Serving: The entire Texas Panhandle and much of West Texas and the
Waco area.
Enrollment in this Plan is limited. You must live or work in
our Geographic service area to enroll. See page 7 for requirements.
West Texas
Enrollment codes for this Plan: CK1 Self Only
CK2 Self and Family
Waco Area
Enrollment codes for this Plan: 6U1 Self Only
6U2 Self and Family
RI 73-496
For changes in benefits
see page 8. 1
1
Page 2 3
2002 FIRSTCARE 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
...............................................................................................................................................
7
Section 2. How we change for 2002
............................................................................................................................
8
Program-wide changes
...............................................................................................................................
8
Changes to this Plan
...................................................................................................................................
8
Section 3. How you get care
........................................................................................................................................
9
Identification cards
.....................................................................................................................................
9
Where you get covered care
.......................................................................................................................
9
Plan providers
......................................................................................................................................
9
Plan facilities
.......................................................................................................................................
9
What you must do to get covered care
........................................................................................................
9
Primary care
......................................................................................................................................
10
Specialty care
....................................................................................................................................
10
Hospital care
......................................................................................................................................
11
Circumstances beyond our control
...........................................................................................................
12
Services requiring our prior approval
.......................................................................................................
12
Section 4. Your costs for covered services
................................................................................................................
13
Copayments
.......................................................................................................................................
13
Deductible
.........................................................................................................................................
13
Coinsurance
.......................................................................................................................................
13
Your catastrophic protection out-of-pocket maximum
.............................................................................
13
Section 5. Benefits
.....................................................................................................................................................
14
Overview
..................................................................................................................................................
14
(a) Medical services and supplies provided by
physicians and other health care professionals .......... 15
(b) Surgical and anesthesia services provided by physicians and
other health care professionals ....... 25
(c)
Services provided by a hospital or other facility, and ambulance services
.................................... 29
(d) Emergency
services/ accidents
.......................................................................................................
32
(e) Mental health and substance abuse benefits
...................................................................................
35
(f) Prescription drug benefits
..............................................................................................................
36 2
2 Page 3 4
2002 FIRSTCARE 3 Table of Contents
(g) Special
features
..............................................................................................................................
41
Services for deaf and hearing impaired
......................................................................................
41
Centers of excellence for transplants/ heart
surgery/ etc. .............................................................
41
(h) Dental benefits
...............................................................................................................................
42
Section 6. General exclusions – things we don't
cover
.............................................................................................
43
Section 7. Filing a claim for covered services
...........................................................................................................
44
Section 8. The disputed claims process
.....................................................................................................................
45
Section 9. Coordinating benefits with other
coverage
...............................................................................................
47
When you have…
Other health coverage
........................................................................................................................
47
Original Medicare
.............................................................................................................................
47
Medicare managed care plan
.............................................................................................................
49
TRICARE/ Workers' Compensation/ Medicaid .........................................................................................
50
Other Government agencies
.....................................................................................................................
50
When others are responsible for injuries
..................................................................................................
50
Section 10. Definitions of terms we use in this
brochure
............................................................................................
51
Section 11. FEHB facts
...............................................................................................................................................
53
Coverage information
...............................................................................................................................
53
No pre-existing condition limitation
..................................................................................................
53
Where you get information about enrolling in the
FEHB Program ................................................... 53
Types of coverage available for you and your family
....................................................................... 53
When benefits and premiums start
....................................................................................................
54
Your medical and claims records are confidential
.............................................................................
54
When you retire
.................................................................................................................................
54
When you lose benefits
.............................................................................................................................
55
When FEHB coverage
ends...............................................................................................................
55
Spouse equity coverage
.....................................................................................................................
55
Temporary Continuation of Coverage (TCC)
....................................................................................
55
Enrolling in TCC
...............................................................................................................................
55
Converting to individual coverage
....................................................................................................
55
Getting a Certificate of Group Health Plan
Coverage .......................................................................
56
Long term care insurance is coming later in 2002
.......................................................................................................
57
Index
............................................................................................................................................................................
58
Summary of benefits
....................................................................................................................................................
59
Rates
..............................................................................................................................................................
Back cover 3
3 Page
4 5
2002 FIRSTCARE 4 Introduction/
Plain Language
Introduction
Southwest Health Alliances (SHA),
L. L. C., dba FIRSTCARE 12940 Research Blvd.
Austin, Texas 78750
This
brochure describes the benefits of FIRSTCARE under our contract (CS 2321) with
the Office of Personnel Management (OPM), as authorized by the Federal Employees
Health Benefits law. This brochure is the official
statement of benefits. No
oral statement can modify or otherwise affect the benefits, limitations, and
exclusions of this brochure.
If you are enrolled in this Plan, you are entitled to the benefits described
in this brochure. If you are enrolled for Self and Family coverage, each
eligible family member is also entitled to these benefits. You do not have a
right to benefits
that were available before January 1, 2002, unless those
benefits are also shown in this brochure.
OPM negotiates benefits and rates
with each plan annually. Benefit changes are effective January 1, 2002, and
changes are summarized on page 8. Rates are shown at the end of this brochure.
Plain Language
Teams of Government and health plans' staff worked
on all FEHB brochures to make them responsive, accessible, and understandable to
the public. For instance,
Except for necessary technical terms, we use
common words. For instance, "you" means the enrollee or
family member; "we"
means FIRSTCARE.
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. 4
4 Page 5 6
2002 FIRSTCARE 5 Introduction/ Plain Language
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 806/ 356-5155 or 800/
884-4901 and explain the situation.
If we do not resolve the issue, call or write
THE HEALTH CARE FRAUD
HOTLINE 202/ 418-3300
The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400
Washington, DC 20415
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB
Program benefits can be prosecuted for fraud. Also, the Inspector General may
investigate anyone
who uses an ID card if the person tries to obtain
services for someone who is not an eligible family member, or is no longer
enrolled in the Plan
and tries to obtain benefits. Your agency may also take
administrative action against you. 5
5 Page 6 7
2002 FIRSTCARE 6
Section 1
Section 1. Facts about this HMO plan
This Plan is a
health maintenance organization (HMO). We require you to see specific
physicians, hospitals, and other providers that contract with us. These Plan
providers coordinate your health care services.
HMOs emphasize preventive
care such as routine office visits, physical exams, well-baby care, and
immunizations, in addition to treatment for illness and injury. Our providers
follow generally accepted medical practice when prescribing
any course of
treatment.
When you receive services from Plan providers, you will not have
to submit claim forms or pay bills. You only pay the copayments and coinsurance
described in this brochure. When you receive emergency services from non-Plan
providers, you may have to submit claim forms.
You should join an HMO
because you prefer the plan's benefits, not because a particular provider is
available. You cannot change plans because a provider leaves our Plan. We cannot
guarantee that any one physician,
hospital, or other provider will be
available and/ or remain under contract with us.
How we pay providers
We contract with individual physicians, medical groups, and hospitals to
provide the benefits in this brochure. These Plan providers accept a negotiated
payment from us, and you will only be responsible for your copayments or
coinsurance.
Your Rights
OPM requires that all FEHB Plans
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.
We have been
operational since June, 1986, and we have been providing quality healthcare to
Federal employees since January 1, 1988.
As a state certified and federally qualified health plan, FIRSTCARE is in
compliance with all the rules and regulations of these governing bodies.
FIRSTCARE is a limited liability company.
We are an Individual Practice
Prepayment (IPP) Plan. We contract with approximately 721 PCPs, 1156 Specialists
and 63 hospitals in our Waco and West Texas service areas.
If you want more information about us, call 806/ 356-5155 or 800/ 884-4901,
or write to 3310 Danvers, Amarillo, TX 79106. You may also contact us by fax at
806/ 356-5263 or visit our website at www. firstcare. com. 6
6 Page 7 8
2002 FIRSTCARE 7 Section 1
Service Area
To enroll in this Plan, you must live in or work in our Service Area.
