A Health Maintenance Organization
Serving: The Greater Des Moines, Central Iowa, Waterloo, Sioux
City,
and Cedar Rapids areas.
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:
SV1 Self Only
SV2 Self and Family
RI-73-186
2002
For changes
in benefits
see page 7. 1
1 Page 2 3
2002 Coventry Health Care of Iowa, Inc. 2
Table of Contents
Table of Contents
Introduction…………………………………………………………………...............................................................4
Plain
Language..............................................................................................................................................................4
Inspector General Advisory
........................................................................................................................................5
Section 1. Facts about this HMO plan
........................................................................................................................6
How we pay providers
................................................................................................................................6
Your
Rights..................................................................................................................................................6
Service Area
................................................................................................................................................6
Section 2. How we change for 2002
............................................................................................................................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............................................................................................................10
Services requiring our prior approval
......................................................................................................10
Section 4. Your costs for covered services
................................................................................................................11
Copayments..........................................................................................................................................11
Deductible
............................................................................................................................................11
Coinsurance..........................................................................................................................................11
Your out-of-pocket maximum
..................................................................................................................11
Section 5.
Benefits......................................................................................................................................................12
Overview
..................................................................................................................................................12
(a) Medical services and supplies provided by physicians and other health
care professionals..............13
(b) Surgical and anesthesia services
provided by physicians and other health care professionals ..........20
(c)
Services provided by a hospital or other facility, and ambulance services
........................................23
(d) Emergency services/accidents
............................................................................................................26
(e) Mental health and substance abuse
benefits........................................................................................28
(f) Prescription drug benefits
....................................................................................................................29
(g) Special features
..................................................................................................................................31
(h) Dental benefits
....................................................................................................................................32
(i) Non-FEHB benefits available to Plan members
................................................................................33
2
2 Page 3 4
2002 Coventry Health Care of Iowa, Inc. 3
Table of Contents
Section 6. General exclusions --things we don't
cover
............................................................................................34
Section 7. Filing a claim for covered services
..........................................................................................................35
Section 8. The disputed claims
process......................................................................................................................37
Section 9. Coordinating benefits with other coverage
..............................................................................................39
When you have…
Other health coverage
..........................................................................................................................39
Original Medicare
................................................................................................................................39
Medicare managed care plan
..............................................................................................................41
TRICARE/Workers' Compensation/Medicaid
........................................................................................41
Other Government agencies
......................................................................................................................42
When others are responsible for injuries
..................................................................................................42
Section 10. Definitions of terms we use in this brochure
............................................................................................43
Section 11. FEHB facts
..............................................................................................................................................44
Coverage
information................................................................................................................................44
No pre-existing condition
limitation....................................................................................................44
Where you get information about enrolling in the FEHB
Program....................................................44
Types of
coverage available for you and your family
........................................................................44
When benefits and premiums start
......................................................................................................45
Your medical and claims records are confidential
..............................................................................45
When you retire
..................................................................................................................................45
When you lose benefits
............................................................................................................................45
When FEHB coverage ends
................................................................................................................45
Spouse equity coverage
......................................................................................................................45
Temporary Continuation of Coverage
(TCC)......................................................................................45
Converting to individual coverage
......................................................................................................46
Getting a Certificate of Group Health Plan Coverage
........................................................................46
Long term care insurance is coming later in 2002
....................................................................................................47
Department of Defense/FEHB Demonstration Project
..............................................................................................48
Index............................................................................................................................................................................50
Summary of benefits
..................................................................................................................................................51
Rates
............................................................................................................................................................Back
Cover 3
3 Page 4 5
2002 Coventry Health Care of Iowa, Inc. 4
Introduction/Plain Language
Introduction
Coventry Health
Care of Iowa, Inc.
4600 Westown Parkway, Suite 200
West Des Moines, Iowa
50266-1099
This brochure describes the benefits of Coventry Health Care of Iowa, Inc.
under our contract (CS 1983) 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
Iowa, 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 OPM know. Visit OPM's
"Rate Us" feedback
area at www.opm.gov/insure or e-mail OPM at fehbwebcomments@opm.gov. You may
also write
to OPM at the Office of Personnel Management, Office of Insurance
Planning and Evaluation Division, 1900 E Street,
NW, Washington, DC
20415-3650. 4
4 Page
5 6
2002 Coventry Health Care of Iowa,
Inc. 5 Inspector General Advisory
Inspector General Advisory
Stop health care fraud! Fraud increases the cost of health care for
everyone. If you suspect that a physician, pharmacy, or hospital has charged you
for services you did not
receive, billed you twice for the same service, or
misrepresented any
information, do the following:
Call the provider and ask for an explanation. There may be an error.
If the provider does not resolve the matter, call us at 800/257-4692 and
explain the situation.
If we do not resolve the issue, call or write
THE HEALTH CARE FRAUD HOTLINE
202/418-3300
The United States
Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400
Washington, DC 20415
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB
Program benefits can be
prosecuted for fraud. Also, the Inspector General
may investigate anyone
who uses an ID card if the person tries to obtain
services for someone who
is not an eligible family member, or is no longer
enrolled in the Plan and
tries to obtain benefits. Your agency may also take
administrative action
against you. 5
5 Page 6 7
2001 Coventry
Health Care of Iowa, 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 accept a negotiated payment from us, and you will only be
responsible for your copayments or coinsurance.
Your Rights
OPM requires that all FEHB Plans to provide certain
information to their FEHB members. You may get information
about us, our
networks, providers, and facilities. OPM’s FEHB website (www.opm.gov/insure)
lists the specific types of
information that we must make available to you.
Some of the required information is listed below.
Coventry Health Care of Iowa, Inc. came together officially on January 1,
2000. Formerly it was known as Principal Health Care of Iowa, Inc.
If you want more information about us, call 800-257-4692, or write to 4600
Westown Parkway, Suite 200, West Des
Moines, Iowa 50266-1099. You may also
contact us by fax at 302-283-6786 or visit our website at www.chciowa.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:
Benton, Black Hawk, Boone, Bremer, Clark, Dallas, Guthrie, Jasper, Linn,
Lucas, Madison, Marion, Polk, Story,
Woodbury, and Warren counties.
You may also enroll with us if you live in the following places; Hamilton,
Mahaska, Marshall, and Poweshiek counties.
Ordinarily, you must get your
care from providers who contract with us. If you receive care outside our
service area, we
will pay only for emergency care benefits. We will not pay
for any other health care services out of our service area
unless the
services have prior plan approval.
If you or a covered family member move outside of our service area, you can
enroll in another plan. If your dependents
live out of the area (for
example, if your child goes to college in another state), you should consider
enrolling in a
fee-for-service plan or an HMO that has agreements with
affiliates in other areas. If you or a family member move, you
do not have
to wait until Open Season to change plans. Contact your employing or retirement
office. 6
6 Page 7
8
2002 Coventry Health Care of Iowa, 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 changed the address for sending disputed
claims to OPM. (Section 8)
Changes to this Plan
Your share of the non-Postal premium will
increase by 38.9% for Self Only or 61.6% for Self and Family.
We have
expanded our service area to include the following Iowa counties: Benton, Linn
and Woodbury.
We have changed to a 3-tier pharmacy program, which includes
mail order benefits. Pharmacy benefits are now administered with a $5/$15/$30
copayment. This means that you will pay a $5 copay for formulary generic
medications, a $15 copay for formulary brand medications (a formulary is a
preferred list of drugs), and a $30 copay
for non-formulary medications.
If a brand name prescription drug is dispensed when an equivalent generic
drug is available, you will pay the difference in cost between the brand name
drug and the generic in addition to the formulary copayment, regardless
of whether or not your physician writes “dispense as written”.
Pharmacy
benefit copayments no longer count toward your out-of-pocket maximum.
We now
cover certain intestinal transplants. (Section 5(b))
Preventive/diagnostic
dental benefits are no longer part of your benefit plan. Coverage is available
for accidental dental injury only.
We clarified rehabilitation therapies to show that we cover physical,
occupational and speech therapies from the original onset of the condition up to
60 days after. 7
7 Page
8 9
2002 Coventry Health Care of Iowa,
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 800-257-4692.
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.
Plan facilities Plan facilities are hospitals and other facilities in
our service area that we contract with to provide covered services to our
members. We list these in
the provider directory, which we update
periodically. The list is also on our
website.
It depends on the type of care you need. First, you and each family member
must choose a primary care physician. This decision is important since your
primary care physician provides or arranges for most of your health care.
You
choose a primary care physician when you enroll in the plan. You may
change your primary care physician up to twice a year.
Primary care Your primary care physician can be a family
practitioner, internist, pediatrician. Your primary care physician will
provide most of your health care, or give
you a referral to see a
specialist.
If you want to change primary care physicians or if your primary
care physician
leaves the Plan, call us. We will help you select a new one.
