coverage You must tell us if you are covered or a family member is covered
under another group health plan or have automobile insurance that pays health
care expenses without regard to
fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full
as the
primary payer and the other plan pays a reduced benefit as the
secondary payer. We, like
other insurers, determine which coverage is
primary according to the National
Association of Insurance Commissioners'
guidelines.
When we are the primary payer, we will pay the benefits described in this
brochure.
When we are the secondary payer, we will determine our allowance.
After the primary
plan pays, we will pay what is left of our allowance, up
to our regular benefit. We will
not pay more than our allowance.
What is Medicare? Medicare is a Health Insurance Program for:
People 65 years of age and older.
Some people with disabilities, under 65
years of age.
People with End-Stage Renal Disease (permanent kidney
failure requiring dialysis or
a transplant).
Medicare has two parts:
Part A (Hospital Insurance). Most people do not
have to pay for Part A. If you or
your spouse worked for at least 10 years
in Medicare-covered employment, you
should be able to qualify for
premium-free Part A insurance. (Someone who was a
Federal employee on
January 1, 1983 or since automatically qualifies.) Otherwise, if
you are age
65 or older, you may be able to buy it. Contact 1-800-MEDICARE for
more
information.
Part B (Medical Insurance). Most people pay monthly for Part B. Generally,
Part B
premiums are withheld from your monthly Social Security check or your
retirement
check.
If you are eligible for Medicare, you may have choices in how you get your
health care.
Medicare + Choice is 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. Your
care must continue to be
authorized by your Plan PCP, or precertified as
required. We will not waive any of our
copayments, coinsurance.
The Original Medicare Plan
(Part A or Part B) 48
48 Page 49 50
2002 Coventry Health Care of Kansas, Inc. 49
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 …
Original Medicare This Plan
1) Are an active employee withthe
Federal government (including when you or a
family member are eligible for
Medicare solely becauseof adisability),
2) Are an annuitant,
3) Are a re-employed annuitant with the Federal government when…
a) The position is excluded from FEHB, or
b) The position is not excluded from FEHB
Ask your employing office which
of these applies to you
4) Are a Federal judge who retired under title 28, U. S. C., or a Tax Court
judge who retired under Section 7447 of title 26, U. S. C. (or if your
covered spouse is this type of judge),
5) Are enrolled in Part B only, regardless of your employment status, (for
Part B services) (for other services)
6) Are a former Federal employee
receiving Workers' Compensation and
the Office of Workers' Compensation
Programs has determined that
you are unable to return to duty,
(except for claims
related to Workers'
Compensation.)
B. When you --or a covered family member --have Medicare based on end
stage renal disease (ESRD) and…
1) Are within the first 30 months of eligibility to receive Part A benefits
solely because of ESRD,
2) Have completed the 30-month ESRD coordination period and are still
eligible for Medicare due to ESRD,
3) Become eligible for Medicare due to 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 49
49 Page 50 51
2002 Coventry Health Care of Kansas, Inc. 50
Section 9
Claims process when you have the Original Medicare Plan
--You probably will never
have to file a claim form when you have both
our Plan and the Original Medicare Plan.
When we are the primary payer, we process the claim first.
When Original Medicare is the primary payer, Medicare processes your claim
first.
In most cases, your claims will be coordinated automatically and we
will pay the
balance of covered charges. You will not need to do anything.
To find out if you
need to do something about filing your claims, call us at
1-800-969-3343 or visit our
website at www. chckansascity. com.
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, known as Coventry Health Care
of Kansas Advantra, and also remain
enrolled in our FEHB plan. In this case,
we do waive some of our copayments,
coinsurance, or deductibles for your
FEHB coverage.
Medical office visits: $10.00 (PCP) or $20.00 (Specialist)
Preventive
office visits: $10.00 (physical exams)
Urgent care: $50. 00 per visit
Prescription benefits: $10.00 for Formulary generic; $20.00 Formulary
brand name;
or $50.00 non-Formulary
Vision: $10.00 for routine exam; $100.00 every
24 months for frames
Hearing aid: No benefit
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, if you
use our Plan providers. However, we will not
waive any of our copayments or
coinsurance. 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 season unless you involuntarily
lose
coverage or move out of the Medicare managed care plan's service area.
If you do not enroll in If you do not have one or both Parts of
Medicare, you can still be covered under the
Medicare Part A or Part B
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.