This is where our providers practice. Our service area is:
In West Texas, the counties of Andrews, Armstrong, Bailey, Borden,
Brewster, Briscoe, Carson, Castro, Childress, Cochran, Collingsworth, Cottle,
Crane, Crosby, Dallam, Dawson, Deaf Smith, Dickens, Donley, Ector, Floyd,
Gaines,
Garza, Glasscock, Gray, Hale, Hall, Hansford, Hartley, Hemphill,
Hockley, Howard, Hutchinson, King, Lamb, Lipscomb, Loving, Lubbock, Lynn,
Martin, Midland, Moore, Motley, Ochiltree, Oldham, Parmer, Pecos, Potter,
Randall, Reagan, Reeves, Roberts, Scurry, Sherman, Swisher, Terry, Upton,
Ward, Wheeler, Winkler, and Yoakum.
In the Waco area, the counties of
Bell, Bosque, Brazos, Burleson, Burnet, Coryell, Falls, Freestone, Grimes,
Hamilton, Hill, Houston, Lampasas, Lee, Leon, Limestone, Llano, Madison,
McLennan, Milam, Mills, Navarro, Robertson, San
Saba, Somervell, Walker, and
Washington.
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. We will not pay for any other health care services 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. FIRSTCARE will only
provide coverage for emergency care outside our service area. If you or a family
member move, you do not have to wait until Open
Season to change plans.
Contact your employing or retirement office. 7
7
Page 8 9
2002
FIRSTCARE 8 Section 2
Section 2. How we change for 2002
Do
not rely on these change descriptions; this page is not an official statement of
benefits. For that, go to Section 5 Benefits. Also, we edited and clarified
language throughout the brochure; any language change not shown here is a
clarification that does not change benefits.
Program-wide changes
We changed the address for sending disputed claims to OPM. (Section 8)
Changes to this Plan
Your share of the non-Postal premium for
Enrollment Code CK will decrease by 20.8% for Self Only or 24.8% for Self and
Family. Enrollment Code 6U will increase by 25.1% for Self Only or 16.2% for
Self and Family.
We now cover certain intestinal transplants. (Section 5( b))
We
changed speech therapy benefits by removing the requirement that services must
be required to restore functional speech. (Section 5( a))
We no longer limit total blood cholesterol tests to certain age groups.
(Section 5( a))
For emergency care received at any doctor's office,
outside our Plan's service area, you will be subject to a $15 copay per office
visit, plus all amounts over our Plan allowance of Usual, Customary and
Reasonable (UCR)
charges for the services rendered. (See Section 5( d) and
Section 10 for the definition of our Plan allowance of UCR). 8
8 Page 9 10
2002 FIRSTCARE 9 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/ 884-
4901.
Where you get covered care You get care from "Plan
providers" and "Plan facilities." You will only pay copayments and 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.
FIRSTCARE services are provided through 721 primary care
physicians, 1156 specialists, 63 contracted hospitals and many other health
professionals and facilities. FIRSTCARE has been serving FEHB employees and
eligible dependents since 1988.
We list Plan providers in the provider directory, which we update
periodically. The list is also on our website.
Plan facilities Plan
facilities are hospitals and other facilities in our service area that we
contract with to provide covered services to our members. We list these
in
the provider directory, which we update periodically. The list is also on our
website.
What you must do It depends on the type of care you need. First, you
and each family to get covered care 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.
Each female member may select an obstetrician-gynecologist (OB/ GYN) in
addition to her primary care physician. She may go directly to him/
her for
an annual well-woman examination, care for pregnancy and all gynecological
conditions. The OB/ GYN may diagnose, treat and refer
for any disease or
condition within the scope of professional practice of a credentialed
obstetrician or gynecologist.
Services of other providers are covered only when your primary care physician
has referred you. 9
9 Page
10 11
2002 FIRSTCARE 10 Section 3
Primary care Your primary care physician can be a family
practitioner or an internist and you may select a pediatrician for your
children. 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 your primary care physician 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. However, you may see your designated obstetrician/ gynecologist
(OB/ GYN) or seek emergency care without a referral. Your primary care
physician will arrange your referral to a specialist. Referral to a
participating specialist is given at the primary care physician's
discretion, if non-Plan specialists or consultants are required, the primary
care
physician will arrange appropriate referrals.
When you receive a
referral from your primary care physician, you must return to the primary care
physician after the consultation unless your
doctor authorizes additional
visits. The primary care physician must provide or authorize all follow-up care.
Do not go to the specialist for a
return visit unless your primary care
physician gives you a referral, and the Plan has issued an authorization for the
referral in advance.
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 us 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. 10
10 Page 11 12
2002 FIRSTCARE 11 Section 3
If you are
seeing a specialist and your specialist leaves the Plan, call your primary care
physician, who will arrange for you to see another specialist.
You may
receive services from your current specialist until we can make arrangements for
you to see someone else.
If you have a chronic or disabling condition and lose access to your
specialist because we:
– terminate our contract with your specialist for
other than cause; 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/ 884-4901. If you
are new to the FEHB Program,
we will arrange for you to receive care.
If you changed from another FEHB
plan to us, your former plan will pay for the hospital stay until:
You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92 nd
day after you become a member of this Plan, whichever happens first.
These provisions apply only to the benefits of the hospitalized person. 11
11 Page 12 13
2002 FIRSTCARE 12 Section 3
Circumstances beyond Under certain extraordinary circumstances,
such as natural disasters, our control we may have to delay your services
or we may be unable to provide them.
In that case, we will make all
reasonable efforts to provide you with the necessary care.
Services requiring our Your primary care physician has authority to
refer you for most services. prior approval 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 pre-authorization. Your physician
must obtain pre-authorization for certain services, such as
outpatient
surgery, inpatient hospital admissions, growth hormone therapy (GHT), certain
prescription drugs, durable medical equipment (DME)
such as oxygen and
equipment, etc.
In some cases, charges for medical procedures may not be
covered without proper authorization. If you have any questions, call our
Customer Services Department at 800/ 884-4901. Remember, when in doubt,
CALL! 12
12 Page
13 14
2002 FIRSTCARE 13 Section 4
Section 4. Your costs for covered services
You must share the
cost of some services. You are responsible for:
Copayments A
copayment is a fixed amount of money you pay to the provider, facility,
pharmacy, etc. when you receive services.
Example: When you see your primary care physician you pay a copayment of $10
per office visit.
Deductible We do not have a deductible.
Coinsurance
Coinsurance is the percentage of our negotiated fee that you must pay for
certain services.
Example: In our Plan, you pay 50% of our allowance for infertility services;
and 20% of charges for durable medical equipment.
Your catastrophic protection After your copayments and coinsurance
total 200% of annual premium out-of-pocket maximum for per Self Only
enrollment or 200% of annual premium per Self and Family
copayments and
coinsurance enrollment in any calendar year, you do not have to pay any more
for covered services. However, copayments and coinsurance for prescription
drugs, and Durable Medical Equipment (DME) do not count toward your out-of
pocket maximum, and you must continue to pay copayments and
coinsurance for prescription drug benefits.
Be sure to keep accurate
records of your copayments and coinsurance since you are responsible for
informing us when you reach the maximum. 13
13
Page 14 15
2002
FIRSTCARE 14 Section 5
Section 5. Benefits – OVERVIEW (See
page 8 for how our benefits changed this year and page 59 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/ 884-4901 or at our website www. firstcare. com.
(a) Medical services and supplies provided by physicians and other health
care professionals ............................ 15-24
Diagnostic and
treatment services Lab, X-ray, and other diagnostic tests
Preventive
care, adult Preventive care, children
Maternity care Family planning
Infertility services Allergy care
Treatment therapies Physical
and occupational therapies
Speech therapy
(b) Surgical and anesthesia services provided by physicians and other health
care professionals ........................ 25-28
Surgical procedures
Oral and maxillofacial surgery Reconstructive surgery Organ/ tissue
transplants
Anesthesia
(c) Services provided by a hospital or other
facility, and ambulance services
...................................................... 29-31
Inpatient
hospital Extended care benefits/ skilled nursing care Outpatient hospital or
ambulatory facility benefits
surgical center Hospice care Ambulance
(d) Emergency services/ accidents
.........................................................................................................................