Specialty care Your primary care physician will refer you to a
specialist for needed care. When you receive a referral from your primary care
physician, you must
return to the primary care physician after the
consultation, unless your primary
care physician authorized a certain number
of visits without additional referrals.
The primary care physician must
provide or authorize all follow-up care. Do
not go to the specialist for
return visits unless your primary care physician
gives you a referral.
However, you may see either an optometrist or
ophthalmologist for a
routine eye exam once per year without a referral.
Women in our plan may
also see a gynecologist once a year for a routine
check without a referral.
What you must do to get covered care 8
8
Page 9 10
2002
Coventry Health Care of Iowa, Inc. 9 Section 3
How you get
care (continued)
Here are other things you should know about
specialty care:
If you need to see a specialist frequently because of a
chronic, complex, or serious medical condition, your primary care physician will
work with
the specialist and the plan to develop a treatment plan that
allows you to
see your specialist for a certain number of visits without
additional
referrals. Your primary care physician will use our criteria
when creating
your treatment plan (the physician may have to get an
authorization or
approval beforehand).
If you are seeing a specialist when you enroll in our Plan, talk to your
primary care physician. Your primary care physician will decide what
treatment you need. If he or she decides to refer you to a specialist, ask
if
you can see your current specialist. If your current specialist does not
participate with us, you must receive treatment from a specialist who
does. Generally, we will not pay for you to see a specialist who does not
participate with our Plan.
If you are seeing a specialist and your specialist leaves the Plan, call your
primary care physician, who will arrange for you to see another specialist.
You may receive services from your current specialist until we can make
arrangements for you to see someone else.
If you have a chronic or disabling condition and lose access to your
specialist because we:
– terminate our contract with your specialist for other than cause; or
– drop out of the Federal Employees Health Benefits (FEHB) Program
and you enroll in another FEHB Plan; or
– reduce our service area and you enroll in another FEHB Plan,
you may be able to continue seeing your specialist for up to 90 days after
you receive notice of the change. Contact us or, if we drop out of the
Program, contact your new plan.
If you are in the second or third trimester of pregnancy and you lose access
to
your specialist based on the above circumstances, you can continue to see
your specialist until the end of your postpartum care, even if it is beyond
the
90 days.
Hospital care Your Plan primary care physician or specialist will make
necessary hospital arrangements and supervise your care. This includes admission
to a skilled
nursing or other type of facility.
If you are in the
hospital when your enrollment in our Plan begins, call our
customer service
department immediately at 800-257-4692. If you are new
to the FEHB Program,
we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay for
the hospital stay until:
You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or 9
9 Page 10 11
2002 Coventry Health Care of Iowa, Inc. 10
Section 3
How you get care (continued)
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 Under certain extraordinary circumstances,
such as natural disasters, we control may have to delay your services or
we may be unable to provide them. In
that case, we will make all reasonable
efforts to provide you with the
necessary care.
Services requiring our
prior approval Your primary care physician
has authority to refer you for most services. For certain services, however,
your physician must obtain approval from us.
Before giving approval, we consider if the service is covered, medically
necessary, and follows generally accepted medical practice.
We call this review and approval process prior approval. Your physician
must obtain prior approval for the following services: hospital inpatient
admissions, outpatient surgeries, home health care, home infusion services,
durable medical equipment, outpatient therapy (physical, occupational,
speech and manipulative services), growth hormone therapy, and any out of
network services. 10
10 Page 11 12
2002 Coventry
Health Care of Iowa, 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 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 20% of our allowance for durable
medical equipment.
Your out-of-pocket maximum
for coinsurance, and copayments After
your copayments and/or coinsurance total $750 per person or $1,500 per
family enrollment in any calendar year, you do not have to pay any more
for covered services. However, copayments for the following services do not
count toward your out-of-pocket maximum, and you must continue to pay
copayments for these services:
• Pharmacy benefits
Be sure to keep accurate records of your
copayments since you are responsible
for informing us when you reach the
maximum. 11
11 Page
12 13
2002 Coventry Health Care of
Iowa, Inc. 12 Section 5 (Overview)
Section 5. Benefits
--OVERVIEW (See page 7 for how our benefits changed this year and page
51 for a benefits summary.)
NOTE: This benefits section is
divided into subsections. Please read the important things you should keep in
mind at
the beginning of each subsection. Also read the General Exclusions
in Section 6; they apply to the benefits in the
following subsections. To
obtain claims forms, claims filing advice, or more information about our
benefits, contact us
at 800-257-4692 or at our website at www.chciowa.com.
(a) Medical services and supplies provided by physicians and other health
care professionals . . . . . . . . . . . . . .13-19
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
(b) Surgical and anesthesia services provided by physicians and other health
care professionals . . . . . . . . . . . .20-22
Surgical procedures Oral and
maxillofacial surgery
Reconstructive surgery Organ/tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services
. . . . . . . . . . . . . . . . . . . . . . . . . . .23-25
Inpatient
hospital Extended care benefits/skilled nursing care
Outpatient hospital or
ambulatory surgical facility benefits center
Hospice care
Ambulance
(d) Emergency services/accidents . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26-27
Medical emergency Ambulance
(e) Mental health and substance abuse benefits . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28
(f) Prescription drug benefits . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.29-30
(g) Special features . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . .31
Services for deaf and hearing impaired
High
Risk Pregnancies
Centers of Excellence for transplants/heart
surgery/etc.
Travel benefit/services overseas
(h) Dental benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . .32
(i) Non-FEHB benefits available to Plan members . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33
Summary of benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . .51
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
Alternative treatments
Educational classes and
programs 12
12 Page
13 14
2002 Coventry Health Care of
Iowa, Inc. 13 Section 5 (a)
Section 5 (a) Medical services and
supplies provided by physicians and
other health care professionals
Here are some important things to keep in mind about these benefits:
• Please remember that all benefits are subject to the definitions,
limitations, and exclusions
in this brochure and are payable only when we
determine they are medically necessary.
• We have no calendar year deductible.
• Plan physicians must provide or
arrange your care.
• Be sure to read Section 4, Your costs for covered
services, for valuable information about
how cost sharing works. Also
read Section 9 about coordinating benefits with other
coverage, including
with Medicare.
Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians $10 per visit to your primary care
physician
In physician’s office $15 per visit to a specialist
Professional services of physicians
In an urgent care center Nothing
During a hospital stay Nothing
In a skilled nursing facility Nothing
Office medical consultations $10 per office visit to primary care physician,
or
Second surgical opinion $15 per office visit to a specialist
At home $10 per house call by a primary care physician
Lab, X-ray and other diagnostic tests
Tests, such as: Nothing if
you receive these
Blood tests services during your office visit;
Urinalysis otherwise, $10 per office visit to
Non-routine pap tests
primary care physician or $15 per
Pathology office visit to a specialist.
X-rays
Non-routine Mammograms
Cat Scans/MRI
Ultrasound
Electrocardiogram and EEG
I
M
P
O
R
T
A
N
T
I
M
P
O
R
T
A
N
T 13
13 Page 14 15
2002 Coventry Health Care of Iowa, Inc. 14
Section 5 (a)
Preventive care, adult You pay
Routine
screenings, such as: $10 per office visit to a primary care
Total Blood
Cholesterol – once every three years physician, or $15 per visit to a
Colorectal Cancer Screening, including
specialist.
–– Fecal occult blood test
–– Sigmoidoscopy, screening –
every five years starting at age 50
Prostate Specific Antigen (PSA test) – one annually for men age $10 per
office visit to a primary care 40 and older physician, or $15 per visit to a
specialist.
Routine pap test $10 per office visit to a primary care physician, or $15 per
office visit to a
Note: The office visit is covered if pap test is received
on the same day; specialist. see Diagnosis and Treatment, above.
Routine mammogram –covered for women age 35 and older, as follows: $10 per
office visit to a primary care
From age 35 through 39, one during this five
year period physician, or $15 per visit
From age 40 through 64, one every
calendar year to a specialist.
At age 65 and older, one every two
consecutive calendar years
Not covered: Physical exams required for obtaining or continuing All
charges.
employment or insurance, attending schools or camp, or travel.
Routine immunizations, limited to: $10 per office visit to a primary care
Tetanus-diphtheria (Td) booster – once every 10 years, ages 19 and
physician, or $15 per visit over (except as provided for under Childhood
immunizations) to a specialist.
Influenza/Pneumococcal vaccines, annually, age 65 and over
Preventive
care, children
Childhood immunizations recommended by the American
Academy $10 per office visit to a primary care of Pediatrics physician, or $15
per visit to
a specialist.
Well-child care charges for routine examinations, immunizations and $10 per
office visit to a primary care care (through age 21) physician, or $15 per visit
to
Examinations, such as: a specialist.
–– 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 21) 14
14 Page 15 16
2002 Coventry Health Care of Iowa, Inc. 15
Section 5 (a)
Maternity care You pay
Complete maternity
(obstetrical) care, such as: $50 at the time of delivery.