50
50 Page 51 52
2002 Coventry Health Care of Kansas, Inc. 51
Section 9
TRICARE TRICARE is the health care program for
eligible dependents of military persons and retirees of the military. TRICARE
includes the CHAMPUS program. If both TRICARE
and this Plan cover you, we
pay first. See your TRICARE Health Benefits Advisor if you
have questions
about TRICARE coverage.
Workers' Compensation We do not cover services that:
you need
because of a workplace-related illness or injury that the Office of Workers'
Compensation Programs (OWCP) or a similar Federal or State agency determines
they
must provide; or
OWCP or a similar agency pays for through a third party injury settlement
or other
similar proceeding that is based on a claim you filed under OWCP or
similar laws.
Once OWCP or similar agency pays its maximum benefits for your treatment, we
will
cover your care. You must use our providers.
Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies We do not cover services and supplies
when a local, State, are responsible for your care or Federal Government
agency directly or indirectly pays for them.
When others are responsible When you receive money to compensate you
for medical or hospital care for injuries 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. 51
51 Page
52 53
2002 Coventry Health Care of
Kansas, Inc. 52 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 Coinsurance is the percentage of our allowance that you
must pay for your care. 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
Care that is primarily for meeting personal needs: such as walking, getting
in and out of bed, bathing, dressing, shopping, eating and preparing meals,
performing general
household services, or taking medicine.
Deductible A deductible is a fixed amount of covered expenses you must
incur for certain covered services and supplies before we start paying benefits
for those services. See page 11.
A health product or service is deemed Experimental, Investigational or
Unproven if one
of the following criteria are met: (1) Any drug not approved
for use by the FDA; any
drug that is classified as IND (investigational new
drug) by the FDA; any drug requiring
pre-authorization that is proposed for
off-label prescribing; (2) Any health service or
product that is subject to
Investigational Review Board (IRB) review or approval; (3)
Any health
service or product that is the subject of a clinical trial that meets criteria
for
Phase I, Phase II or Phase III as set forth by FDA regulations; (4) Any
health product or
service that is not considered standard treatment by the
medical community, based on
clinical evidence reported by peer review
medical literature and by generally recognized
academic experts.
Group health coverage Health care benefits that are available as a
result of your employment, or the employment of your spouse, and that are
offered by an employer or through membership in an
employee organization.
Health care coverage may be insured or indemnity coverage,
self-insured or
self-funded coverage, or coverage through health maintenance
organizations
or other managed care plans. Health care coverage purchased through
membership in an organization is also "group health coverage."
Medical necessity Health Services and supplies which are deemed by the
Plan to be medically appropriate and (1) necessary to meet the basic health
needs of the Plan member; (2) rendered in the
most cost-efficient manner and
type of setting appropriate for the delivery of the health
service; (3)
consistent in type, frequency and duration of treatment with relevant
guidelines of national medical, research or health care coverage
organizations and
governmental agencies; (4) consistent with the diagnosis
of the condition; (5) required for
reasons other than the comfort or
convenience of the Plan member or his or her provider;
and (6) of
demonstrated medical value. The fact that a Physician has performed or
prescribed a procedure or treatment of the fact that it may be the only
treatment for a
particular injury or sickness does not necessarily mean that
the procedure or treatment is
medically necessary.
Experimental or investigational services 52
52 Page 53 54
2002 Coventry Health Care of Kansas, Inc. 53
Section 10
Our allowance Is the amount we use to determine our
payment and your coinsurance for covered services. When you receive services or
supplies from Plan providers, it is the amount
that we set for the services
or supplies if we were to charge for them. When you receive
services from
non-Plan providers, we determine the amount that we believe is usual and
customary for the service or supply, and compare it to the charges. Our
allowance is
based upon the reasonableness of the charges. If the charges
exceed what we believe is
reasonable, you may be responsible for the excess
over our allowance in addition to your
coinsurance.
Us/ We Us and we refer to Coventry Health Care of Kansas, Inc.
You You refers to the enrollee and each covered family member. 53
53 Page 54 55
2002 Coventry Health Care of Kansas, Inc. 54
Section 11
Section 11. FEHB facts
No pre-existing condition
We will not refuse to cover the treatment of a condition that you had before
you enrolled limitation in this Plan solely because you had the condition
before you enrolled.
Where you can get information See www. opm. gov/ insure. Also, your
employing or retirement office can answer your about enrolling in the
questions, and give you a Guide to Federal Employees Health Benefits
Plans, brochures
FEHB Program 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 season for enrollment 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 Self Only coverage is for you alone. Self
and Family coverage is for you, your spouse, for you and your family 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 c