32-34
Medical emergency Ambulance
(e) Mental health and substance
abuse benefits
.........................................................................................................
35
(f) Prescription drug benefits
................................................................................................................................
36-40
(g) Special features
.....................................................................................................................................................
41
Services for deaf and hearing impaired
Centers of excellence for
transplants/ heart surgery/ etc.
(h) Dental benfits
........................................................................................................................................................
42
Summary of benefits
....................................................................................................................................................
59
Hearing services (testing, treatment, and supplies)
Vision services
(testing, treatment, and supplies)
Foot care Orthopedic and prosthetic
devices
Durable medical equipment (DME) Home health services
Chiropractic Alternative treatments
Educational classes and programs 14
14 Page 15 16
2002 FIRSTCARE 15 Section 5 (a)
I M
P O
R T
A N
T
I M
P O
R T
A N
T
Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
In physician's office
Professional services of physicians $25 per visit
In an urgent care
center
Professional services of physicians Nothing
During a hospital stay
In a skilled nursing facility
Professional services of physicians
Office medical consultations
Second surgical opinion
Professional services of physicians $20 per visit
At home
$10 per office visit to your primary
care physician
$15 per office visit to a specialist
$10 per office visit to your primary
care physician
$15 per office visit to a specialist
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.
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. 15
15 Page 16 17
2002 FIRSTCARE 16 Section 5 (a)
Lab,
X-ray and other diagnostic tests You pay
Tests, such as:
Blood
tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG
Preventive care, adult
Routine screenings, such as:
Total Blood Cholesterol – once every three
years
Colorectal Cancer Screening, including:
– Fecal occult blood
test
– Sigmoidoscopy, screening – every five years starting at age 50
Prostate Specific Antigen (PSA test) – one annually for men
age 40 and older
Routine PAP test
Routine mammogram – covered for women age 35 and older,
as follows:
From age 35 to 39, one during this five year period
From age 40
through 64, one every calendar year
At age 65 and older, one every two
consecutive calendar years
Routine immunizations according to generally
accepted medical
practice standards and the U. S. Public Health Service for
people
in the United States, including immunizations for travel outside
the United States.
Eye screenings, biennially, for members age 19 and older for the
purpose of determining vision loss
Hearing screenings, biennially, for members age 19 and older for
the
purpose of determining hearing loss
Speech screenings, biennially, for members age 19 and older for
the
purpose of determining speech impairment
Not covered: Physical exams, health reports and/ or treatments
required for employment, insurance, school, camp, travel, fight
clearance, sports or legal proceedings
Nothing
Nothing if you receive these
services during your office
visit
All charges 16
16 Page 17 18
2002 FIRSTCARE
17 Section 5 (a)
Preventive care, children You pay
Childhood immunizations recommended by the American Nothing
Academy of
Pediatrics or those required by the Texas
Department of Health
Well-child care charges for routine examinations,
immunizations and
care (through age 22).
Examinations, such as:
– Eye screenings, annually, through age 18 to
determine vision loss.
– Ear screenings, annually, through age 18 to determine hearing loss.
–
Speech screenings, annually, through age 18 to determine speech impairment
Maternity care
Complete maternity (obstetrical) care, such as:
Nothing
Prenatal care
Delivery
Postnatal care
Note: Here
are some things to keep in mind:
Your physician will pre-authorize your
normal delivery; see page 11 for other circumstances, such as extended stays for
you or your
baby.
You may remain in the hospital up to 48 hours after a regular
delivery and 96 hours after a cesarean delivery. We will extend
your inpatient stay if medically necessary.
We cover routine nursery
care of the newborn child during the covered portion of the mother's maternity
stay. We will cover
other care of an infant who requires non-routine treatment only if we cover
the infant under a Self and Family enrollment.
We pay hospitalization and surgeon services (delivery) the same as for
illness and injury. See Hospital benefits (Section 5c) and
Surgery benefits
(Section 5b).
Not covered: Sonograms to determine sex All charges
Nothing if you receive these
services during your office visit
$10 per office visit to your primary
care physician 17
17 Page 18 19
2002 FIRSTCARE 18 Section 5 (a)
Family
planning You pay
A broad range of voluntary family planning services,
limited to: 20% of charges
Voluntary sterilization
Surgically
implanted contraceptives (such as, Norplant).
Injectable contraceptive
drugs (such as, Depo Provera)
Diaphragms
Intrauterine devices (IUDs)
Note: We cover oral contraceptives under the prescription drug benefit.
There is no charge when Norplant is implanted during a
covered hospitalization. There will be no refund of any portion of the
coinsurance if the implanted time-release medication is removed
before the
end of its expected life.
Not covered: Reversal of voluntary surgical
sterilization, All charges
genetic counseling and testing, except for
medically
necessary prenatal genetic testing.
Infertility services
Diagnosis and treatment of infertility, such as: 50% of charges
Artificial insemination:
– intravaginal insemination (IVI)
–
intracervical insemination (ICI)
– intrauterine insemination (IUI)
Fertility drugs
Lab and x-ray services
Note: We cover
injectable fertility drugs administered by Plan
providers under medical
benefits and self-administered injectable and
oral fertility drugs under the
prescription drug benefit.
Not covered: All charges
Assisted reproductive technology
(ART) procedures, such as:
– In vitro fertilization
–
Embryo transfer, gamete GIFT and zygote GIFT
– Zygote transfer
Services and supplies related to excluded ART procedures
Surrogate parenting fees
Cost of donor sperm
Cost
of donor egg 18
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2002 FIRSTCARE 19 Section 5 (a)
Allergy care You pay
Testing and treatment $15 per office
visit to a specialist
Allergy injection, when administered without an
office visit. 50% of charges
Allergy serum Nothing
Not covered:
provocative food testing and All charges
sublingual allergy desensitization
Treatment therapies
Chemotherapy and radiation therapy Nothing
Note: High dose chemotherapy
in association with autologous bone
marrow transplants is limited to those
transplants listed under Organ/
Tissue Transplants on page 27.
Respiratory and inhalation therapy
Dialysis – Hemodialysis and
peritoneal dialysis
Intravenous (IV)/ Infusion Therapy – Home IV and
antibiotic
therapy
Growth hormone therapy (GHT)
Note: Growth hormone is covered under the
prescription drug benefit.
Note: – We will only cover GHT when we authorize
the treatment.
We will ask your physician to submit information that
establishes
that the GHT is medically necessary. Your physician needs to
authorize GHT before you begin treatment; otherwise, we will only
cover
GHT services from the date your physician submits the
information. If your
physician does not ask or if we determine GHT
is not medically necessary, we
will not cover the GHT or related
services and supplies. See Services
requiring our prior approval in
Section 3.
Physical and occupational therapies
Physical therapy and occupational therapy $15 per office or outpatient
visit;
services of each of the following: nothing inpatient.
– Qualified physical therapists; and
– Occupational therapists.
Note:
We only cover therapy to restore bodily function when there
has been a total
or partial loss of bodily function due to illness or
injury.
Physical and occupational theraphies continued on the next page
See Prescription Drug benefit. 19
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2002 FIRSTCARE
20 Section 5 (a)
Physical and occupational therapies
(Continued) You pay
Cardiac rehabilitation following a
heart transplant, bypass surgery
or a myocardial infarction must be provided
at a Plan facility, and
is covered for up to two months per condition, or
for up to 60 days
per condition per calendar year, whichever is greater, if
significant
improvement can be expected within that time.
Note: Your coverage is limited to services that continue to meet or
exceed the treatment goals established for you. For a physically
disabled person, treatment goals may include maintenance of
functioning
or prevention of or slowing of other deterioration.
Not covered: All charges
Long-term rehabilitative therapy
Exercise programs
Speech therapy
Speech therapy services provided by a speech therapist
Hearing services (testing, treatment, and supplies)
Hearing
screenings, annually, for children through age 18
(see Preventive care,
children)
Hearing screenings, biennially, for members age 19 and older (see
Preventive care, adult)
Hearing aids
Note: Must be medically necessary as determined by a Plan
physician, authorized in advance by the Plan, and obtained from a
Plan
provider.