Prenatal care One
copay per pregnancy.
Delivery
Postnatal care
Note: Here are some
things to keep in mind:
You do not need to precertify your normal delivery; see page 9 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).
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: $10 per office visit to a primary
Voluntary
sterilization care physician, or $15 per
Surgically implanted contraceptives
(such as Norplant) visit to a specialist.
Injectable contraceptive drugs
(such as Depo provera)
Intrauterine devices (IUDs)
Diaphragms
Note:
We cover oral contraceptives under the prescription drug benefit.
Not covered: reversal of voluntary surgical sterilization, genetic All
charges.
counseling
Infertility services
Diagnosis and treatment of infertility, such
as: 50% of the allowable charges.
Artificial insemination:
––
intravaginal insemination (IVI)
–– intracervical insemination
(ICI)
–– intrauterine insemination (IUI)
Fertility drugs
Note: We cover injectable fertility drugs under medical benefits and oral
fertility drugs under the prescription drug benefit. 15
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2002 Coventry Health Care of Iowa, Inc. 16
Section 5 (a)
Infertility services (continued) You
pay
Not covered: All charges.
Infertility services after
voluntary sterilization
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
Allergy care
Testing and treatment $10 per office visit to a
primary care
Allergy injection physician, or $15 per visit to a specialist.
Allergy serum Nothing
Not covered: provocative food testing and
sublingual allergy All charges.
desensitization
Treatment therapies
Chemotherapy and radiation therapy $10 per
office visit to a primary care
Note: High dose chemotherapy in association
with autologous bone marrow physician, or $15 per visit to a
transplants are
limited to those transplants listed under Organ/Tissue specialist.
Transplants on page 22.
Respiratory and inhalation therapy
Dialysis – Hemodialysis and peritoneal
dialysis
Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy
Growth hormone therapy (GHT)
Note: – We will only cover GHT for
medically necessary conditions See copayments on pg. 42
when we have
preauthorized the treatment. Such authorization must be
obtained through
Health Services at 800-470-6352. See Services
requiring our prior
approval in Section 3. 16
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2002 Coventry
Health Care of Iowa, Inc. 17 Section 5 (a)
Physical and
occupational therapies You pay
Covered from the original onset of the
condition up to 60 days per $10 per outpatient session; nothing
condition
for the services of each of the following: per inpatient visit
–– qualified physical therapists and
–– occupational therapists.
Note: These services are covered when determined by the plan to
be
medically necessary.
Cardiac rehabilitation following a heart transplant, bypass surgery or a
myocardial infarction, is provided for up to two months.
Not covered: All charges.
services after 60 days per condition
excercise programs
Speech therapy
Covered from the original onset of the condition up
to 60 days per condition. $10 per outpatient session; nothing per
inpatient
visit
Not covered:
services after 60 days per condition All charges.
Hearing services (testing, treatment, and supplies)
First hearing
aid and testing only when necessitated by accidental $10 per office visit to
primary care injury physicians or $15 per office visit
to a specialist
Hearing testing for children through age 17 (see Preventive care,
children)
Not covered: All charges.
all other hearing testing
hearing aids, testing and examinations for them
Vision services (testing, treatment, and supplies)
One annual eye
refraction (which includes the written lens Nothing to an optometrist; $15
prescription) may be obtained from Plan providers. per visit to an
opthalmologist
One pair of eyeglasses or contact lenses to correct an impairment 20% of
allowable charges directly caused by intraocular surgery (such as for cataracts)
Eye exam to determine the need for vision correction for children Nothing to
an optometrist; $15 through age 17 (see Preventive care, children) per visit to
an opthalmologist
Annual eye refractions
Not covered: All charges.
Eyeglasses or contact lenses and, after age 17, examinations for them
Eye exercises and orthoptics
Radial keratotomy and other
refractive surgery 17
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2002 Coventry
Health Care of Iowa, Inc. 18 Section 5 (a)
Foot care You pay
Routine foot care when you are under active treatment for a metabolic
$10 per office visit to primary care
or peripheral vascular disease, such as
diabetes. physician, or $15 per office visit to a
See orthopedic and prosthetic devices for information on podiatric shoe
specialist
inserts.
Not covered: All charges.
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)
Orthopedic and prosthetic devices
Artificial limbs and eyes; stump
hose 20% of allowable charges.
Foot Orthotics
Externally worn breast
prostheses and surgical bras, including necessary replacements, following a
mastectomy
Internal prosthetic devices, such as artificial joints, pacemakers, cochlear
implants, and surgically implanted breast implant
following mastectomy.
Note: See 5(b) for coverage of the surgery to
insert the device.
Not covered: All charges.
orthopedic and corrective shoes
arch supports
foot orthotics
heel pads and heel
cups
lumbosacral supports
corsets, trusses, elastic
stockings, support hose, and other supportive devices
prosthetic replacements provided less than 3 years after the last one we
covered
Durable medical equipment (DME)
Rental or purchase, at our option,
including repair and adjustment, of 20% of allowable charges
durable medical
equipment prescribed by your Plan physician, such as
oxygen and dialysis
equipment. Under this benefit, we also cover:
manual hospital beds;
manual wheelchairs;
crutches;
walkers;
blood glucose monitors; and
insulin pumps. 18
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2002 Coventry Health Care of Iowa, Inc. 19
Section 5 (a)
Durable medical equipment (DME) (continued)
You pay
Not covered: All charges.
Motorized wheel
chairs
Convenience items or exercise equipment
Home health services
Home health care ordered by a Plan physician
and provided by a $10 per visit to primary care registered nurse (R.N.),
licensed practical nurse (L.P.N.), licensed physician; nothing by nurse or
vocational nurse (L.V.N.), or home health aide. home health aide
Services
include oxygen therapy, intravenous therapy and medications.
Not covered: All charges.
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.
Alternative treatments
Chiropractic services including: $10 per
office visit when authorized
Manipulation of the spine and extremities by
the primary care physician.
Adjunctive procedures such as ultrasound,
electrical muscle stimulation, vibratory therapy, and cold pack application
Note: Limited to 60 days per condition from the original onset of the
condition.
Not covered: All charges.
services after 60 days per condition
naturopathic services
hypnotherapy
biofeedback
acupuncture services
Educational classes and programs
Coverage is limited to:
Smoking Cessation – Up to $100 for one smoking cessation program Call us at
800-257-4692 for benefit per member per lifetime, including all related expenses
such as drugs. restrictions and guidelines.
Diabetes self-management 19
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2002 Coventry
Health Care of Iowa, Inc. 20 Section 5 (b)
Section 5 (b).
Surgical and anesthesia services provided by physicians and other health care
professionals
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 end deductible.
• Be sure to read Section 4, Your costs for
covered services, for valuable information about how
cost sharing works.
Also read Section 9 about coordinating benefits with other coverage,
including with Medicare.
• The amounts listed below are for the charges billed by a physician or other
health care
professional for your surgical care. Look in Section 5(c) for
charges associated with the
facility (i.e. hospital, surgical center, etc.).
• YOU MUST GET PRECERTIFICATION OF SOME SURGICAL PROCEDURES. Please
refer
to the precertification information shown in Section 3 to be sure which services
require
precertification and identify which surgeries require
precertification.
Benefit Description You pay After the calendar year deductible...
Surgical procedures
A comprehensive range of services, such as: $10
per office visit to primary care
Operative procedures physicians or $15 per
office visit
Treatment of fractures, including casting to a specialist
Normal pre-and post-operative care by the surgeon Nothing as an inpatient
Correction of amblyopia and strabismus
Endoscopy procedures
Biopsy
procedures
Removal of tumors and cysts
Correction of congenital
anomalies (see reconstructive surgery)
Surgical treatment of morbid obesity
--a condition in which an individual weighs 100 pounds or 100% over his or her
normal
weight according to current underwriting standards; eligible
members must
be age 18 or over
Insertion of internal prosthetic devices, such as pacemakers and 40% of
allowable charges artificial joints. See 5(a) – Orthopedic braces and prosthetic
devices
for device coverage information
Voluntary sterilization $10 per office visit to primary care
Treatment of
burns physician, or $15 per office visit to a specialist
Nothing as an inpatient
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2002 Coventry Health Care of Iowa, Inc. 21
Section 5 (b)
Surgical procedures (continued) You
pay
Not covered: All charges.
Reversal of voluntary
sterilization
Routine treatment of conditions of the foot; see Foot
care.