Not covered: All charges
Repair or replacement of hearing
aids due to normal wear and
tear and loss or damage
Vision services (testing, treatment, and supplies)
Eye
screenings, annually, for children through age 18 to
determine vision loss
(see Preventive care, children)
Eye screenings, biennially, for members age 19 and older to
determine
vision loss (see Preventive care, adult)
Not covered: All charges
Eyeglasses, frames, or contact
lenses (including the fitting of
contact lenses), except as necessary for
the first pair of corrective
lenses following cataract removal
Eye exercises and orthoptics
Radial keratotomy and other
refractive surgery
Refractions, including lens prescriptions, to
determine the need for
glasses or contacts.
$10 per office visit to your primary
care physician
$15 per office visit to a specialist
Nothing up to Plan maximum of
$500 per ear once every 36 months;
all
charges over $500 per ear.
Nothing if you receive these
services during your primary care
physician office visit
$15 per office or outpatient visit;
nothing inpatient.
$15 per office or outpatient visit;
nothing inpatient. 20
20 Page 21 22
2002 FIRSTCARE 21 Section 5 (a)
Foot
care You pay
Routine foot care when you are under active treatment for a
metabolic or peripheral vascular disease, such as diabetes.
See orthopedic and prosthetic devices for information on
podiatric shoe
inserts.
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, spurs, and treatment 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 charges
Externally worn
breast prostheses and surgical bras, including
necessary replacements,
following a mastectomy
Corrective orthopedic appliances for non-dental treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome.
Foot orthotics
Podiatric appliances for the prevention of
complications associated
with diabetes.
Braces (limb or back only)
Internal prosthetic devices, such as artificial joints, pacemakers, Nothing
surgically implanted breast implant following mastectomy,
and implanted
lenses during cataract surgery. Note: See 5( b)
for coverage of the surgery
to insert the device.
Not covered: All charges
Orthopedic and corrective shoes
Arch supports
Heel pads and heel cups
Lumbosacral supports
Corsets, trusses, elastic stockings,
support hose, and other
supportive devices
Prosthetic replacements, except for breast prostheses and surgical
bras, and as necessitated by bodily growth.
Cochlear implanted device
Wigs or prosthetic hair
Implanted neurological stimulators, including but not limited to
spinal
or dorsal column stimulators for relief of pain, Parkinson's,
movement
disorders or seizures.
$10 per visit to your primary care
physician
$15 per visit to a specialist 21
21 Page 22 23
2002 FIRSTCARE
22 Section 5 (a)
Durable medical equipment (DME) continued on the next page
Durable medical equipment (DME) You pay
Rental or purchase, at our
option, including repair and adjustment,
of durable medical equipment
prescribed by your Plan physician,
such as oxygen (see below) and dialysis
equipment. Under this
benefit, we also cover:
Manual hospital beds
Manual wheelchairs
Crutches
Canes
Walkers
Braces (limb or back only)
Traction devices
Nebulizers
Indwelling urinary catheters
C-PAP monitoring device
(when there is a diagnosis of
documented obstructive sleep apnea)
Oxygen, oxygen concentrators, rental of equipment for
administration of
oxygen, and mechanical equipment necessary for
the treatment of chronic or
acute respiratory failure
Note: Oxygen and equipment must be prescribed and directed by a
Plan
provider, and approved in advance by the Plan.
Monitoring devices, such as apnea monitors and uterine monitors
for use
in the home, when prescribed and directed by a Plan
provider
Ostomy supplies
Sterile dressing change kits, i. e., tracheostomy
suction and dressing
kits, and central line dressing kits
Equipment and supplies used for the treatment of diabetes as
follows:
– Blood glucose monitors, including monitors designed
to be used by blind
individuals
– Insulin pumps and associated appurtenances
– Insulin infusion devices
– Podiatric appliances for the prevention of complications
associated
with diabetes
– Glucose monitors
– Injection aids
– Insulin cartridges
–
Infusion sets
Note: DME must be pre-authorized, unless it is provided by
your
physician's office.
20% of charges 22
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2002 FIRSTCARE 23 Section 5 (a)
Durable medical equipment (DME) (Continued) You pay
Not covered: All charges
Motorized, deluxe, and custom
wheelchairs and hospital beds; auto
tilt chairs.
Comfort or convenience items, such as bathtub chairs, whirlpool
tubs, safety grab bars, stair gliders or elevators, over-the-bed
tables,
bed boards, saunas, and exercise equipment.
Environmental control equipment, such as air conditioners,
purifiers, humidifiers, de-humidifiers, electrostatic machines and
heat
lamps.
Institutional equipment, such as fluidized beds and diathermy
machines.
Consumable medical supplies, such as over-the-counter bandages,
dressings and other disposable supplies and skin preparations.
Foam cervical collars.
Stethoscopes, sphygmomanometers, reading
oximeters.
Hygienic or self help items or equipment.
Sports cords.
TENS units.
Repair or replacement resulting from misuse or abuse.
Home health services
Home health care visits ordered by a Plan physician and provided
by a
skilled home health care professional or 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;
Home care primarily for personal assistance that does not include
a
medical component and is not diagnostic, therapeutic, or
rehabilitative.
Chiropractic
No benefit. All charges
Nothing 23
23 Page
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2002 FIRSTCARE 24 Section 5 (a)
Alternative treatments
Telemedicine to deliver health care,
which includes use of
interactive audio, video, or other electronic media
for diagnosis,
consultation, treatment, transfer of medical data, and
medical
education, but excludes services performed using a telephone or
facsimile (FAX) machine.
Not covered: All charges
Naturopathic services
Hypnotherapy
Biofeedback
Acupuncture
Equine or Hippo therapy
Massage therapy, unless associated with
a physical therapy
modality provided by a licensed physical therapist
Educational classes and programs
Coverage is limited to:
Diabetes self-management training, including
counseling and use
of diabetic equipment and supplies.
Nutritional counseling for morbid obesity.
$10 per office visit to your primary
care physician
$15 per office visit to a specialist
Nothing 24
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2002 FIRSTCARE 25 Section 5 (b)
Benefit Description You pay
Surgical procedures
A
comprehensive range of services, such as: Nothing
Operative procedures
Treatment of fractures, including casting
Normal pre-and
post-operative care by the surgeon
Correction of amblyopia and strabismus
Endoscopy procedures
Biopsy procedures
Removal of tumors and
cysts
Correction of congenital anomalies (see reconstructive surgery)
Treatment of burns
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
Insertion of
internal prosthetic devices. See 5( a) – Orthopedic and prosthetic devices for
device coverage information.
Note: Generally, we pay for internal prostheses (devices) according to where
the procedure is done. For example, we pay Hospital
benefits for a
pacemaker, and Surgery benefits for insertion of the pacemaker.
Voluntary sterilization 20% of charges
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.
Be sure to read
Section 4, Your costs for covered services, for valuable information
about how cost sharing works. Also read Section 9 about coordinating benefits
with other coverage,
including with Medicare.
The amounts listed below are for the charges
billed by a physician or other health care professional for your surgical care.
Look in Section 5( c) for charges associated with the facility
(i. e., hospital, surgical center, etc.).
YOUR PHYSICIAN MUST GET
PRECERTIFICATION 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.
Assistant surgeon services will be covered for those surgeries which
require an assistant surgeon and when we pre-approve them.
Surgical procedures continued on next page
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2002
FIRSTCARE 26 Section 5 (b)
Surgical procedures (Continued)
You pay
Not covered: All charges
Reversal of
voluntary sterilization.
Any surgical procedures related to snoring
and sleep apnea.
Routine treatment of conditions of the foot; see
Foot care.
Reconstructive surgery
Surgery to correct a functional defect Nothing
Surgery to correct a
condition caused by injury or illness if:
– the condition produced a major
effect on the member's
appearance, and
– the condition can reasonably be expected to be corrected
by such
surgery
Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form or norm. Examples
of
congenital anomalies are: protruding ear deformities; cleft lip;
cleft
palate; birth marks; webbed fingers; and webbed toes.