Reconstructive surgery
Surgery to correct a functional defect $10
per office visit to primary care
Surgery to correct a condition caused by
injury or illness if: physician, or $15 per office visit
–– the condition
produced a major effect on the member’s
to a specialist
appearance and
–– the condition can reasonably be expected to be
corrected by Nothing as an inpatient
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, $10 per
office visit to primary care such as: physician, or $15 per office visit
–– surgery to produce a symmetrical appearance on the other breast; to a
specialist
–– treatment of any physical complications, such as lymphedemas;
Nothing as an inpatient
–– breast prostheses and surgical bras and
replacements
(see Prosthetic devices)
Note: If you need a mastectomy, you may choose to have this procedure
performed on an inpatient basis and remain in the hospital up to 48 hours
after the procedure.
Not covered: All charges
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
Oral and maxillofacial surgery
Oral surgical procedures, limited
to: $10 per office visit to primary
Reduction of fractures of the jaws or
facial bones; care physician, or $15 per office visit
Surgical correction of
cleft lip, cleft palate or severe functional to a specialist. malocclusion;
Nothing as an inpatient
Removal of stones from salivary ducts;
Excision of leukoplakia or
malignancies;
Excision of cysts and incision of abscesses when done as
independent procedures; and
Other surgical procedures that do not involve the teeth or their supporting
structures. 21
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2002 Coventry Health Care of
Iowa, Inc. 22 Section 5 (b)
Oral and maxillofacial surgery
(continued) You pay
Not covered: All charges.
Oral implants and transplants
Conservative or surgical
treatment at TMJ
Procedures that involve the teeth or their
supporting structures (such as the periodontal membrane, gingiva, and alveolar
bone)
Organ/tissue transplants
Limited to: Nothing as an inpatient
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. Coverage limited to protocols established by the plan.
Note: We cover related medical and hospital expenses of the donor when
we cover the recipient.
Not covered: All charges
Donor screening tests and donor search
expenses, except those performed for the actual donor
Implants of artificial organs
Transplants not listed as covered
Anesthesia
Professional services provided in – Nothing
Hospital (inpatient)
Professional services provided in – Nothing
Hospital outpatient
department
Skilled nursing facility
Ambulatory surgical center
Office 22
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2002 Coventry Health Care of
Iowa, Inc. 23 Section 5 (c)
Section 5 (c). Services provided
by a hospital or other facility, and ambulance services
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.
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).
YOU MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please refer to
Section 3 to be sure which services require precertification.
Benefit Descriptions You pay
Inpatient hospital
Room and
board, such as Nothing
ward, semiprivate, or intensive care accommodations;
general nursing care; and
meals and special diets.
NOTE: If you want
a private room when it is not medically necessary,
you pay the additional
charge above the semiprivate room rate.
Other hospital services and supplies, such as: Nothing
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
Take-home items
Medical supplies, appliances, medical
equipment, and any covered items billed by a hospital for use at home (Note:
calendar year
deductible applies.)
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2002 Coventry Health Care of Iowa, Inc. 24
Section 5 (c)
Inpatient hospital (continued) You pay
Not covered: All charges.
Custodial care
Non-covered facilities, such as nursing homes, convalescent
facilities, schools
Personal comfort items, such as telephone, television, barber services,
guest meals and beds
Private nursing care
Outpatient
hospital or ambulatory surgical center
Operating, recovery, and other
treatment rooms Nothing
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.
Not covered: blood and blood derivatives not replaced by the member All
charges.
Extended care benefits/skilled nursing care facility benefits
Extended care/skilled nursing care benefit: Nothing
We cover a
comprehensive range of benefits up to 62 days per calendar
year when
full-time skilled nursing is necessary and confinement in a
skilled nursing
facility is medically appropriate as determined by a plan
doctor and
approved by the plan.
Not covered: custodial care All charges 24
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2002 Coventry Health Care of Iowa, Inc. 25
Section 5 (c)
Hospice care You pay
Supportive and
palliative care for a terminally ill member is covered in the Nothing
home
or hospice facility. Services include inpatient and outpatient care and
family counseling; these services are provided under the direction of a plan
doctor who certifies that the patient is in the terminal stages of illness,
with
a life expectancy of approximately
Not covered: Independent nursing, homemaker services All charges
Ambulance
Local professional ambulance service when medically
appropriate Nothing 25
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2002 Coventry Health Care of
Iowa, Inc. 26 Section 5 (d)
Section 5 (d). Emergency
services/accidents
Here are some important things to keep in mind about
these benefits:
Please remember that all benefits are subject to the
definitions, limitations, and exclusions in this brochure.
We have no calendar year deductible.
Be sure to read Section 4, Your
costs for covered services, for valuable information about how cost sharing
works. Also read Section 9 about coordinating benefits with
other coverage, including with Medicare.
What is a medical emergency?
A medical emergency is the sudden and
unexpected onset of a condition or an injury that you believe endangers your
life or could result in serious injury or disability, and requires immediate
medical or surgical care. Some problems are
emergencies because, if not
treated promptly, they might become more serious; examples include deep cuts and
broken
bones. Others are emergencies because they are potentially
life-threatening, such as heart attacks, strokes, poisonings,
gunshot
wounds, or sudden inability to breathe. There are many other acute conditions
that we may determine are
medical emergencies – what they all have in common
is the need for quick action.
What to do in case of emergency:
Emergencies within our service area:
If you are in an emergency situation, please contact your primary
care
doctor. In extreme emergencies, if you are unable to contact your doctor,
contact the local emergency room system
(e.g., the 911 telephone system) or
go to the nearest hospital emergency room. Be sure to tell the emergency room
personnel that you are a Plan member so they can notify the Plan.
You or a family member must notify the primary care doctor as soon as
possible and/or contact the Plan within 48
hours of the emergency room
visit. It is your responsibility to ensure that the Plan has been timely
notified.
If you need to be hospitalized, the Plan must be notified within 48 hours or
on the first working day following your
admission, unless it is not
reasonable possible to notify the Plan within that time. If you are hospitalized
in non-Plan
facilities and Plan doctors believe care can be better provided
in a Plan hospital, you will be transferred when medically
feasible and any
ambulance charges are covered in full.
Benefits are available for care from non-Plan providers in a medical
emergency only if delay in reaching a Plan
provider would result in death,
disability or significant jeopardy to your condition.
To be covered by this Plan, any follow-up care recommended by non-Plan
providers must be approved by the Plan.
The plan pays reasonable charges for
emergency services to the extent the services would have been covered if
received
from Plan providers. You pay $50 copayment or 50% of the charges,
whichever is less, per hospital emergency room
visit or $30 copayment per
urgent care center visit for emergency services which are covered benefits of
this Plan.
The copayment or coinsurance will be waived if you are admitted
as a result of your condition.
Emergencies outside our service area: Benefits are available for any
medically necessary health service that is
immediately required because of
injury or unforeseen illness.
If you need to be hospitalized, the Plan must be notified within 48 hours or
on the first working day following your
admission, unless it was not
reasonably possible to notify the Plan within that time. If a Plan doctor
believes that care
can be better provided in a Plan hospital, you will be
transferred when medically feasible with any ambulance charges
covered in
full.
To be covered by this Plan, any follow-up care recommended by non-Plan
providers must be approved by the Plan.
The Plan pays reasonable charges for
emergency services to the extent the services would have been covered if
received from Plan providers. You pay $50 copayment or 50% of covered
charges, whichever is less, per hospital
emergency room visit for emergency
services received at a non-Plan facility or doctor's office or urgent care
center.
The copayment or coinsurance will be waived if you are admitted to
the hospital as a result of your condition.
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2002 Coventry Health Care of Iowa, Inc. 27
Section 5 (d)
Benefit Descriptions You pay
Emergency within
our service area
Emergency care at a doctor's office $10 per office
visit to a primary care physician; $15 per office visit
to a specialist
Emergency care at an urgent care center $30 per visit
Emergency care as
an outpatient at a hospital $50 per visit or 50% of allowable charges, whichever
is less
Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area
Emergency care at a
doctor's office $50 per visit or 50% of allowable
Emergency care at an
urgent care center charges, whichever is less
Emergency care as an
outpatient or inpatient at a hospital, including doctors’ services
Not covered: All charges.
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
Ambulance
Professional ambulance service when medically
appropriate. Nothing
See 5(c) for non-emergency service. 27
27 Page 28 29
2002 Coventry Health Care of Iowa, Inc. 28
Section 5 (e)
Section 5 (e). Mental health and substance abuse
benefits
When you get our approval for services and follow a treatment
plan we approve, cost-sharing
and limitations for Plan mental health and
substance abuse benefits will be no greater than for
similar benefits for
other illnesses and conditions.
Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and exclusions
in this brochure.
We have no calendar year deductible.
Be sure to read
Section 4, Your costs for covered services, for valuable information
about how cost sharing works. Also read Section 9 about coordinating benefits
with other
coverage, including with Medicare.
YOU MUST GET PREAUTHORIZATION OF
THESE SERVICES. See the instructions after the benefits description below.
Benefit Description You pay After the calendar year deductible...
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.
Professional services, including individual or group therapy by providers $15
per office visit such as psychiatrists, psychologists, or clinical social
workers
Medication management
Diagnostic tests $10 per office visit or test by a
primacy care physician, or $15 per
office visit or test by a specialist
Services provided by a hospital or other facility Nothing
Not covered:
Services we have not approved. All charges.
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.
Preauthorization To be eligible to receive these benefits you must
follow your treatment plan and all the following authorization processes:
All mental conditions/substance abuse services are coordinated by American
Psych
Systems (APS). To access your mental conditions/substance abuse
benefits, call APS
directly at 1-800-752-7242. A primary care physician referral is not
required.
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2002 Coventry Health Care of
Iowa, Inc. 29 Section 5 (f)
Section 5 (f). Prescription drug
benefits
Here are some important things to keep in mind about these
benefits:
We cover prescribed drugs and medications, as described in the
chart beginning on the next page.
All benefits are subject to the definitions, limitations and exclusions in
this brochure and are payable only when we determine they are medically
necessary.
Be sure to read Section 4, Your costs for covered services,
for valuable information about how cost sharing works. Also read Section 9
about coordinating benefits with other
coverage, including with Medicare.
There are important features you should be aware of. These include:
Who can write your prescription. A licensed plan or referral
physician must write the prescription.
Where you can obtain them. You
must fill the prescription at a plan pharmacy, or by mail for a maintenance
prescription.
We use a formulary. We have an open formulary. If your physician
believes a name brand product is necessary or there is no generic available,
your physician may prescribe a name brand drug from a formulary
list. This
list of name brand drugs is a preferred list of drugs that we selected to meet
patient needs at a
lower cost. To order a prescription drug brochure, call
800-257-4692.
These are the dispensing limitations. One Copayment is due each time a
prescription is filled or refilled up to a thirty-one (31) day supply.
Maintenance drugs obtained through a mail order pharmacy designated by
the Plan, may be dispensed with two (2) Copayments for up to a ninety-three
(93) day supply. Drugs that
are not listed on the maintenance listing are
not eligible for the mail order program. If a brand name
prescription drug
is dispensed, and an equivalent generic prescription drug is available, you will
pay an
ancillary charge in addition to the formulary brand name copayment.
The ancillary charge will be due
regardless of whether or not your physician
indicates that the pharmacy is to “Dispense as written”. The
ancillary
charge is the difference between the average wholesale price (AWP) of the brand
name prescription
and the MAC price of the generic prescription. Call
800-257-4692 for additional questions.
Why use generic drugs? Generic drugs offer a safe and economic way to
meet your prescription drug needs. The generic name of a drug is its chemical
name; the name brand is the name under which the
manufacturer advertises and sells a drug. Under federal law, generic and name
brand drugs must meet the
same standards for safety, purity, strength, and
effectiveness. A generic prescription costs you --and us --
less than a name
brand prescription.
When you have to file a claim. Participating pharmacies will file your
claim for you.
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2002 Coventry Health Care of Iowa, Inc. 30
Section 5 (f)
Benefit Description You pay After the calendar year
deductible...
Covered medications and supplies
We cover the
following medications and supplies prescribed by a Plan $ 5 per formulary
generic drug and
physician and obtained from a Plan pharmacy or through our
mail order brand name insulin
program:
Drugs and medicines that by Federal law of the United States require a $15
per formulary brand name drug physician’s prescription for their purchase,
except those listed as $30 per non-formulary drug
Not Covered.
Insulin – one copayment per vial Note: If there is no
generic equivalent
Disposable needles and syringes for the administration of
covered available, you will still have to pay medications the brand name copay.
FDA approved contraceptive drugs and devices
Maintenance drugs
Smoking cessation drugs, limited to Prostep, Habitrol, and Nicoderm patches.
Call us for benefit restrictions and guidelines.
Diabetic supplies, including insulin syringes, needles, glucose test tablets
and test tape, Benedict's solution or equivalent, and acetone
test tablets.
Contraceptive drugs and devices
Drugs to treat sexual dysfunction are
limited to four tablets per month. Prior approval is required by the Plan
Fertility drugs – Note: See Section 5 (b) for coverage of Norplant 50% of the
cost of the drug implementation and removal
Note: Mail order drugs require
two (2) copayments for up to a 93-day
supply.
Not covered: All charges.
Drugs and supplies for cosmetic
purposes
Drugs to enhance athletic performance
Vitamins,
nutrients and food supplements even if a physician prescribes or administers
them
Nonprescription medicines 30
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2002 Coventry
Health Care of Iowa, Inc. 31 Section 5 (g)
Section 5 (g).
Special features
Feature Description
Services for deaf and
hearing
impaired 1-877-843-1942 extension 6979
High risk pregnancies Members identified as having high risk
pregnancies will be assigned to a nurse within our organization who will work
with them to monitor their care.
Centers of excellence
for transplants/heart
surgery/etc
Coventry Health Care of Iowa, Inc. does utilize a network of centers of
excellence for transplant care.
Travel benefit/ services Anytime you are outside of the service area,
you and your covered
overseas dependents are always covered for true
emergency situations. 31
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Section 5 (h). Dental benefits
Here are some important things to keep
in mind about these benefits:
Please remember that all benefits are
subject to the definitions, limitations, and exclusions in this brochure and are
payable only when we determine they are medically necessary.
Plan dentists must provide or arrange your care.
We cover hospitalization
for dental procedures only when a nondental physical impairment exists which
makes hospitalization necessary to safeguard the health of the patient; we do
not cover the dental procedure unless it is described below.
Be sure to
read Section 4, Your costs for covered services, for valuable information
about how cost sharing works. Also read Section 9 about coordinating benefits
with other
coverage, including with Medicare.
Accidental injury benefit You pay
We cover restorative services
and supplies necessary to promptly repair 20% of allowable charges
(but not replace) sound natural teeth. The need for these services must
result from an accidental injury. Prior authorization is required through
your primary care physician and the plan.
Dental Benefits
We have no other dental benefits. 32
32 Page 33 34
2002 Coventry Health Care of Iowa, Inc. 33
Section 5 (i)
Section 5 (i). Non-FEHB benefits available to Plan
members
The benefits on this page are not part of the FEHB contract or
premium, and you cannot file an FEHB disputed
claim about them. Fees
you pay for these services do not count toward FEHB deductibles or out-of-pocket
maximums.
Discounts on eyeglasses and contacts: Coventry Health Care of Iowa, Inc.
members receive a discount on their contacts
or eyeglasses at the following
participating optometric locations: J.C. Penney Optical, Sears Optical,
Montgomery Ward
Optical, Target, and Pearl Vision.
The Baby Beeper Program: During the last four weeks of pregnancy, Coventry
Health Care of Iowa, Inc. members in the
Des Moines area are provided a free
baby beeper so that husbands or birthing coaches can be contacted immediately
when labor begins.
Health Club Discount Program: Fitness World West waives the enrollment fee
and offers a reduced monthly rate to
Coventry Health Care of Iowa, Inc.
members. 33
33 Page
34 35
2002 Coventry Health Care of
Iowa, Inc. 34 Section 6
Section 6. General exclusions --things
we don't cover
The exclusions in this section apply to all benefits.
Although we may list a specific service as a benefit, we will
not cover
it unless your Plan doctor determines it is medically necessary to prevent,
diagnose, or treat your
illness, disease, injury, or condition.
We do not cover the following:
Care by non-Plan providers except for
authorized referrals or emergencies (see Emergency Benefits);
Services,
drugs, or supplies you receive while you are not enrolled in this Plan;
Services, drugs, or supplies that are not medically necessary;
Services,
drugs, or supplies not required according to accepted standards of medical,
dental, or psychiatric practice;
Experimental or investigational procedures,
treatments, drugs or devices;
Services, drugs, or supplies related to
abortions, except when the life of the mother would be endangered if the fetus
were carried to term or when the pregnancy is the result of an act of rape or
incest;
Services, drugs, or supplies related to sex transformations; or
Services,
drugs, or supplies you receive from a provider or facility barred from the FEHB
Program. 34
34 Page
35 36
2002 Coventry Health Care of
Iowa, Inc. 35 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, or deductible.
You will only need to file a claim when you receive emergency services from
non-plan providers. Sometimes these
providers bill us directly. Check with
the provider. If you need to file the claim, here is the process:
Medical and hospital benefits In most cases, providers and facilities
file claims for you. Physicians must file on the form HCFA-1500, Health
Insurance Claim Form. Facilities will
file on the UB-92 form. For claims
questions and assistance, call us at
800-257-4692.
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 Iowa, Inc.
P.O. Box 7709
London, KY 40742
Prescription drugs In most cases, participating pharmacies will file
claims for you. However, if you should need to file a claim for reimbursement
(if you have to obtain a
prescription out of the area), receipts should be
itemized and show:
Covered member's name and ID number;
Name and address
of the dispensing pharmacy;
Date the prescription was obtained; and
Receipt reflecting that you paid for your prescription.