All stages of breast reconstruction surgery following a mastectomy,
such as:
– surgery to produce a symmetrical appearance on
the other breast;
– treatment of any physical complications, such as
lymphedemas;
– breast prostheses and surgical bras and replacements
(see Prosthetic
devices)
Note: If you need a mastectomy, you may choose to have the
procedure
performed on an inpatient basis and remain in the
hospital up to 48 hours
after the procedure.
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 26
26 Page 27 28
2002 FIRSTCARE 27 Section 5 (b)
Oral and
maxillofacial surgery You pay
Oral surgical procedures, limited to:
Nothing
Reduction of fractures of the jaws or facial bones;
Surgical
correction of cleft lip, cleft palate or severe functional
malocclusion;
Removal of stones from salivary ducts;
Excision of leukoplakia or
malignancies;
Excision of cysts and incision of abscesses when done as
independent procedures; and
Treatment of temporomandibular joint (TMJ) surgery, including
surgical
and non-surgical intervention, corrective orthopedic
appliances and physical
therapy and other surgical procedures that
do not involve the teeth or their
supporting structures.
Not covered: All charges
Oral implants and transplants
Procedures or related dental work that involve the teeth or their
supporting structures (such as the periodontal membrane, gingiva,
and
alveolar bone)
Organ/ tissue transplants
Limited to: Nothing
Cornea
Heart
Heart/ Lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single– Double
Pancreas
Allogenic (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.
Organ/ tissue transplants continued on next page
27
27 Page 28
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2002 FIRSTCARE 28 Section 5 (b)
Organ/ tissue transplants (Continued) You pay
Note: Immuno-suppressive medications necessary to prevent rejection of
any transplanted organ listed above are covered subject
to no copay while
hospitalized. After discharge, these medications are covered under the
Prescription drug benefit and subject to the
applicable prescription drug
copay per 30-day supply. They are not available through the Mail Order Pharmacy.
Note: All covered transplants must be evaluated by a nationally recognized
medical facility designated by FIRSTCARE and they
must agree that the
proposed transplant is appropriate for the treatment of your condition. Also,
they must agree to perform the
transplant. The FIRSTCARE Medical Director
must approve all covered transplants. All related medical and hospital expenses
of
the donor are covered when the recipient is covered by this Plan.
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)
Hospital outpatient department
Skilled nursing
facility
Ambulatory surgical center
Office 28
28 Page 29 30
2002 FIRSTCARE 29 Section 5 (c)
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Inpatient hospital continued on next page
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).
YOUR PHYSICIAN MUST GET PREAUTHORIZATION OF HOSPITAL STAYS. Please refer to
the preauthorization information shown in Section 3 to be sure which
services require preauthorization and identify which surgeries require
preauthorization.
Benefit Description You pay
Inpatient hospital
Room and board,
such as: Nothing
Ward, semiprivate room or intensive care accommodations;
Private rooms and/ or special duty nursing when medically
necessary
General nursing care; and
Meals and special diets.
NOTE: If you
want a private room when it is not medically
necessary, you pay the
additional charge above the semiprivate room
rate.
Other hospital services and supplies, such as:
Operating, recovery,
maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Administration of blood and blood
products
Blood or blood plasma
Dressings, splints, casts, and
sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services
Medical supplies,
appliances, medical equipment, and any covered
items billed by a hospital
for use at home. 29
29 Page
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2002 FIRSTCARE 30 Section 5 (c)
Inpatient hospital (Continued) You pay
Not
covered: All charges
Custodial care, rest cures, domiciliary or
convalescent care
Non-covered facilities, such as nursing homes,
schools
Personal comfort items, such as telephone, television,
barber
services, guest meals and beds
Private nursing care
Take-home drugs
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
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.
Extended care benefits/ skilled nursing care facility benefits
Extended care benefit: Nothing
A comprehensive range of benefits to a
maximum of 100 days
per calendar year when full-time skilled nursing care is
necessary
and confinement in a skilled nursing facility is medically
appropriate as determined by a Plan doctor and approved by the
Plan.
Bed, board and general nursing care.
Drugs, biologicals, supplies,
and equipment ordinarily provided or
arranged by the skilled nursing
facility when prescribed by a Plan
doctor.
Not covered: All charges
Custodial care
Rest
cures
Domiciliary or convalescent care 30
30 Page 31 32
2002 FIRSTCARE 31 Section 5 (c)
Hospice
care You pay
We cover supportive and palliative care in the home or a
Nothing
hospice facility. Services include:
– Inpatient and outpatient care, and
– Family counseling.
Note: A
Plan physician must certify that the patient is in the
terminal stages of
illness, with a life expectancy of approximately
6 months or less.
Not covered: All charges
Independent nursing
Homemaker
services
Ambulance
Local professional ambulance service when $75 per trip
medically
appropriate 31
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2002 FIRSTCARE 32 Section 5 (d)
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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.
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.
Our Plan's allowance of Usual, Customary and Reasonable (UCR) charges will
apply
to emergency care received at any doctor's office outside our Plan's
services area for the services rendered. (See next page and Section 10 for the
definition of our Plan's
allowance of UCR charges).
What is a medical emergency?
A medical emergency is the sudden and
unexpected onset of a condition or an injury that you believe endangers
your
life or could result in serious injury or disability, and requires immediate
medical or surgical care. Some
problems are emergencies because, if not
treated promptly, they might become more serious; examples include
deep cuts
and broken bones. Others are emergencies because they are potentially
life-threatening, such as
heart attacks, strokes, poisonings, gunshot
wounds, or sudden inability to breathe. There are many other
acute
conditions that we may determine are medical emergencies – what they all have in
common is the need
for quick action.
What to do in case of emergency:
Emergencies within our service area:
If you are in an emergency situation, please call your primary care
physician right away. In extreme
emergencies, if you are unable to contact
your doctor, contact the local emergency system (such as, the 911-
telephone
system) or go to the nearest hospital emergency room. Be sure to tell the
emergency room personnel
that you are a FIRSTCARE member so they can notify
us. You or a family member should notify
FIRSTCARE within 24 hours unless it
was not reasonably possible to do so. It is your responsibility to
ensure
that we have been notified in a timely manner.
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.
Emergency care includes the following services:
An initial medical
screening examination by the facility providing the emergency care or other
evaluation
required by state or federal law that is necessary to determine
whether an emergency medical condition
exists.
Services for the treatment and stabilization of an emergency condition.
Post-stabilization care originating in a hospital emergency room or
comparable facility, if approved by us,
provided that we must approve or
deny coverage within one hour of a request for approval by the treating
physician or the hospital emergency room.
Requirements for All Emergency Care. To be covered, emergency care
must meet all of these conditions:
You must obtain the services
immediately, or as soon as possible, after the emergency condition occurs.
As soon as possible after the emergency occurs and you seek treatment, you (or
someone acting for you)
must contact your primary care physician for advice
and instructions. In any event, you must contact the
Plan within 24 hours,
unless it is impossible to do so.
You must be transferred to the care of Plan providers as soon as this can be
done without harming your
condition. We do not cover services provided by
non-Plan providers after the point at which you can be
safely transferred to
the care of a Plan provider. 32
32 Page 33 34
2002 FIRSTCARE
33 Section 5 (d)
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, FIRSTCARE must be notified within 24 hours or
on the first working day following your admission, unless it was not reasonably
possible to notify Us within that time. If a Plan doctor believes care
can
be better provided in a Plan hospital, you will be transferred when medically
feasible with any ambulance charges covered in full.
Any follow-up care recommended by non-Plan providers must be approved by the
Plan or provided by Plan providers.
Benefit Description You pay
Emergency within our service area
Emergency care at a doctor's office $10 per office visit to your
primary care physician
$15 per office visit to a specialist
Emergency care at an urgent care
center $25 per visit
Emergency care as an outpatient or inpatient at a
hospital, including doctors' services
Not covered: All charges
Elective care or non-emergency care
Emergency outside our service area
Emergency care at a doctor's
office $15 per office visit, plus all amounts over our Plan's allowance of the
Usual, Customary and Reasonable (UCR) charges for the services
rendered.
Emergency care at an urgent care center $25 per visit
Emergency care
as an outpatient or inpatient at a hospital,
including doctors' services
$75 per visit; if admitted, the copay is waived. However, if admitted for
an observation period of less than 24 hours, the copay is not waived.
$75 per visit; if admitted, the copay is waived. However, if admitted for
an observation period of less than 24 hours, the copay is not waived.
Emergencies outside our service area continued on the next page 33
33 Page 34 35
2002 FIRSTCARE 34 Section 5 (d)
Emergency outside our service area (Continued) You pay
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
Charges for the normal delivery of a baby (vaginal or cesarean section)
outside our Plan's Service Area, if the delivery is within
30 days of your
due date specified by your participating physician,
except in case of
emergency; however, complications of pregnancy or premature delivery are
covered.
Ambulance
Professional ambulance service, including air
ambulance, $75 per trip when medically appropriate.
See 5( c) for non-emergency service. 34
34
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2002
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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.
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
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 $15 per office visit by providers such as
psychiatrists, psychologists, or clinical
social workers
Medication management
Diagnostic tests Nothing
Services provided by a hospital or other
facility Nothing
Services in approved alternative care settings such as
partial hospitalization, full-day hospitalization, facility based intensive
outpatient treatment.
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
obtain a treatment plan and follow all of our network authorization processes.
Mental health and substance abuse services are provided through these
behavioral health benefit managers:
In the Amarillo and Lubbock regions (which includes Midland/ Odessa):
Comprehensive Behavioral Care – 800/ 541-3647
In the Waco region: MHNet,
Inc. – 800/ 336-2030
Your primary care physician may refer you, or you may
contact the benefit manager for your region without a referral.
Limitation If you do not obtain an approved treatment plan, we may
limit your benefits.
Your cost sharing responsibilities
are no greater than for other
illnesses or conditions. 35
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2002 FIRSTCARE
36 Section 5 (f)
Prescription drug benefits begin on the next page
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 Plan physician or dentist,
or an out-of-Plan doctor when you have been referred must write the
prescription.
Where you can obtain them.
– Retail Pharmacy
You may
fill your prescriptions at a retail Plan pharmacy, or
– Mail Order
Pharmacy
You may obtain a medication for chronic conditions through the
Plan mail order pharmacy.
Medications for chronic conditions are defined as
those that you have taken for at least six months.
Our mail order pharmacy
for the Amarillo region is Maxor Pharmacies 800/ 687-8629 and for the
Waco
and Lubbock regions is Express Scripts 888/ 202-4560.
We use a formulary.
Our drug formulary includes all generic
drugs and a comprehensive list of preferred name brand
drugs approved by our
Pharmacy and Therapeutics (P& T) Committee, and used by Plan physicians
to be dispensed through our Plan pharmacies to meet patient needs at a lower
cost. You must use
drugs included on the formulary to take advantage of the
best combination of safety, effectiveness
and cost savings. Drugs not
included in the formulary are called "non-formulary" drugs and you
must pay
a higher copayment for these drugs. If you need to order a drug formulary or
have any
questions, please call our Customer Services Department at 800/
884-4901.
These are the dispensing limitations.
FIRSTCARE requires prior
authorization and imposes dispensing limitations on certain drugs, due
to
specific therapeutic indications or requirements for closer monitoring to help
insure appropriate
dispensing. The criteria used in administering these
programs follow FDA approved dosing
guidelines. For specific information
about your prescription coverage, please consult a Customer
Services
Representative at 800/ 884-4901.
Prescriptions are limited to a 30-day supply, except medications for chronic
conditions that may be
filled up to a 90-day supply, but only when filled
through a Participating Mail Service Pharmacy.
All generic equivalent drugs are covered when used to treat a covered medical
condition. Name
brand drugs are covered when a generic equivalent is
available; however, if your physician has not
specified Dispense as Written
for the name brand drug, you have to pay the generic copay plus the
difference in cost between the name brand and the generic drug.
I M
P O
R T
A N
T
I M
P O
R T
A N
T 36
36
Page 37 38
2002
FIRSTCARE 37 Section 5 (f)
What should I do if I am at the pharmacy
and find out that my prescription is not on the
FIRSTCARE formulary list?
Your pharmacist should contact your physician's office and explain the
circumstances. Your
physician may change your prescription to a formulary
drug, or if you prefer, you may pay a higher
copay to obtain the
non-formulary drug.
Why use generic drugs?
Generic drugs are lower-priced
drugs that are pharmaceutically and therapeutically equivalent in
strength
and dosage to the more expensive original name brand product. The U. S. Food and
Drug
Administration closely regulates both generic and name brand drugs to
ensure they meet the same
standards for safety, purity, strength and
effectiveness. Generic drugs are less expensive for you –
and us – and can
reduce your out-of-pocket expenses.
When you have to file a claim.
You may have to file a claim for
reimbursement if you are out of the service area and have to pay for
an
emergency prescription filled at an out-of-network pharmacy. To obtain these
forms, call our
Customer Services department at 800/ 884-4901. 37
37 Page 38 39
2002 FIRSTCARE 38 Section 5 (f)
Benefit
Description You pay
Covered medications and supplies
We cover the
following medications and supplies prescribed by a
Plan physician or dentist
and obtained from a Plan retail pharmacy
or through our mail order program:
Drugs and medicines that by Federal law require a physician's
prescription for their purchase, except as Not Covered.
Formulas necessary for the treatment of a heritable disease, such
as
phenylketonuria (PKU).
Drugs for sexual dysfunction are subject to dosage limits set by
the
Plan. Contact the Plan for details.
Oral contraceptive drugs.
Prescription and non-prescription oral
agents for controlling blood
sugar levels.
Growth hormone therapy (GHT) drugs
Insulin, insulin analogs, and glucagon emergency kits.
Oral and
injectable fertility drugs 50% of charges
Retail Pharmacy, for up to a 30-day
supply per prescription unit
or refill:
A $10 copay for generic drugs;
A $20 copay for name brand drugs
when
a generic equivalent is not
available;
A $30 copay for non-formulary drugs;
and
A $10 copay for name brand drugs
when a generic equivalent is
available, plus the difference between
the cost of the generic drug and
the
cost of the name brand drug.
Mail Order Pharmacy, for up to a 90-day
supply per prescription
unit or refill:
A $20 copay for generic drugs;
A $40 copay for name brand drugs
when
a generic equivalent is not
available;
A $60 copay for non-formulary drugs;
and
A $20 copay for name brand drugs
when a generic equivalent is
available, plus the difference between
the cost of the generic drug and
the
cost of the name brand drug.
Covered medications and supplies continued on the next page
Retail
Pharmacy:
A $20 copay per prescription unit
or refill for name brand
drugs.
Mail Order Pharmacy:
A $40 copay per prescription unit
or refill for
name brand drugs. 38
38 Page
39 40
2002 FIRSTCARE 39 Section 5 (f)
Covered medications and supplies (Continued) You pay
Contraceptive drugs and devices, such as: 20% of all charges
–
Diaphragms
– Intrauterine devices (IUDs)
– Implantable drugs, such as
Norplant
– Injectable drugs, such as Depo Provera
Disposable needles
and syringes for the administration
of covered medications
Allergy syringes
Diabetic supplies, including:
– Test strips for
blood glucose monitors
– Visual reading and urine test strips
– Lancets
and lancet devices
– Injection aids
– Syringes
– Needles
–
Glucose test tablets and test tape
– Benedict's solution or equivalent
–
Acetone test tablets
Here are some things to keep in mind about our prescription drug
program:
A generic equivalent will be dispensed if it is available, unless
your
physician specifically requires a name brand. If you receive
a name brand
drug when a Federally-approved generic drug is
available, and your physician
has not specified Dispense as
Written for the name brand drug, you have to
pay the generic
copay plus the difference in cost between the name brand and
the generic drug.