Submit your
claims to: Caremark Inc.
P.O. Box 686005
San Antonio, TX 78268-6005
35
35 Page 36
37
2002 Coventry Health Care of Iowa, Inc. 36
Section 7
Filing a claim for covered services (continued)
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. 36
36 Page
37 38
2002 Coventry Health Care of
Iowa, Inc. 37 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims
process if you disagree with our decision on
your claim or request for
services, drugs, or supplies – including a request for preauthorization:
Step Description
1 1 Ask us in writing to reconsider our initial decision. You must: (a) Write
to us within 6 months from the date of our decision; and
(b) Send your request to us at: 4600 Westown Parkway, Suite 200 West Des
Moines, Iowa 50266-1099; and
(c) Include a statement about why you believe
our initial decision was wrong, based on specific benefit
provisions in this
brochure; and
(d) Include copies of documents that support your claim, such as physicians'
letters, operative reports, bills,
medical records, and explanation of
benefits (EOB) forms.
2 2 We have 30 days from the date we receive your request to: (a) Pay the
claim (or, if applicable, arrange for the health care provider to give you the
care); or
(b) Write to you and maintain our denial --go to step 4; or
(c) Ask you
or your provider for more information. If we ask your provider, we will send you
a copy of our
request—go to step 3.
3 3 You or your provider must send the information so that we receive it
within 60 days of our request. We will then decide within 30 more days.
If
we do not receive the information within 60 days, we will decide within 30 days
of the date the information
was due. We will base our decision on the
information we already have.
We will write to you with our decision.
4 4 If you do not agree with our decision, you may ask OPM to review it. You
must write to OPM within:
90 days after the date of our letter upholding our initial decision; or
120 days after you first wrote to us --if we did not answer that request in
some way within 30 days; or
120 days after we asked for additional
information.
Write to OPM at: Office of Personnel Management, Office of
Insurance Programs, Contracts Division 2,
1900 E Street, NW, Washington,
D.C. 20415-3620.
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. 37
37 Page 38 39
2002 Coventry Health Care of Iowa, Inc. 38
Section 8
The disputed claims process (continued)
Note: You are the only person who has a right to file a disputed claim
with OPM. Parties acting as your
representative, such as medical providers,
must include a copy of your specific written consent with the review
request.
Note: The above deadlines may be extended if you show that you were unable to
meet the deadline because of
reasons beyond your control.
5 5 OPM will review your disputed claim request and will use the information
it collects from you and us to decide whether our decision is correct. OPM will
send you a final decision within 60 days. There are no other
administrative
appeals.
6 6 If you do not agree with OPM’s decision, your only recourse is to sue. If
you decide to sue, you must file the suit against OPM in Federal court by
December 31 of the third year after the year in which you received the
disputed services, drugs, or supplies or from the year in which you were
denied precertification or prior approval.
This is the only deadline that
may not be extended.
OPM may disclose the information it collects during the review process to
support their disputed claim
decision. This information will become part of
the court record.
You may not sue until you have completed the disputed claims process.
Further, Federal law governs your
lawsuit, benefits, and payment of
benefits. The Federal court will base its review on the record that was before
OPM when OPM decided to uphold or overturn our decision. You may recover
only the amount of benefits in
dispute.
NOTE: If you have a serious or life threatening condition (one that
may cause permanent loss of bodily
functions or death if not treated as soon
as possible), and
(a) We haven't responded yet to your initial request for care or
preauthorization/prior approval, then call us at
800-257-4692 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 2 at 202/606-3818
between 8 a.m. and 5 p.m. eastern time. 38
38
Page 39 40
2002
Coventry Health Care of Iowa, Inc. 39 Section 9
Section 9.
Coordinating benefits with other coverage
When you have other You must
tell us if you are covered or a family member is covered under health
coverage
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
(Part A or Part B) The Original
Medicare Plan (Original Medicare) is available everywhere in the United States.
It is the way everyone used to get Medicare benefits and is
the way most people get their Medicare Part A and Part B benefits now. You
may go to any doctor, specialist, or hospital that accepts Medicare. The
Original Medicare Plan pays its share and you pay your share. Some things
are not covered under Original Medicare, like prescription drugs.
When you are enrolled in Original Medicare along with this Plan, you still
need to follow the rules in this brochure for us to cover your care.
(Primary payer chart begins on next page.) 39
39 Page 40 41
2002 Coventry Health Care of Iowa, Inc. 40
Section 9
The following chart illustrates whether the Original
Medicare Plan or this Plan should be the primary payer for you
according to
your employment status and other factors determined by Medicare. It is critical
that you tell us if you or a
covered family member has Medicare coverage so
we can administer these requirements correctly.
Primary Payer Chart
A. When either you --or your covered spouse --are
age 65 or over and … Then the primary payer is…
Original Medicare This Plan
1) Are an active employee with the
Federal government (including when
you or a family member are eligible for
Medicare solely because of a
disability),
2) Are an annuitant,
3) Are a reemployed annuitant with the Federal
government when
a) The position is excluded from FEHB, or
b) The position is not excluded from FEHB
(Ask your employing office
which of these applies to you.)
4) Are a Federal judge who retired under
title 28, U.S.C., or a Tax Court
judge who retired under Section 7447 of
title 26, U.S.C. (or if your
covered spouse is this type of judge),
5) Are enrolled in Part B only, regardless of your employment status,
(for Part B (for other
services) services)
6) Are a former Federal employee receiving Workers’ Compensation and
the
Office of Workers’ Compensation Programs has determined that (except for claims
you are unable to return to duty, 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 40
40 Page 41 42
2002 Coventry Health Care of Iowa, Inc. 41
Section 9
Coordinating benefits with other coverage
(continued)
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
800-257-4692 or visit our web-site at http://www.chciowa.com.
We do not waive any costs when you have Medicare.
Medicare managed
care plan If you are eligible for Medicare, you may choose to enroll in and
get your Medicare benefits from another type of Medicare+Choice plan --a
Medicare
managed care plan. These are health care choices (like HMOs) in
some areas
of the country. In most Medicare managed care plans, you can only
go to
doctors, specialists, or hospitals that are part of the plan. Medicare
managed
care plans provide all the benefits that Original Medicare covers.
Some
cover extras, like prescription drugs. To learn more about enrolling in
a
Medicare managed care plan, contact Medicare at 1-800-MEDICARE
(1-800-633-4227) or at www.medicare.gov.
If you enroll in a Medicare managed care plan, the following options are
available to you:
This Plan and another plan’s Medicare managed care plan: You may
enroll in another plan’s Medicare managed care plan and also remain enrolled
in our FEHB plan. We will still provide benefits when your Medicare managed
care plan is primary, even out of the managed care plan's network and/or
service area (if you use our Plan providers), but we will not waive any of
our
copayments 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
retire-
ment 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 have one or both Parts of Medicare, you can still be covered
under the FEHB Program. We will not require you to enroll in Medicare Part
B and, if you can't get premium-free Part A, we will not ask you to enroll
in it.
TRICARE TRICARE is the health care program for eligible dependents of
military persons and retirees of the military. TRICARE includes the CHAMPUS
program. If both TRICARE and this Plan cover you, we pay first. See your
TRICARE Health Benefits Advisor if you have questions about TRICARE
coverage. 41
41 Page
42 43
2002 Coventry Health Care of
Iowa, Inc. 42 Section 9
Coordinating benefits with other
coverage (continued)
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, or Federal
are responsible for your care
Government agency directly or indirectly pays for them.
When others are responsible When you receive money to compensate you
for medical or hospital
for injuries care for injuries or illness
caused by another person, you must reimburse us for any expenses we paid.
However, we will cover the cost of treatment that
exceeds the amount you received in the settlement.
If you do not seek
damages you must agree to let us try. This is called
subrogation. If you
need more information, contact us for our subrogation
procedures. 42
42 Page 43 44
2002 Coventry Health Care of Iowa, Inc. 43
Section 10
Section 10. Definitions of terms we use in this
brochure
Calendar year January 1 through December 31 of the same year.
For new enrollees, the calendar year begins on the effective date of their
enrollment and ends on
December 31 of the same year.
Coinsurance 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 such as help in walking, getting in and out of bed, bathing, dressing,
shopping, preparing meals, or performing general household services.
Experimental or Any treatment, procedure, facility, equipment, drug or
drug usage, device or
Investigational services supply that is not
accepted as standard medical practice by the general medical community or us, or
does not have federal government agency,
approval for its use or application.
The Plan's experimental/investigational determination process is based on
authoritative information obtained from medical literature, medical
consensus bodies, health care standards, database searches, evidence from
national medical organizations, State and Federal government agencies and
research organizations. The review and approval process for medical policies
and clinical practice guidelines includes clinical input from doctors with
specialty expertise in the subject.