We administer a 3-tier 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 have selected to meet
patient needs at a lower cost.
A non-formulary drug is a prescription medication that is not on
the
FIRSTCARE approved formulary list. Non-formulary drugs
require a higher
copayment.
Prescriptions will not be refilled until 70% of the prescription has
been used.
Covered medications and supplies continued on the next page 39
39 Page 40 41
2002 FIRSTCARE 40 Section 5 (f)
Covered
medications and supplies (Continued) You pay
Not
covered: All charges
Drugs and supplies for cosmetic purposes.
Vitamins, and nutritional substances that can be purchased without
a prescription, except for pre-natal vitamins.
Non-prescription medicines, except for the treatment of diabetes.
Drugs available without a prescription or for which there is a
non-prescription
equivalent available.
Drugs obtained at a non-Plan pharmacy except for out-of-area
emergencies.
Medical supplies such as dressings and antiseptics.
Drugs
to enhance athletic performance.
Smoking cessation drugs and
medication, including nicotine
patches.
Drugs prescribed for weight loss and appetite suppressants, except
for medications prescribed for morbid obesity.
Prescription refills in excess of the number specified by the
Physician and any refill dispensed more than one year after the
Physician's order.
Any prescription drug for which the actual cost is less than the
required copayment is not covered and you will be responsible for
the
cost of the drug.
Prescriptions or refills that replace lost, stolen, spoiled, expired,
spilled or are otherwise misplaced or mishandled by the Member. 40
40 Page 41 42
2002 FIRSTCARE 41 Section 5 (g)
Section
5 (g). Special Features
Feature Description
Services for deaf and hearing impaired TDD LINE 1-800/ 562-5259
Centers of excellence for
transplants/ heart surgery/ etc.
FIRSTCARE coordinates with
nationally recognized medical
facilities to evaluate the Member's
case; to determine that the proposed
transplant or treatment is
appropriate for the Member's
condition;
and to perform the
transplant or treatment. 41
41
Page 42 43
2002
FIRSTCARE 42 Section 5 (h)
Section 5 (h). Dental benefits
Accidental injury benefit You pay
No benefit All charges
Dental benefits
No benefit
All charges 42
42 Page
43 44
2002 FIRSTCARE 43 Section 6
Section 6. General exclusions – things we don't cover
The
exclusions in this section apply to all benefits. Although we may list a
specific service as a benefit,
we will not cover it unless your Plan doctor
determines it is medically necessary to prevent, diagnose,
or treat your
illness, disease, injury, or condition and we agree, as discussed under
Services requiring our
prior approval on page 12.
We do not cover the following:
Care by non-Plan providers except for
authorized referrals or emergencies (see Emergency Benefits);
Services,
drugs, or supplies you receive while you are not enrolled in this Plan;
Services, drugs, or supplies that are not medically necessary;
Services,
drugs, or supplies not required according to accepted standards of medical,
dental, or
psychiatric practice;
Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or supplies related to abortions, except when the life of
the mother would be endangered
if the fetus were carried to term;
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. 43
43 Page
44 45
2002 FIRSTCARE 44 Section 7
Section 7. Filing a claim for covered services
When you see
Plan physicians, receive services at Plan hospitals and facilities, or fill your
prescription drugs at Plan
pharmacies, you will not have to file claims.
Just present your identification card and pay your copayment or
coinsurance.
You will only need to file a claim when you receive emergency services from
non-plan providers. Sometimes these
providers bill us directly. Check with
the provider. If you need to file the claim, here is the process:
Medical, hospital and
drug 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/
884-4901.
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:
FIRSTCARE
12940 Research Blvd.
Austin, Texas 78750
Deadline for filing your claim Send us all of the documents for your
claim as soon as possible. You must submit the claim by December 31 of the
year after the year you received the service, unless timely
filing was
prevented by administrative operations of
Government or legal incapacity,
provided the claim was
submitted as soon as reasonably possible.
When we need more information Please reply promptly when we ask for
additional information. We may delay processing or deny your claim if you do not
respond. 44
44 Page
45 46
2002 FIRSTCARE 45 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 pre-authorization:
Step Description
Ask us in writing to reconsider our initial decision. You must:
(a) Write
to us within six months from the date of our decision; and
(b) Send your
request to our Customer Services Department at 3310 Danvers, Amarillo, Texas
79106;
and
(c) Include a statement about why you believe our initial decision was wrong,
based on specific benefit
provisions in this brochure; and
(d) Include copies of documents that support your claim, such as physicians'
letters, operative reports,
bills, medical records, and explanation of
benefits (EOB) forms.
We have 30 days from the date we receive your request to:
(a) Pay the
claim (or, if applicable, arrange for the health care provider to give you the
care); or
(b) Write to you and maintain our denial – go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider,
we will send you a copy of
our request – go to step 3.
You or your provider must send the information so that we receive it within
60 days of our request. We
will then decide within 30 more days.
If we do not receive the information within 60 days, we will decide within 30
days of the date the
information was due. We will base our decision on the
information we already have.
We will write to you with our decision.
If you do not agree with our decision, you may ask OPM to review it.
You
must write to OPM within:
90 days after the date of our letter upholding
our initial decision; or
120 days after you first wrote to us – if we did
not answer that request in some way within 30 days; or
120 days after we
asked for additional information.
Write to OPM at: Office of Personnel
Management, Office of Insurance Programs, Contracts Division 3,
1900 E
Street, NW, Washington, DC 20415-3630.
45
45 Page 46 47
2002 FIRSTCARE
46 Section 8
Send OPM the following information:
A statement about
why you believe our decision was wrong, based on specific benefit provisions in
this brochure;
Copies of documents that support your claim, such as physicians' letters,
operative reports, bills,
medical records, and explanation of benefits (EOB)
forms;
Copies of all letters you sent to us about the claim;
Copies of all
letters we sent to you about the claim; and
Your daytime phone number and
the best time to call.
Note: If you want OPM to review different claims, you
must clearly identify which documents apply to
which claim.
Note: You are the only person who has a right to file a disputed claim with
OPM. Parties acting as your
representative, such as medical providers, must
include a copy of your specific written consent with the
review request.
Note: The above deadlines may be extended if you show that you were unable to
meet the deadline because
of reasons beyond your control.
OPM will review your disputed claim request and will use the information it
collects from you and us to
decide whether our decision is correct. OPM will
send you a final decision within 60 days. There are no
other administrative
appeals.
If you do not agree with OPM's decision, your only recourse is to sue. If you
decide to sue, you must file
the suit against OPM in Federal court by
December 31 of the third year after the year in which you received
the
disputed services, drugs, or supplies or from the year in which you were denied
preauthorization. This
is the only deadline that may not be extended.
OPM may disclose the information it collects during the review process to
support their disputed claim
decision. This information will become part of
the court record.
You may not sue until you have completed the disputed claims process.
Further, Federal law governs your
lawsuit, benefits, and payment of
benefits. The Federal court will base its review on the record that was
before OPM when OPM decided to uphold or overturn our decision. You may
recover only the amount of
benefits in dispute.
NOTE: If you have a serious or life threatening condition (one that
may cause permanent loss of bodily
functions or death if not treated as soon
as possible), and
(a) We haven't responded yet to your initial request for care or
pre-authorization/ prior approval, then
call our Customer Services
Department at 800/ 884-4901 and we will expedite our review; or
(b) We denied your initial request for care or pre-authorization/ prior
approval, then:
If we expedite our review and maintain our denial, we will
inform OPM so that they can give
your claim expedited treatment too, or
You can call OPM's Health Benefits Contracts Division 3 at 202/ 606-0755
between 8 a. m. and
5 p. m. eastern time.
The Disputed Claims process (Continued)
46
46 Page 47
48
2002 FIRSTCARE 47 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 managed care plan is the
term used to describe the various health plan choices available to Medicare
beneficiaries. The information in the next few pages shows how we coordinate
benefits with Medicare, depending on the type of Medicare
managed care plan
you have.