Medical necessity A service or supply for prevention, diagnosis or
treatment that, as determined by us, is consistent with the illness or injury
and is consistent with the
approved, and generally accepted medical or
surgical practice.
Plan allowance Plan allowance is the amount we use to determine our
payment and your coinsurance for covered services. Providers that participate
with us agree to
accept our Plan allowance as payment in full, minus any
copayment or
coinsurance.
Us/We Us and we refer to Coventry Health Care of Iowa, Inc.
You
You refers to the enrollee and each covered family member. 43
43 Page 44 45
2002 Coventry Health Care of Iowa, Inc. 44
Section 11
Section 11. FEHB Facts
No pre-existing condition
We will not refuse to cover the treatment of a condition that you had
limitation before you enrolled 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
about enrolling in the can answer your
questions, and give you a Guide to Federal Employees
FEHB Program
Health Benefits Plans, brochures for other plans, and other materials
you need to make an informed decision about:
When you may change your enrollment;
How you can cover your family
members;
What happens when you transfer to another Federal agency, go on
leave without pay, enter military service, or retire;
When your enrollment ends; and
When the next open 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 for you and your family you, your spouse, and
your unmarried dependent children under age 22,
including any foster
children or stepchildren your employing or retirement
office authorizes
coverage for. Under certain circumstances, you may also
continue coverage
for a disabled child 22 years of age or older who is
incapable of
self-support.
If you have a Self Only enrollment, you may change to a Self and Family
enrollment if you marry, give birth, or add a child to your family. You may
change your enrollment 31 days before to 60 days after that event. The Self
and Family enrollment begins on the first day of the pay period in which the
child is born or becomes an eligible family member. When you change to
Self and Family because you marry, the change is effective on the first day
of
the pay period that begins after your employing office receives your
enrollment form; benefits will not be available to your spouse until you
marry.
Your employing or retirement office will not notify you when a family
member is no longer eligible to receive health benefits, nor will we. Please
tell us immediately when you add or remove family members from your
coverage for any reason, including divorce, or when your child under age 22
marries or turns 22.
If you or one of your family members is enrolled in one FEHB plan, that
person may not be enrolled in or covered as a family member by another
FEHB plan. 44
44 Page
45 46
2002 Coventry Health Care of
Iowa, Inc. 45 Section 11
FEHB Facts (continued)
When benefits and The benefits in this brochure are effective on
January 1. If you joined this Plan premiums start during Open Season,
your coverage begins on the first day of your first pay
period that starts on or after January 1. Annuitants’ coverage and premiums
begin on January 1. If you joined at any other time during the year, your
employing office will tell you the effective date of coverage.
Your medical and claims We will keep your medical and claims
information confidential. Only the records are confidential following
will have access to it:
OPM, this Plan, and subcontractors when they administer this contract;
This Plan and appropriate third parties, such as other insurance plans and
the Office of Workers' Compensation Programs (OWCP), when
coordinating benefit payments and subrogating claims;
Law enforcement
officials when investigating and/or prosecuting alleged civil or criminal
actions;
OPM and the General Accounting Office when conducting audits;
Individuals
involved in bona fide medical research or education that does not disclose your
identity; or
OPM, when reviewing a disputed claim or defending litigation about a claim.
When you retire When you retire, you can usually stay in the FEHB
Program. Generally, you must have been enrolled in the FEHB Program for the last
five years of your
Federal service. If you do not meet this requirement, you
may be eligible for
other forms of coverage, such as temporary continuation
of coverage (TCC).
When you lose benefits
When FEHB coverage ends You will
receive an additional 31 days of coverage, for no additional premium, when:
Your enrollment ends, unless you cancel your enrollment, or
You are a
family member no longer eligible for coverage.
You may be eligible for
spouse equity coverage or Temporary Continuation
of Coverage.
Spouse equity If you are divorced from a Federal employee or
annuitant, you may not coverage continue to get benefits under your
former spouse’s enrollment. But, you
may be eligible for your own FEHB coverage under the spouse equity law. If
you are recently divorced or are anticipating a divorce, contact your
ex-
spouse’s employing or retirement office to get RI 70-5, the Guide to
Federal
Employees Health Benefits Plans for Temporary Continuation of
Coverage
and Former Spouse Enrollees, or other information about your
coverage
choices.
TCC If you leave Federal service, or if you lose coverage because you
no longer qualify as a family member, you may be eligible for Temporary
Continuation
of Coverage (TCC). For example, you can receive TCC if you are
not able to
continue your FEHB enrollment after you retire, if you lose your
job, if you
are a covered dependent child and you turn 22 or marry, etc.
You may not elect TCC if you are fired from your Federal job due to gross
misconduct. 45
45 Page
46 47
2002 Coventry Health Care of
Iowa, Inc. 46 Section 11
FEHB Facts (continued)
Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI
70-5,
the Guide to Federal Employees Health Benefits Plans for Temporary
Continuation of Coverage and Former Spouse Enrollees, from your
employing or retirement office or from www.opm.gov/insure. It explains
what you have to do to enroll.
Converting to You may convert to a non-FEHB individual policy if:
individual coverage
Your coverage under TCC or the spouse equity law ends (If you canceled your
coverage or did not pay your premium, you cannot convert);
You decided not
to receive coverage under TCC or the spouse equity law; or
You are not
eligible for coverage under TCC or the spouse equity law.
If you leave
Federal service, your employing office will notify you of your
right to
convert. You must apply in writing to us within 31 days after you
receive
this notice. However, if you are a family member who is losing
coverage, the
employing or retirement office will not notify you. You must
apply in
writing to us within 31 days after you are no longer eligible for
coverage.
Your benefits and rates will differ from those under the FEHB Program;
however, you will not have to answer questions about your health, and we
will not impose a waiting period or limit your coverage due to pre-existing
conditions.
Getting a Certificate of The Health Insurance Portability and
Accountability Act of 1996 (HIPPA) is a
Group Health Plan Coverage
Federal law that offers limited Federal protections for health coverage
availability and continuity to people who lose employer group coverage. If
you leave the FEHB Program, we will give you a Certificate of Group Health
Plan Coverage that indicates how long you have been enrolled with us. You
can use this certificate when getting health insurance or other health care
coverage. Your new plan must reduce or eliminate waiting periods,
limitations,
or exclusions for health related conditions based on the
information in the
certificate, as long as you enroll within 63 days of
losing coverage under this
Plan. If you have been enrolled with us for less
than 12 months, but were
previously enrolled in other FEHB plans, you may
also request a certificate
from those plans.
For more information, get OPM pamphlet RI 79-27, Temporary Continuation
of Coverage (TCC) under the FEHB Program. See also the FEHB web site
(www.opm.gov/insure/health); refer to the “TCC and HIPPA” frequently
asked questions. These highlight HIPAA rules, such as the requirement that
Federal employees must exhaust any TCC eligibility as one condition for
guaranteed access to individual health coverage under HIPAA, and it have
information about Federal and State agencies you can contact for more
information. 46
46 Page
47 48
2002 Coventry Health Care of
Iowa, Inc. 47 Section 11
Long Term Care Insurance Is Coming
Later in 2002!
Many FEHB enrollees think that their health plan and/or
Medicare will cover their long-term care needs. Unfortunately, they are
WRONG!
How are YOU planning to pay for the future custodial or
chronic care you may need? You should consider buying long-term care insurance.
The Office of Personnel Management (OPM) will sponsor a high-quality long
term care insurance program effective in
October 2002. As part of its
educational effort, OPM asks you to consider these questions:
It’s insurance to help pay for long term care services you may need if you
can’t take care of yourself because of an extended illness or injury, or an
age-related disease such as Alzheimer’s.
LTC insurance can provide
broad, flexible benefits for nursing home care, care in an assisted living
facility, care in your home, adult day care,
hospice care, and more. LTC insurance can supplement care provided by
family members, reducing the burden you place on them.
Welcome to the club! 76% of Americans believe they will never need long term
care, but the
facts are that about half of them will. And it’s not just the
old folks.
About 40% of people needing long term care are under age 65. They
may
need chronic care due to a serious accident, a stroke, or developing
multiple
sclerosis, etc.
We hope you will never need long term care, but
everyone should have a plan just in case. Many people now consider long term
care insurance to
be vital to their financial and retirement planing.
Yes, it can be very expensive. A year in a nursing home can exceed $50,000.
Home care for only three 8-hour shifts a week can exceed
$20,000 a year. And
that’s before inflation!
Long term care can easily exhaust your savings.
Long term care insurance can protect your savings.
Not FEHB. Look at the "Not covered" blocks in sections 5(a) and 5(c)
of your FEHB brochure. Health plans don’t cover custodial care or a stay in an
assisted living facility or a continuing need for a home health aide to help
you get in and out of bed and with other activities of daily living. Limited
stays in skilled nursing facilities can be covered in some circumstances.
Medicare only covers skilled nursing home care (the highest level of nursing
care) after a hospitalization for those who are blind, age 65 or older or fully
disabled. It also has a 100 day limit.
Medicaid covers long term care for
those who meet their state’s poverty guidelines, but has restrictions on covered
services and where they can be
received. Long term care insurance can provide choices of care and
preserve your independence.
Employees will get more information from their agencies during the LTC open
enrollment period in the late summer/early fall of 2002.
Retirees will
receive information at home.
Our toll-free teleservice center will begin in
mid-2002. In the meantime, you can learn more about the program on our web site
at www.opm.gov/insure/ltc.
What is long term care
(LTC) insurance?
I’m healthy. I won’t need
long term care. Or, will I?
Is long term care expensive?
But won’t my FEHB plan,
Medicare or
Medicaid cover
my long term care?
When will I get more information
on how to apply for this new
insurance coverage?
How can I find out more about the
program NOW? 47
47 Page 48 49
Department of Defense/
2002 Coventry Health
Care of Iowa, Inc. 48 FEHB Demonstration Project
Department of Defense/FEHB Demonstration Project
What is it? The
Department of Defense/FEHB Demonstration Project allows some active and retired
uniformed service members and their dependents to enroll in the
FEHB
Program. The demonstration will last for three years and began with
the 1999
open season for the year 2000. Open season enrollments will be
effective
January 1, 2002. DoD and OPM have set up some special
procedures to
implement the Demonstration Project, noted below. Otherwise,
the provisions
described in this brochure apply.
Who is eligible DoD determines who is eligible to enroll in the FEHB
Program. Generally, you may enroll if:
You are an active or retired uniformed service member and are eligible for
Medicare;
You are a dependent of an active or retired uniformed service
member and are eligible for Medicare;
You are a qualified former spouse of
an active or retired uniformed service member and you have not remarried; or
You are a survivor dependent of a deceased active or retired uniformed
service member; and
You live in one of the geographic demonstration areas.
If you are eligible to enroll in a plan under the regular Federal Employees
Health Benefits Program, you are not eligible to enroll under the
DoD/FEHBP Demonstration Project.
The demonstration areas Dover AFB, DE Commonwealth of Puerto Rico
Fort Knox, KY Greensboro/Winston Salem/High Point, NC
Dallas, TX
Humboldt County, CA area
New Orleans, LA Naval Hospital, Camp Pendleton, CA
Adair County, IA area Coffee County, GA area
When you can join You may enroll under the FEHB/DoD Demonstration
Project during the 2001 open season, November 12, 2001, though December 10,
2001. Your coverage
will begin January 1, 2001. DoD has set-up an
Information Processing Center
(IPC) in Iowa to provide you with information
about how to enroll. IPC staff
will verify your eligibility and provide you
with FEHB Program information,
plan brochures, enrollment instructions and
forms. The toll-free phone
number for the IPC is 1-877/DOD-FEHB
(1-877/363-3342).
You may select coverage for yourself (Self Only) or for you and your family
(Self and Family) open season. Your coverage will January 1, 2002. If you
become eligible for the DoD/FEHB Demonstration Project outside of open
season, contact the IPC to find out how to enroll and when your coverage
will begin.
If you become eligible for the DoD/FEHB Demonstration Project outside of
open season, contact the IPC to find out how to enroll and when your
coverage will begin. 48
48 Page 49 50
Department of
Defense/
2002 Coventry Health Care of Iowa, Inc. 49 FEHB
Demonstration Project
Department of Defense/FEHB Demonstration Project (continued)
DoD has a web site devoted to the Demonstration Project. You can view
information such as their Marketing/Beneficiary Education Plan, Frequently
Asked Questions, demonstration area locations and zip code lists at
www.tricare.osd.mil/fehbp. You can also view information about the
demonstration project, including “The 2002 Guide to Federal Employees
Health Benefits Plans Participating in the DoD/FEHB Demonstration
Project,” on the OPM web site at www.opm.gov.
TCC eligibility See Section 11, FEHB Facts; it explains temporary
continuation of coverage (TCC). Under this DoD/FEHB Demonstration Project the
only individual
eligible for TCC is one who ceases to be eligible as
a “member of family”
under your self and family enrollment. This occurs when
a child turns 22, for
example, or if you divorce and your spouse does not
qualify to enroll as an
unremarried former spouse under title 10, United
States Code. For these
individuals, TCC begins the day after their
enrollment in the DoD/FEHB
Demonstration Project ends. TCC enrollment
terminates after 36 months or
the end of the Demonstration Project,
whichever occurs first. You, your
child, or another person must notify the
IPC when a family member loses
eligibility for coverage under the DoD/FEHB
Demonstration Project.
TCC is not available if you move out of a DoD/FEHB Demonstration Project
area, you cancel your coverage, or your coverage is terminated for any
reason. TCC is not available when the demonstration project ends.
Other features The 31-day extension of coverage and right to convert
do not apply to the DoD/FEHB Demonstration Project. 49
49 Page 50 51
2002 Coventry Health Care of Iowa, Inc. 50
Index
Index
Do not rely on this page; it is for your
convenience and may not show all pages where the terms appear.
Effective date of enrollment ........42
Emergency
....................................26
Experimental or investigational....34
Eyeglasses ....................................17
Family planning
............................15
General Exclusions ......................34
Hearing services............................17
Home health
services....................18
Hospice
care..................................25
Home nursing
care........................19
Hospital
........................................23
Immunizations
..............................14
Infertility
......................................15
Inhospital physician care
..............13
Inpatient Hospital Benefits ..........23
Insulin
..........................................29
Laboratory and pathological
services ....................................24
Machine diagnostic tests
..............13
Magnetic Resonance Imagings ........
(MRIs)......................................13
Mammograms
..............................13
Maternity Benefits
........................15
Medicaid ......................................42
Medically necessary......................43
Medicare
......................................39
Mental Conditions/Substance
Abuse Benefits ........................28
Non-FEHB Benefits
....................33
Obstetrical care ............................15
Occupational therapy ....................16
Office visits
..................................13
Oral and maxillofacial surgery ....21
Orthopedic devices ......................18
Ostomy and catheter supplies
......19
Out-of-pocket expenses ................11
Outpatient facility
care ................24
Pap test..........................................14
Physical examination
....................13
Physical therapy............................17
Physician ......................................13
Preventive care,
adult ..................14
Preventive care, children ..............14
Prescription drugs ........................29
Preventive services
......................14
Prior approval ................................9
Prostate cancer screening..............14
Prosthetic devices
........................18
Psychologist ..................................28
Psychotherapy ..............................28
Radiation
therapy..........................16
Room and
board............................23
Second surgical
opinion................13
Skilled nursing facility care..........13
Smoking cessation ........................19
Speech
therapy..............................17
Sterilization procedures
................15
Subrogation ..................................42
Substance abuse ............................28
Surgery..........................................20
• Anesthesia
................................20
• Oral
..........................................21
• Outpatient
................................20
Syringes
........................................30
Temporary continuation of
coverage ..................................45
Transplants
....................................22
Vision services
..............................17
Well child care
..............................14
Wheelchairs
..................................18
Workers’ compensation
................42
X-rays............................................13
Accidental injury ..........................32
Allergy tests
..................................16
Alternative treatment
....................19
Allogenetic (donor) bone
marrow transplant
....................22
Ambulance ....................................27
Anesthesia ....................................22
Autologous bone marrow
transplant..................................22
Biopsies
........................................20
Blood and blood plasma
..............24
Breast cancer screening ................14
Casts..............................................24
Catastrophic
protection ................11
Changes for 2002............................7
Chemotherapy ..............................16
Childbirth
......................................15
Chiropractic
..................................19
Cholesterol
tests............................14
Claims
..........................................37
Coinsurance
..................................11
Colorectal cancer screening..........14
Congenital anomalies....................20
Contraceptive devices and
drugs ..15
Coordination of benefits ..............44
Covered
charges............................43
Covered providers
..........................8
Crutches
........................................18
Definitions
....................................43
Dental care
....................................32
Diagnostic services
......................13
Disputed claims review ................37
Donor
expenses (transplants)........22
Durable medical equipment
(DME)......................................18
Educational classes and
programs ..................................19 50
50 Page 51 52
2002 Coventry Health Care of Iowa, Inc. 51
Summary
Summary of benefits for the Coventry Health Care of Iowa,
Inc. Plan -2002
Do not rely on this chart alone. All benefits are
provided in full unless indicated and are subject to the definitions,
limitations, and exclusions in this brochure. On this page we summarize specific
expenses we cover;
for more detail, look inside.
If you want to enroll or change your
enrollment in this Plan, be sure to put the correct enrollment code from the
cover on your enrollment form.
We only cover services provided or arranged by Plan physicians, except in
emergencies.
Benefits You Pay Page
Medical services provided by
physicians:
Diagnostic and treatment services provided in the office
........................ Offi