The Original Medicare Plan The Original Medicare Plan
(Original Medicare) is a plan that is available
(Part A or Part B)
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. 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 you. Your
care must continue to be authorized by your Plan PCP, or pre-certified as
required. We will not waive any of our copayments or coinsurance.
(Primary payer chart begins on next page.) 47
47 Page 48 49
2002 FIRSTCARE 48 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
Please note, if Medicare is primary and your Plan physician does not
participate in Medicare, you will have to file a
claim with Medicare. When
you receive your Medicare Explanation of Benefits, you must send a copy to us at
3310
Danvers, Amarillo, Texas 79106, so we can determine the secondary
coverage.
A. When either you – or your covered spouse – are age 65 or over and …
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,
6) Are a former Federal employee receiving Workers' Compensation and the
Office of Workers' Compensation Programs has determined that you are
unable to return to duty,
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
Then the primary payer is ...
Original Medicare This Plan
(for Part B (for other
services) services)
(except for claims
related to Workers'
Compensation)
48
48 Page 49 50
2002 FIRSTCARE
49 Section 9
Claims process when you have the Original Medicare Plan
– You probably will never have to file a claim form when you have both our
Plan and the Original Medicare Plan.
When we are the primary payer, we
process the claim first.
When Original Medicare is the primary payer,
Medicare processes your claim first. In most cases, your claims will be
coordinated
automatically and we will pay the balance of covered charges.
You will not need to do anything. To find out if you need to do something
about filing your claims, call us at 800/ 884-4901.
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
retirement office. If you later want to re-enroll
in the FEHB Program,
generally you may do so only at the next open season unless you involuntarily
lose coverage or move out of the
Medicare managed care plan's service area.
If you do not enroll in If you do not have one or both Parts of
Medicare, you can still be Medicare Part A or covered under the FEHB
Program. We will not require you to enroll in
Part B Medicare Part B
and, if you can't get premium-free Part A, we will not ask you to enroll in it.
49
49 Page 50 51
2002 FIRSTCARE 50 Section 9
TRICARE
TRICARE is the health care program for eligible dependents of military
persons and retirees of the military. TRICARE includes the CHAMPUS
program.
If both TRICARE and this Plan cover you, we pay first. See your TRICARE Health
Benefits Advisor if you have questions about
TRICARE coverage.
Workers' Compensation We do not cover services that:
you need
because of a workplace-related illness or injury that the Office of Workers'
Compensation Programs (OWCP) or a similar
Federal or State agency determines
they must provide; or
OWCP or a similar agency pays for through a third
party injury settlement or other similar proceeding that is based on a claim you
filed under OWCP or similar laws.
Once OWCP or similar agency pays its
maximum benefits for your treatment, we will cover your care. You must use our
providers.
Medicaid When you have this Plan and Medicaid, we pay first.
When other Government We do not cover services and supplies when a
local, State, or Federal agencies are responsible Government agency
directly or indirectly pays for them.
for your care
When others are When you receive money to compensate you for medical
or hospital care responsible for injuries for injuries or illness caused
by another person, you must reimburse us
for any expenses we paid. However,
we will cover the cost of treatment that exceeds the amount you received in the
settlement.
If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our subrogation
procedures. 50
50 Page
51 52
2002 FIRSTCARE 51 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 13.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services. See page 13.
Covered services Care we
provide benefits for, as described in this brochure.
Custodial care
Custodial care is care that:
Primarily helps with or supports daily
living activities (such as, eating, dressing, and eliminating body wastes); or
Can be given by people other than trained medical personnel.
Care can
be custodial even if it is prescribed by a physician or given by trained medical
personnel, and even if it involves artificial methods such
as feeding tubes
or catheters.
Experimental or Determining eligibility of coverage for
a new technology requires investigational services evaluation of its
health effects by the Plan's Medical Advisory
Committee, which consists of
Medical Directors from all of the Plan's regions and appropriate Ad Hoc
Specialists. A service or supply shall be
considered to be experimental or
investigational as follows:
If the protocols or consent document of the
entity prescribing or rendering the service or supply describes it as an
alternative to more
conventional therapies;
Authoritative medical or
scientific literature published in the United States and written by experts in
the field indicates that additional
research is necessary before the service
or supply could be classified as equally or more effective than conventional
therapies;
Food and Drug Administration (FDA) approval is required in order for the
service or supply to be lawfully marketed, and such approval
has not been
granted at the time the service or supply is prescribed or rendered; and
The prescribed service or supply is available to the member only through
participation in FDA Phase I or Phase II clinical trials, or
through FDA
Phase III experimental or research clinical trials or corresponding trials
sponsored by the National Cancer Institute.
Group health coverage Health coverage, such as FEHB, that is provided
through an employer group. 51
51 Page 52 53
2002 FIRSTCARE
52 Section 10
Medical necessity Medical necessity and/ or
medically necessary means that the service must meet all of the following
conditions:
The service is required for diagnosing, treating or preventing
an illness or injury, or a medical condition such as pregnancy;
If you are
ill or injured, it is a service you need in order to improve your condition or
to keep your condition from getting worse;
It is generally accepted as
safe and effective under standard medical practice in your community; and
The service is provided in the most cost-efficient way, while still giving you
an appropriate level of care.
Not every service that fits this definition is
covered under your Plan. Just because a physician or other health care provider
has performed,
prescribed or recommended a service does not mean it is a
medical necessity and/ or medically necessary or that it is covered under your
Plan.
Plan allowance Plan allowance is the amount we use to determine our
payment and your coinsurance for covered services. Plans determine their
allowances in
different ways. Our Plan allowance is the amount our
contracted providers have agreed to accept as payment in full.
For emergency care received at any doctor's office, outside our Plan's
service area, our Plan's allowance is the amount FIRSTCARE has
determined to
be the allowable prevailing charge for a particular professional service in the
geographical area in which the service is
performed.
Usual,
Reasonable and The UCR charge is the amount we have determined to be the
allowable Customary (UCR) charge prevailing charge for a particular
professional service in the geographical
area in which the service is
provided.
Us/ We Us and we refer to FIRSTCARE.
You You
refers to the enrollee and each covered family member. 52
52 Page 53 54
2002 FIRSTCARE 53 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.
See www. opm. gov/ insure. Also, your employing or retirement office can
answer your questions, and give you a Guide to Federal Employees
Health Benefits Plans, brochures for other plans, and other materials
you
need to make an informed decision about:
When you may change your enrollment;
How you can cover your family
members;
What happens when you transfer to another Federal agency, go on
leave without pay, enter military service, or retire;
When your enrollment ends; and
When the next open season for
enrollment begins.
We do not determine who is eligible for coverage and, in
most cases,
cannot change your enrollment status without information from
your
employing or retirement office.
Types of coverage available Self Only coverage is for you alone. Self
and Family coverage is for you,
for you and your family 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.
Where you can get information
about enrolling in the
FEHB Program
53
53 Page 54
55
2002 FIRSTCARE 54 Section 11
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.
When benefits and The benefits in this brochure are effective on
January 1. If you joined premiums start this Plan during Open Season,
your coverage begins on the first day of
your first pay period that starts
on or after January 1. Annuitants'
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 records are confidential the 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). 54
54 Page 55 56
2002 FIRSTCARE
55 Section 11
When you lose benefits
When FEHB coverage
ends You will receive an additional 31 days of coverage, for no additional
premium, when:
Your enrollment ends, unless you cancel your enrollment, or
You are a
family member no longer eligible for coverage.
You may be eligible for
spouse equity coverage or Temporary
Continuation of Coverage.
Spouse equity coverage If you are divorced from a Federal employee
or annuitant, you may not continue to get benefits under your former spouse's
enrollment. But, you
may be eligible for your own FEHB coverage under the
spouse equity
law. If you are recently divorced or are anticipating a
divorce, contact
your ex-spouse's employing or retirement office to get RI
70-5, the Guide
to Federal Employees Health Benefits Plans for Temporary
Continuation
of Coverage and Former Spouse Enrollees, or other
information about
your coverage choices.
Temporary Continuation If you leave Federal service, or if you lose
coverage because you no longer of Coverage (TCC) 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 aft